European Journal of Cardiovascular Medicine

Heart failure has now been declared as a global pandemic with 26 million adults across the world living with Heart failure.¹ Coronary artery disease, Cardiomyopathies and valvular heart disease contribute the major etiology for heart failure in India.²

In India, the burden of heart failure is estimated to rise with prevalence range from 1.3 million – 4.6 million and annual incidence of 491-1.8 million.³ According to Trivandrum Heart Failure Registry, 5-year mortality rate was 59% and median survival was 3.1 years.⁴

Due to rapid transition towards the age of chronic diseases, the burden of cardiovascular diseases in India has progressively risen with leading risk factors being dietary intake (56.4%), high systolic blood pressure (54.6%), air pollution (31-1%), increased total cholesterol (29.4%), use of tobacco (18.9%), impaired fasting blood glucose (16.7%) and high BMI (14.7) for both gender.⁵

According to the ESC guidelines, Heart Failure is defined as “a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intra cardiac pressures at rest or during stress”.⁶

Distinction of HF into HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)was made with EF less than equal 40% and EF more than equal to 50 %, respectively. Recently, a “grey area” has been defined by ESC guidelines which includes EF between 40-49% termed as HF with mildly reduced ejection fraction. (HFmrEF) changed from HF with mid-range ejection fraction.⁷

Cornerstone modality for assessment of left ventricular systolic function is 2D Echocardiography which records LV imaging in different views including apical and parasternal long and short axis views.⁸

A study done by Maisel et al. suggested the use of Natriuretic peptide levels for BNP and NT- proBNP for diagnosis of heart failure.²⁴ the relationship between disease severity and NT- pro BNP levels found that levels above 1000pg/ml were associated with adverse prognosis.²⁵

This current descriptive cross-sectional study was conducted on 84 patients admitted at our tertiary care hospital from period on 2019 to 2021. Patients having symptoms of heart failure ranging from NYHA (New York heart association) grade 1- 4 were included. Diagnosis was made based on latest ESC guidelines along with echocardiographic assessment. An elaborate proforma recording patients’ demographic profile, physical examination, laboratory studies and echocardiography findings was made. All the patients above 18 years and clinically and echocardiographically labelled as HF were included in the study. Patients with malignancy, chronic kidney disease and debilitating medical conditions were excluded.

 Detailed history of contributory cardiovascular risk factors like hypertension, diabetes mellitus, ischemic heart disease, smoking, obesity were taken into consideration. Anthropometric assessment in terms of BMI (kg/m2) were calculated. The echocardiographic variables like Left ventricular ejection fraction (LVEF), pulmonary artery systolic pressure (PASP), diastolic function, Systolic function, Chamber enlargement were noted.

The collected data after entering on Microsoft excel was analysed in statistical software STATA, version 10.1,2011. Descriptive statistics were used to summarize qualitative variables with frequency and percentages. A tabular representation for necessary variables was made.

This study showed maximum number of patients of HF in 5^th-6^th decade. Mean age was 58.7 years. Male to female ratio was 1.6:1. Clinical characteristics of patients are illustrated in the table-1

TABLE 1: Clinical characteristics of patients with HF (n= 84)

Abbreviations: BPM (beats per minute), NYHA (New York Hear Association)

About 25(29.7%) had tobacco chewing habit and 14.2% had history of alcohol abuse. Among comorbid illness, Hypertension (55.95%), Diabetes (50%), ischemic heart disease (33.3%) were commonly observed in our study while Hypothyroidism (9.52%), Chronic Obstructive Pulmonary disease (7.14%), Hyperthyroidism (2.38%) were less common.

TABLE 2: Comorbidities in HF (n=84)

Anthropometric assessment in terms of Body Mass Index (BMI)(kg/m2) was calculated which showed 46.42% (39) of patients in BMI between 25-29.9kg/m2 which comes in overweight category and 5.95% in morbid obese (BMI>30kg/m2). On physical examination, Raised JVP was seen in 92.85% followed 90.48% with oedema feet. Pulmonary crepitations were observed in about half of the patients whereas S3 gallop was seen in 41(48.8%) of the patients.

TABLE 3: Signs of heart failure in patients (n= 84)

Among the laboratory studies, 48(57.14%) had deranged HbA1c levels, whereas dyslipidemia were observed in 33(39.28%) of the patients.

TABLE 4: Chest X-Ray, Electrocardiograph (ECG) Echocardiographic (2DEcho)findings of patients with HF

Abbreviations: LVH (Left ventricular hypertrophy), RVH (Right ventricular hypertrophy),LBBB (left bundle branch block), RBBB( right bundle branch block),LVEF(left ventricular ejection fraction), PASP(pulmonary artery systolic pressure), HF(heart failure)

 Among Chest Xray, Cardiomegaly was found in 66.6% of patients whereas failure changes were seen in 28.57%. On ECG findings,57.14% showed Ischemic changes, atrial fibrillation (23.8%) whereas LBBB and RBBB was seen in 14.28% and 8.33% respectively. Changes of LVH and RVH were noted in 45.23% and 28.57% respectively. Changes of pulmonary embolism on ECG were noted in 3.52%.

 2-D echo findings showed maximum patients with reduced Ejection fraction with 55(65.48%) while Preserved ejection fraction were 21(25%) and Mildly reduced ejection fraction were 8(9.5%). PASP was raised in maximum patients of 64.28%.57.14% of the patients echo showed Mitral regurgitation. Systolic and Diastolic dysfunction were seen in 34.52% and 29.76% of the patients. Further, Regional wall motion abnormality (RWMA) was reported in 35.71% of the patients.

TABLE 5: Etiological diagnosis in patients of HF (n=84)

Leading etiological diagnosis observed in our study was Coronary Artery Disease (32.14%) followed by Cardiomyopathy (23.8%), Rheumatic heart disease (21.42%). Whereas, Hypertensive heart disease (11.90%), Cor pulmonale (3.57%), congenital heart disease (2.38%), pulmonary embolism (2.38%) were less commonly observed etiological diagnosis.2(2.38%) patients of Peripartum cardiomyopathy were etiology for heart failure who presented towards the end of pregnancy with reduced ejection fraction.

Heart failure is one of the most prevalent clinical challenges in India. An estimated incidence has increased to 1.8 million cases mainly attributed to major cardiovascular risk factors like ischemic heart disease, obesity, hypertension, diabetes, and rheumatic heart disease.⁹ With advancing age, HF poses a significant prevalence and mortality which has a health care impact as the older population grows.¹⁰

The results of our study clearly indicate dramatic increase in incidence of HF patients with age. Maximum patients belonged to 5^th -6^th decade, with mean age being 58.7 years. Among gender, male predominance was seen with male: female ratio of 1.6:1. The above mentioned findings are in sync with the findings of Framingham heart study by Ho KKL et al., which stated that incidence of heart failure is one- third lower in women than men.¹¹

As demonstrated in our study, Breathlessness (90.4%) was the commonest symptom with which HF patients presented, followed by swelling over feet (77.38%), chest pain (45%), reduced exercise tolerance (40.4%). Similar findings were noted in study done by Danny Kumar, et al. which showed dyspnoea as the leading symptom seen in 100 % patients, swelling over feet (45%), chest pain (22%).¹²

Various other studies including ADHERE study and Euro HF survey revealed Dyspnoea as the established symptom of HF. Chest pain was the next prevalent complain in 53.5% of our patients, which identified with study done by Nadine A, et al. which that incidence of Acute Coronary Syndrome in HF with chest pain was 32%.¹³

Most predominant sign of HF observed in our study was Elevated JVP (92.85%) and oedema feet (90.48%). A study by Mark et al. concluded that Raised JVP in HF patients was associated with progression of HF. (14) Physical examination of our patients also revealed Tachycardia in 73.8% of patients, although RDS Watson et al. emphasizes on Tachycardia being insensitive to have any useful predictive value and S3 gallop has specificity of 95% which was observed in 48.8% of our patients.¹⁵

About 46.4% of our patients had BMI of 25-29.9kg/m2and 5.9% pts with BMI more than equal 30.BMI ≥30kg/m2 is associated with more incidence of HFrEF(Heart failure with reduced ejection fraction ), while BMI around 26.9kg/m2 in HFpEF(heart failure with preserved ejection fraction).¹⁶

Prevalent comorbidities contributing to HF in our study were Hypertension (59.5%), Diabetes (50%), Ischemic heart disease (33.3%), Hypothyroidism (9.5%). These findings were somewhat similar to trends in comorbidities of heart failure observed in clinical trials between 2001–2016.which reported hypertension (63%), Ischemic heart disease (33.3%), dyslipidemia (48%), Diabetes (33%) as major comorbidities worsening HF.¹⁷

HFrEF(51%) was commonly linked to comorbid illness as compared to HFpEF(27%).Hypertension and Atrial fibrillation were most prevalent in HFrEF whereas prevalence of Coronary artery disease was highest in Acute HF and lowest in HFrEF.¹⁸

Arrythmias, especially Atrial fibrillation predisposes and worsens HF which was seen in 23.8% of our patients.

Abnormal ECG was recorded in maximum patients in our study with bundle branch block in 22.5%, while Ischemic changes were noted in 57.14% and chamber enlargement was revealed in more than half of the patients. If the baseline ECG is abnormal, it is associated with poor prognosis in patients with HFpEF. Predominant abnormalities like bundle block branch is known to predict hospitalization of HF patients and Atrial fibrillation predicted death.¹⁹

2D echocardiography plays a fundamental role for evaluation of systolic, diastolic dysfunction and myocardial contractile reserve. Worsening prognosis is seen in HF patients with weak (LV systolic dysfunction), big, stiff (LV diastolic dysfunction), noisy (mitral regurgitation) and wet (pulmonary oedema).²⁰

LV systolic dysfunction was seen in 34.52% of the patients in line with other studies. Heart failure with reduced ejection fraction was seen in 65.48%patients and Heart failure with preserved ejection fraction was seen in 25%.2/3 of the patients had pulmonary hypertension and about half of the patients had mitral regurgitation.

Coronary Artery disease, Cardiomyopathy, Rheumatic heart disease were the common etiological factors observed in our study with 32.14%, 23.80%, 21.42% respectively. In report by Vakil in 1949, primary aetiology was hypertension-coronary,³¹ RHD(29%) and syphilis(12%), pulmonary(9%) in 1281 patients admitted with heart failure²¹ HFpEF is associated with high prevalence of comorbidities like hypertension, diabetes , chronic pulmonary disease while Coronary Artery disease is highly prevalent in patients with HFrEF , especially in males and elderly patients.²⁶These similar findings were noted in our study.

Due to changing scenarios imposed due to burden of cardiovascular risk factors and presence of pre- transitional diseases like RHD, Peri carditis, the prevalence of HF is on the rise.²² The risk of HF in the patients of Rheumatic heart disease remains obscure due to insufficient evidence on the secondary prevention of valvular disease in RHD. ²³

This comprehensive clinical profile of patients concluded Dyspnoea as the commonest symptom. Hypertension, diabetes, Ischemic heart disease were the prominent risk factors. Coronary Artery disease, Cardiomyopathy and Rheumatic heart disease were leading etiological diagnosis in our study. Due to changing scenarios and increasing prevalence of cardiovascular risk factors Coronary Artery disease is found to be the leading causes of HF while Rheumatic heart disease as a etiology of HF is showing decline as compared to previous trends.

Due to financial constraints NT-proBNP as a biomarker of HF,could not be done in our patients for diagnosis so clinical features along with ECG, Xray chest and 2D Echo findings were used in evaluating them.

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