Bambang Budi Siswanto

Heart failure: preventing disease and death worldwide

Heart failure is a life‐threatening disease and addressing it should be considered a global health priority. At present, approximately 26 million people worldwide are living with heart failure. The outlook for such patients is poor, with survival rates worse than those for bowel, breast or prostate cancer. Furthermore, heart failure places great stresses on patients, caregivers and healthcare systems. Demands on healthcare services, in particular, are predicted to increase dramatically over the next decade as patient numbers rise owing to ageing populations, detrimental lifestyle changes and improved survival of those who go on to develop heart failure as the final stage of another disease. It is time to ease the strain on healthcare systems through clear policy initiatives that prioritize heart failure prevention and champion equity of care for all.

Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) registry.

Our aim is to determine mortality and morbidity in Asian patients under clinical management for heart failure (HF). Specifically, we will define the incidence of, and risk factors for, sudden cardiac death, as well as the socio‐cultural factors influencing therapeutic choices in these patients.

Temporal trends of system of care for STEMI: insights from the Jakarta Cardiovascular Care Unit Network System.

Aim Guideline implementation programs are of paramount importance in optimizing acute ST-elevation myocardial infarction (STEMI) care. Assessment of performance indicators from a local STEMI network will provide knowledge of how to improve the system of care. Methods and Results Between 2008–2011, 1505 STEMI patients were enrolled. We compared the performance indicators before (n = 869) and after implementation (n = 636) of a local STEMI network. In 2011 (after introduction of STEMI networking) compared to 2008–2010, there were more inter-hospital referrals for STEMI patients (61% vs 56%, p<0.001), more primary percutaneous coronary intervention (PCI) procedures (83% vs 73%, p = 0.005), and more patients reaching door-to-needle time ≤30 minutes (84.5% vs 80.2%, p<0.001). However, numbers of patients who presented very late (>12 hours after symptom onset) were similar (53% vs 51%, NS). Moreover, the numbers of patients with door-to-balloon time ≤90 minutes were similar (49.1% vs 51.3%, NS), and in-hospital mortality rates were similar (8.3% vs 6.9%, NS) in 2011 compared to 2008–2010. Conclusion After a local network implementation for patients with STEMI, there were significantly more inter-hospital referral cases, primary PCI procedures, and patients with a door-to-needle time ≤30 minutes, compared to the period before implementation of this network. However, numbers of patients who presented very late, the targeted door-to-balloon time and in-hospital mortality rate were similar in both periods. To improve STEMI networking based on recent guidelines, existing pre-hospital and in-hospital protocols should be improved and managed more carefully, and should be accommodated whenever possible.

Myocardial Perfusion SPECT Utility In Predicting Cardiovascular Events Among Indonesian Diabetic Patients

Background: Indonesia has the fourth largest number of diabetes patients after India, China and the USA. Coronary artery disease (CAD) is the most common cause of death in diabetic patients. Early detection and risk stratification is important for optimal management. Abnormal myocardial perfusion imaging (MPI) is an early manifestation in the ischemic cascade. Previous studies have demonstrated the use of MPI to accurately diagnose obstructive CAD and predict adverse cardiac events. This study evaluated whether MPI predicts adverse cardiac event in an Indonesian diabetic population. Method: The study was undertaken in a consecutive cohort of patients with suspected or known CAD fulfilling entry criteria. All had adenosine stress MPI. The end point was a major adverse cardiac event (MACE) defined as cardiac death or nonfatal myocardial infarction (MI). Results: Inclusion and exclusion criteria were satisfied by 300 patients with a mean follow-up of 26.7 ± 8.8 months. The incidence of MACEs was 18.3% among diabetic patients, versus 9% in the non-diabetic population (p < 0.001). A multivariable Cox proportional hazard model demonstratedin dependent predictors for a MACE as abnormal MPI [HR: 9.30 (3.01 – 28.72), p < 0.001], post stress left ventricular ejection fraction (LVEF) ≤30% [HR:2.72 (1.21 – 6.15), p = 0.016] and the patients diabetic status [HR:2.28 (1.04 – 5.01), p = 0.04]. The Kaplan Meier event free survival curve constructed for the different subgroups based on the patients’ diabetic status and MPI findings demonstrated that diabetic patients with an abnormal MPI had the worst event free survival (log rank p value < 0.001). Conclusions: In an Indonesian population with suspected or known CAD abnormal adenosine stress MPI is an independent and potent predictor for adverse cardiovascular events and provides incremental prognostic value in cardiovascular risk stratification of patients with diabetes.

Blood Leukocyte Count on Admission Predicts Cardiovascular Events in Patients with Acute Non-ST Elevation Myocardial Infarction.

We aim to test the hypothesis that blood leukocyte count adds prognostic information in patients with acute non-ST-elevation myocardial infarction (non-STEMI). A total of 585 patients with acute non-STEMI (thrombolysis in myocardial infarction risk score ≥ 3) were enrolled in this cohort retrospective study. Blood leukocyte count was measured immediately after admission in the emergency department. The composite of death, reinfarction, urgent revascularization, and stroke during hospitalization were defined as the primary end point of the study. The mean age of the patients was 61 ± 9.6 years and most of them were male (79%). Using multivariate Cox regression analysis involving seven variables (history of smoking, hypertension, heart rate > 100 beats/minute, serum creatinine level > 1.5 mg/dL, blood leukocyte count > 11,000/µL, use of β-blocker, and use of angiotensin-converting enzyme inhibitor), leukocyte count > 11,000/µL demonstrated to be a strong predictor of the primary end point (hazard ratio = 3.028; 95% confidence interval = 1.69-5.40, p < 0.001). The high blood leukocyte count on admission is an independent predictor of cardiovascular events in patients with acute non-STEMI.

Serum Uric Acid As An Independent Predictor of Cardiovascular Event In Patients With Acute ST Elevation Myocardial Infarction

Background: There is uncertainty whether uric acid level could be used as a prognostic marker in acute ST elevation myocardial infarction (STEMI) patients. Furthermore, there is a need to find a simple, less expensive but accurate marker that could be use in rural areas where fibrinolytic treatment is the first choice of acute reperfusion therapy. We studied the association of uric acid levels on cardiovascular event in patients with STEMI receiving fibrinolytic treatment. Methods: Seventy-five patients with acute STEMI, eligible for fibrinolytic therapy, were enrolled in this cohort study. Over a night of fasting period, uric acid level was measured. One month clinical follow up was done. Reinfarction, heart failure, urgent revascularization, recurrent angina and death were defined as end point of the study. Results: In STEMI patients with lowest uric acid levels ( 7.3 mg/dl), the cardiovascular event rate increased from 8% to 20%. From multivariate Cox regression analysis showed that elevated levels of uric acid (>7.3 mg/dl) demonstrated an independent, significant positive relation to cardiovascular events [Hazard Ratio 3.10 (95% Confidence Interval 1.16 to 8.29), p <0.024]. Conclusion: Serum uric acid is an independent predictor of cardiovascular event in patients with post fibrinolytic treatment in acute STEMI.

Heart failure with preserved ejection fraction in Asia: HFpEF in Asia

Heart failure with preserved ejection fraction (HFpEF) is a global public health problem. Unfortunately, little is known about HFpEF across Asia.

Prevalence, clinical correlates, and outcomes of anaemia in multi-ethnic Asian patients with heart failure with reduced ejection fraction: Anaemia in multi-ethnic Asian patients with heart failure with reduced ejection fraction

Recent international heart failure (HF) guidelines recognize anaemia as an important comorbidity contributing to poor outcomes in HF, based on data mainly from Western populations. We sought to determine the prevalence, clinical correlates, and prognostic impact of anaemia in patients with HF with reduced ejection fraction across Asia.

Lowering Inflammation Level by Lp-PLA2 Inhibitor (Darapladib) in Early Atherosclerosis Development: in vivo Rat Type 2 Diabetes Mellitus Model

Background: The etiology of the ventricular dilation and dysfunction that occurs in idiopathic dilated cardiomyopathy (DCM) is unknown. Aim: The present study was aimed to study clinical characteristics of the patients admitted with idiopathic DCM and compare them with healthy controls. Methods: Thirty newly diagnosed patients with DCM and 30 healthy control were enrolled from Cardiology OPD, PGIMER, Chandigarh from Jan 2011 to Jun 2012. Patients with heart failure secondary to idiopathic DCM of age >18 years were included if they were willing, provide written informed consent and does not meet any of the exclusion criteria. Idiopathic DCM was diagnosed by the presence of left ventricular dilatation and systolic dysfunction (LVEF Results: Mean age of idiopathic DCM patients and control was 48.37±10.82 years and 49.2±9.27 (P=0.75) respectively. There were more males (66.7%) than females (33.3%) in the patient group. It was observed that the treatment with beta blockers, furosemide, spironolactone, ACE inhibitors, and ARBs significantly improved ejection fraction (EF) (P=0.000), and LVES (P=0.000). Conclusion: In our study, treatment with the medications significantly improved EF and LVES. However, there was no treatment-based difference in the patients on ACE inhibitors or ARBs in the improvement in EF. Our study also observed significance difference in platelets count, SGOT, SGPT, and LDL levels in idiopathic DCM patients when compared with healthy controls. Key words: DCM, LVEF, LVES, NYHA Class, ACE Inhibitors, ARBs

Disparity Between Indications for and Utilization of Implantable Cardioverter Defibrillators in Asian Patients With Heart Failure

Background— Implantable cardioverter defibrillators (ICDs) are lifesaving devices for patients with heart failure (HF) and reduced ejection fraction. However, utilization and determinants of ICD insertion in Asia are poorly defined. We determined the utilization, associations of ICD uptake, patient-perceived barriers to device therapy and, impact of ICDs on mortality in Asian patients with HF. Methods and Results— Using the prospective ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) registry, 5276 patients with symptomatic HF and reduced ejection fraction (HFrEF) from 11 Asian regions and across 3 income regions (high: Hong Kong, Japan, Korea, Singapore, and Taiwan; middle: China, Malaysia, and Thailand; and low: India, Indonesia, and Philippines) were studied. ICD utilization, clinical characteristics, as well as device perception and knowledge, were assessed at baseline among ICD-eligible patients (EF ⩽35% and New York Heart Association Class II-III). Patients were followed for the primary outcome of all-cause mortality. Among 3240 ICD-eligible patients (mean age 58.9±12.9 years, 79.1% men), 389 (12%) were ICD recipients. Utilization varied across Asia (from 1.5% in Indonesia to 52.5% in Japan) with a trend toward greater uptake in regions with government reimbursement for ICDs and lower out-of-pocket healthcare expenditure. ICD (versus non-ICD) recipients were more likely to be older (63±11 versus 58±13 year; P<0.001), have tertiary (versus ⩽primary) education (34.9% versus 18.1%; P<0.001) and be residing in a high (versus low) income region (64.5% versus 36.5%; P<0.001). Among 2000 ICD nonrecipients surveyed, 55% were either unaware of the benefits of, or needed more information on, device therapy. ICD implantation reduced risks of all-cause mortality (hazard ratio, 0.71; 95% confidence interval, 0.52–0.97) and sudden cardiac deaths (hazard ratio, 0.33; 95% confidence interval, 0.14–0.79) over a median follow-up of 417 days. Conclusions— ICDs reduce mortality risk, yet utilization in Asia is low; with disparity across geographic regions and socioeconomic status. Better patient education and targeted healthcare reforms in extending ICD reimbursement may improve access. Clinical Trial Registration— URL: https://clinicaltrials.gov/ct2/show/NCT01633398. Unique identifier: NCT01633398.