Heart Failure in Croatia

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    DOI

    https://doi.org/10.15836/ccar.2014.539

    Full Text

    Heart failure, sometimes called acute decompensated heart failure, is a clinical syndrome that happens as a result of damage to the structure and function of the heart, which leads to a lack of oxygen in the tissue that manifests with typical symptoms (shortness of breath, swollen ankels, fatigue) and clinical signs (tachycardia, gallop rhythm, pulmonary congestion, increased venous pressure, etc.). Insufficient heart function results in weakened systolic and/or diastolic function of the left and/or right ventricle. There are many etiological factors behind heart failure (HF). Most common are myocardial diseases caused by coronary heart disease, accounting for 70% of all cases, followed by the consequences of hypertensive disease and a large group of cardiomyopathies, which can be hereditary (dilatative, hypertrophic, restrictive, spongiform, and arrhythmogenic right ventricular cardiomyopathy) or acquired (various forms of myocarditis, endocrine and infiltrative diseases). Heart valve diseases are also an important cause of HF. According to statistical data, 1-2% of the adult European population suffers from HF; the estimated prevalence in Europe is 3/1000, with a prevalence of >10% in persons older than 70. (1) According to these estimates, 43000 to 80000 people suffer from chronic HF in Croatia, and the incidence in people above the age of 65 grows to 10/1000 per year. In Europe as a whole, the number of patients with HF is about 10 million. Most HF is diagnosed in its chronic form, whereas episodes of acute HF are usually superimposed on the disease progression and are a common cause of hospitalization. Acute HF can be triggered by a deterioration of volume status balance or by disease progression. Today, the most common cause of acute HF is acute coronary syndrome, followed by arrhythmias, heart valve disease, and inflammatory heart diseases. According to the ALARM-HF study, hospital mortality due to acute HF was as high as 11% despite the application of modern diagnostic and treatment. (2) Cardiovascular diseases are the leading cause of morbidity and death in Croatia (in 2012 the mortality was 48.3%, and 48.1% in 2013), despite the fact that mortality has trended downward since 2003 and reached levels below 50% in 2009. (3) Circulatory system diseases are still the leading cause of death in Croatia (24.232 people died in 2013, and a ratio of 569.4/100 000, according to the Croatian Institute of Public Health). Cardiovascular disease is the dominant cause of morbidity and mortality in Croatia (the mortality percentage was 48.3% in 2012 and 48.1% in 2013), despite a significant trend of reduced mortality that started in 2003, with mortality reaching less than 50% in 2009. (3) Circulatory system diseases are still the primary cause of death in Croatia (24.232 people died in 2013, at a ratio of 569.4/100 000 inhabitants, according to data by the Croatian National Institute of Public Health). Tumors are the second most common cause of death (329.2/100 000). Cardiovascular disease is also a leading cause of hospitalization, with HF playing a significant role with a hospitalization rate of 117.5/100 000 (in 2013 5034 patients were hospitalized due to HF, 45.2% men and 54.8% women). Despite these high numbers, hospitalization due to HF is trending downward. The average duration of treatment for HF in Croatia is 11.4 days. (4) HF alone is a significant cause of morbidity and mortality and the 7th most common cause of death in Croatia: in 2013, 1341 people died of HF. Out of these, 63% were women, most likely because there are more women among the elderly. HF still has high rates of five-year mortality, with the likelihood increasing with the age of the patient. In patients above 65 as many as 94.8% died of HF, and 85% of those above 75 years of age. (4) Over the last 15 years, a HF-related mortality has trended down by about 60%, since 3306 deaths were registered in 1998, and only 1341 in 2013. This trend can be attributed to improved treatment of HF and other cardiovascular diseases, as well as earlier diagnosis. Since 2005, the Croatian Register of Heart Failure patients has collected data on patients with HF, which are available on-line from the Croatian Cardiac Society. (5) Before 1990, 60-70% of patients with HF died within 5 years of diagnosis, and repeated hospitalization due to worsening clinical symptoms was common, which placed a great burden on the health systems of many European countries. With the advent of modern therapeutic methods, a better rate of survival and a relative decrease in hospitalization of 30-50% was achieved, as well as a smaller but significant decrease in mortality. Many countries have noted an increase in the rate of hospitalization due to population being older in general, and an increase of prevalence is expected in countries where the age average is rapidly increasing. (1) HF treatment results vary depending on age group, gender, treatment options, and regional specificity. Pharmacological treatment and survival were better in patients treated by cardiologists and in younger patients as well as those that were men. (6) Treatment of chronic HF with standard medication is still the baseline treatment for most patients, and includes the use of ACE-inhibitors or angiotensin receptor blockers, beta-blockers, aldosterone antagonists, diuretics, and eventually digoxin and ivabradine. According to data from the Register of Heart Failure of the Croatian Cardiac Society, the most common medications used in treatment of HF are the following: diuretics (77%), beta-blockers (61%), ACE-inhibitors (48%), spironolactone (31%), digitalis (30%), and angiotensin receptor antagonists (21%). Beta-blockers significantly reduce the mortality and incidence of sudden cardiac death and improve the symptoms in patients with HF; however, beta-blockers are still not prescribed at an adequate level in many patients (with no developed side-effects). (7) Today, in addition to advances in standard medication therapies, a great deal of effort is being invested into discovering potential risk factors for sudden cardiac arrest in cardiomyopathies, especially in younger patients. Sudden cardiac arrest commonly happens in patients with mild existing symptoms, but can also happen before any clinical signs can be observed. In hypertrophic cardiomyopathy, the incidence of sudden cardiac death has decreased by 1% after 2010, but the prevalence of this condition is still very high at 1/500 (which would mean that 8874 persons are suffering from hypertrophic cardiomyopathy in Croatia). (8) Sudden cardiac arrest is associated with physical exertions in young athletes with hypertrophic cardiomyopathy, and appears in 0.06/100 000 cases per year (based on data from the last 27 years). In young athletes with some other form of heart disease it appears in 0.19/100 000 cases per year, and in as many as 0.71/100 000 cases in male athletes older than 15. (9) Cardioverter defibrillator implants have significantly reduced mortality from malign arrhythmias, but the mortality due to cardiomyopathy is still unacceptably high despite the introduction of advanced therapeutic methods such as cardiac resynchronization therapy (CRT), heart transplantation, and implanting ventricular assist devices (VAD). Despite a large number of available centers in Croatia (17 for pacemaker implants, 12 for AICD, 10 for CRT, and 3 centers undertaking electrophysiological studies and catheter ablations) and highly-educated personnel, the total number of implants is still low due to limited funds, adversely affecting the implementation of clinical practice guidelines in Croatia. In 2013, 2418 pacemakers, 81 CTS, and 156 AICD were implanted in Croatia. (10) Cardiac resynchronization therapy has been available worldwide since 2001 when the first cardiac resynchronization device was implanted. This extremely successful treatment for terminal HF is used in Croatia as well; 87 CRT devices were implanted in 2013, which makes for a modest 20 implants per million, far below the European Union average (140 CRT devices per million inhabitants). Since it became a member of the Eurotransplant organization (2008) and developed an desirable organizational model for organ transplants, Croatia has had one of the highest donor rates in Europe. In spite of that fact, there is still lack of donors and VADs have seen increased use and development. The first mechanical heart pump as a pre-transplant measure was implanted in 2008 at the University Hospital Centre Zagreb, and the program has grown since then. (11) Between September 2008 and October 2014, a total of 177 circulatory support system procedures were performed involving mechanical assistance to the heart, of which 165 in adults (a total of 135 patients) and 12 in children. Various pump models were used, including short-term extracorporeal veno-arterial membrane oxygenation (ECMO), short- to mid-term devices as a bridge to decision, transplantation, destination therapy or recovery, and in 2010 the first long-term VAD was implanted as a left ventricular assist device (LVAD). Since then, the HeartMate II pump has been implanted in 27 patients, and the most up-to-date HeartWare model in 5. On October 2, 2014, a total artificial heart was implanted for the first time in Croatia in UHC Zagreb; the patient is still in follow-up. In the US, such a procedure was performed for the first time in 2010. Today, two centers in Croatia perform heart transplants. The first heart transplantation in Croatia (and in Eastern Europe) was performed in 1988 in UHC Zagreb, where the treatment program for terminal HF has developed significantly, with 252 performed in the meantime. Most transplant patients suffered from ischemic cardiomyopathy (44.8%). The second most common indication was dilatative, idiopathic, or postmyocardial cardiomyopathy (31.7%). The third most common category of transplanted patients were performed on consisted of patients with other types of cardiomyopathies such as spongiform, hypertrophic, idiopathic restrictive cardiomyopathy, arrhythmogenic right ventricular dysplasia, and infiltrative diseases such as hemochromatosis and sarcoidosis. Only 5.6% of patients received a transplant due to secondary cardiomyopathy resulting from valve disease, and only 4.6% due to intractable coronary disease or as a consequence of acute myocardial infarction, according to the data from the Registry of Heart Transplant Patient in UHC Zagreb. Heart transplant programs have also been developing since 1995 in the Dubrava Clinical Hospital, with 121 performed to date. A number of new studies in the areas of pharmacological treatment, improvement in treatment possibilities of terminal HF, risk prevention for coronary heart disease, as well as education, better funding, and treatment availability form the basis for future advances in reducing morbidity and mortality from heart failure.

    Literature

    1. McMurray JJ, Adamopoulos A, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33(14):1787–847. https://doi.org/10.1093/eurheartj/ehs104
    2. Mebazaa A, Parissis J, Porcher R, et al. Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods. Intensive Care Med. 2011;37(2):290–301. https://doi.org/10.1007/s00134-010-2073-4
    3. Ivanuša M. Novosti u epidemiologiji srčanožilnih bolesti i zbrinjavanju arterijske hipertenzije. Medicus. 2014;23(1):53-62. http://hrcak.srce.hr/file/180921
    4. Ivanuša M, Kralj V. Epidemiologija zatajivanja srca u Republici Hrvatskoj. Medix. 2014;20(112):76-82. http://kardio.helix.biz.hr/images/stories/medix/m112/medix_112_76-82.pdf
    5. Polić S, Glavaš D. Some specific features of identification and treatment of heart failure in the Republic of Croatia. Cardiol Croat. 2011;6(11):286–8.
    6. Clark AL. Almanac 2011: heart failure. The national society journals present selected research that has driven recent advances in clinical cardiology. Cardiol Croat. 2011;6(11):289–301.
    7. Gheorghiade M. S. Colucci W, Swedberg K. Beta-blockers in chronic heart failure. Circulation. 2003;107(12):1570–5. https://doi.org/10.1161/01.CIR.0000065187.80707.18
    8. Elliott PM, Anastasakis A, Borger MA, et al. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. The Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(39):2733–79. https://doi.org/10.1093/eurheartj/ehu284
    9. Duraković Z, Duraković MM, Skavić J. Hypertrophic cardiomyopathy and sudden cardiac death due to physical exercise in Croatia in a 27-year period. Coll Antropol. 2011;35(4):1051–4. https://pubmed.ncbi.nlm.nih.gov/22397237/
    10. Kuck KH, Hindricks G, Padeletti L, Raatikainen P, Arnar DO. The EHRA White Book 2014: the current status of cardiac electrophysiology in ESC Member countries. http://www.escardio.org/communities/EHRA/publications/Documents/ehra-white-book-2014.pdf
    11. Bušić M. Darivanje i presađivanje organa „Hrvatski model“. Medix. 2011;17(92/93):144-8. http://hrcak.srce.hr/file/127788
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    Heart Failure in Croatia

    Editorial
    Issue11-12
    Published
    Pages539-542
    PDF via DOIhttps://doi.org/10.15836/ccar.2014.539

    Authors

    Jana Ljubas MačekORCIDUniversity of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia

    Full Text

    Heart failure, sometimes called acute decompensated heart failure, is a clinical syndrome that happens as a result of damage to the structure and function of the heart, which leads to a lack of oxygen in the tissue that manifests with typical symptoms (shortness of breath, swollen ankels, fatigue) and clinical signs (tachycardia, gallop rhythm, pulmonary congestion, increased venous pressure, etc.). Insufficient heart function results in weakened systolic and/or diastolic function of the left and/or right ventricle.

    There are many etiological factors behind heart failure (HF). Most common are myocardial diseases caused by coronary heart disease, accounting for 70% of all cases, followed by the consequences of hypertensive disease and a large group of cardiomyopathies, which can be hereditary (dilatative, hypertrophic, restrictive, spongiform, and arrhythmogenic right ventricular cardiomyopathy) or acquired (various forms of myocarditis, endocrine and infiltrative diseases). Heart valve diseases are also an important cause of HF.

    According to statistical data, 1-2% of the adult European population suffers from HF; the estimated prevalence in Europe is 3/1000, with a prevalence of >10% in persons older than 70. (1) According to these estimates, 43000 to 80000 people suffer from chronic HF in Croatia, and the incidence in people above the age of 65 grows to 10/1000 per year. In Europe as a whole, the number of patients with HF is about 10 million.

    Most HF is diagnosed in its chronic form, whereas episodes of acute HF are usually superimposed on the disease progression and are a common cause of hospitalization. Acute HF can be triggered by a deterioration of volume status balance or by disease progression. Today, the most common cause of acute HF is acute coronary syndrome, followed by arrhythmias, heart valve disease, and inflammatory heart diseases. According to the ALARM-HF study, hospital mortality due to acute HF was as high as 11% despite the application of modern diagnostic and treatment. (2)

    Cardiovascular diseases are the leading cause of morbidity and death in Croatia (in 2012 the mortality was 48.3%, and 48.1% in 2013), despite the fact that mortality has trended downward since 2003 and reached levels below 50% in 2009. (3) Circulatory system diseases are still the leading cause of death in Croatia (24.232 people died in 2013, and a ratio of 569.4/100 000, according to the Croatian Institute of Public Health).

    Cardiovascular disease is the dominant cause of morbidity and mortality in Croatia (the mortality percentage was 48.3% in 2012 and 48.1% in 2013), despite a significant trend of reduced mortality that started in 2003, with mortality reaching less than 50% in 2009. (3) Circulatory system diseases are still the primary cause of death in Croatia (24.232 people died in 2013, at a ratio of 569.4/100 000 inhabitants, according to data by the Croatian National Institute of Public Health). Tumors are the second most common cause of death (329.2/100 000). Cardiovascular disease is also a leading cause of hospitalization, with HF playing a significant role with a hospitalization rate of 117.5/100 000 (in 2013 5034 patients were hospitalized due to HF, 45.2% men and 54.8% women). Despite these high numbers, hospitalization due to HF is trending downward. The average duration of treatment for HF in Croatia is 11.4 days. (4) HF alone is a significant cause of morbidity and mortality and the 7th most common cause of death in Croatia: in 2013, 1341 people died of HF. Out of these, 63% were women, most likely because there are more women among the elderly. HF still has high rates of five-year mortality, with the likelihood increasing with the age of the patient. In patients above 65 as many as 94.8% died of HF, and 85% of those above 75 years of age. (4) Over the last 15 years, a HF-related mortality has trended down by about 60%, since 3306 deaths were registered in 1998, and only 1341 in 2013. This trend can be attributed to improved treatment of HF and other cardiovascular diseases, as well as earlier diagnosis.

    Since 2005, the Croatian Register of Heart Failure patients has collected data on patients with HF, which are available on-line from the Croatian Cardiac Society. (5)

    Before 1990, 60-70% of patients with HF died within 5 years of diagnosis, and repeated hospitalization due to worsening clinical symptoms was common, which placed a great burden on the health systems of many European countries. With the advent of modern therapeutic methods, a better rate of survival and a relative decrease in hospitalization of 30-50% was achieved, as well as a smaller but significant decrease in mortality. Many countries have noted an increase in the rate of hospitalization due to population being older in general, and an increase of prevalence is expected in countries where the age average is rapidly increasing. (1)

    HF treatment results vary depending on age group, gender, treatment options, and regional specificity. Pharmacological treatment and survival were better in patients treated by cardiologists and in younger patients as well as those that were men. (6) Treatment of chronic HF with standard medication is still the baseline treatment for most patients, and includes the use of ACE-inhibitors or angiotensin receptor blockers, beta-blockers, aldosterone antagonists, diuretics, and eventually digoxin and ivabradine. According to data from the Register of Heart Failure of the Croatian Cardiac Society, the most common medications used in treatment of HF are the following: diuretics (77%), beta-blockers (61%), ACE-inhibitors (48%), spironolactone (31%), digitalis (30%), and angiotensin receptor antagonists (21%). Beta-blockers significantly reduce the mortality and incidence of sudden cardiac death and improve the symptoms in patients with HF; however, beta-blockers are still not prescribed at an adequate level in many patients (with no developed side-effects). (7)

    Today, in addition to advances in standard medication therapies, a great deal of effort is being invested into discovering potential risk factors for sudden cardiac arrest in cardiomyopathies, especially in younger patients. Sudden cardiac arrest commonly happens in patients with mild existing symptoms, but can also happen before any clinical signs can be observed. In hypertrophic cardiomyopathy, the incidence of sudden cardiac death has decreased by 1% after 2010, but the prevalence of this condition is still very high at 1/500 (which would mean that 8874 persons are suffering from hypertrophic cardiomyopathy in Croatia). (8) Sudden cardiac arrest is associated with physical exertions in young athletes with hypertrophic cardiomyopathy, and appears in 0.06/100 000 cases per year (based on data from the last 27 years). In young athletes with some other form of heart disease it appears in 0.19/100 000 cases per year, and in as many as 0.71/100 000 cases in male athletes older than 15. (9) Cardioverter defibrillator implants have significantly reduced mortality from malign arrhythmias, but the mortality due to cardiomyopathy is still unacceptably high despite the introduction of advanced therapeutic methods such as cardiac resynchronization therapy (CRT), heart transplantation, and implanting ventricular assist devices (VAD). Despite a large number of available centers in Croatia (17 for pacemaker implants, 12 for AICD, 10 for CRT, and 3 centers undertaking electrophysiological studies and catheter ablations) and highly-educated personnel, the total number of implants is still low due to limited funds, adversely affecting the implementation of clinical practice guidelines in Croatia. In 2013, 2418 pacemakers, 81 CTS, and 156 AICD were implanted in Croatia. (10)

    Cardiac resynchronization therapy has been available worldwide since 2001 when the first cardiac resynchronization device was implanted. This extremely successful treatment for terminal HF is used in Croatia as well; 87 CRT devices were implanted in 2013, which makes for a modest 20 implants per million, far below the European Union average (140 CRT devices per million inhabitants).

    Since it became a member of the Eurotransplant organization (2008) and developed an desirable organizational model for organ transplants, Croatia has had one of the highest donor rates in Europe. In spite of that fact, there is still lack of donors and VADs have seen increased use and development. The first mechanical heart pump as a pre-transplant measure was implanted in 2008 at the University Hospital Centre Zagreb, and the program has grown since then. (11) Between September 2008 and October 2014, a total of 177 circulatory support system procedures were performed involving mechanical assistance to the heart, of which 165 in adults (a total of 135 patients) and 12 in children. Various pump models were used, including short-term extracorporeal veno-arterial membrane oxygenation (ECMO), short- to mid-term devices as a bridge to decision, transplantation, destination therapy or recovery, and in 2010 the first long-term VAD was implanted as a left ventricular assist device (LVAD). Since then, the HeartMate II pump has been implanted in 27 patients, and the most up-to-date HeartWare model in 5. On October 2, 2014, a total artificial heart was implanted for the first time in Croatia in UHC Zagreb; the patient is still in follow-up. In the US, such a procedure was performed for the first time in 2010.

    Today, two centers in Croatia perform heart transplants. The first heart transplantation in Croatia (and in Eastern Europe) was performed in 1988 in UHC Zagreb, where the treatment program for terminal HF has developed significantly, with 252 performed in the meantime. Most transplant patients suffered from ischemic cardiomyopathy (44.8%). The second most common indication was dilatative, idiopathic, or postmyocardial cardiomyopathy (31.7%). The third most common category of transplanted patients were performed on consisted of patients with other types of cardiomyopathies such as spongiform, hypertrophic, idiopathic restrictive cardiomyopathy, arrhythmogenic right ventricular dysplasia, and infiltrative diseases such as hemochromatosis and sarcoidosis. Only 5.6% of patients received a transplant due to secondary cardiomyopathy resulting from valve disease, and only 4.6% due to intractable coronary disease or as a consequence of acute myocardial infarction, according to the data from the Registry of Heart Transplant Patient in UHC Zagreb. Heart transplant programs have also been developing since 1995 in the Dubrava Clinical Hospital, with 121 performed to date.

    A number of new studies in the areas of pharmacological treatment, improvement in treatment possibilities of terminal HF, risk prevention for coronary heart disease, as well as education, better funding, and treatment availability form the basis for future advances in reducing morbidity and mortality from heart failure.

    Literature

    1. 1.
      McMurray JJ, Adamopoulos A, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33(14):1787–847.DOI
    2. 2.
      Mebazaa A, Parissis J, Porcher R, et al. Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods. Intensive Care Med. 2011;37(2):290–301.DOI
    3. 3.
      Ivanuša M. Novosti u epidemiologiji srčanožilnih bolesti i zbrinjavanju arterijske hipertenzije. Medicus. 2014;23(1):53-62.Link
    4. 4.
      Ivanuša M, Kralj V. Epidemiologija zatajivanja srca u Republici Hrvatskoj. Medix. 2014;20(112):76-82.Link
    5. 5.
      Polić S, Glavaš D. Some specific features of identification and treatment of heart failure in the Republic of Croatia. Cardiol Croat. 2011;6(11):286–8.
    6. 6.
      Clark AL. Almanac 2011: heart failure. The national society journals present selected research that has driven recent advances in clinical cardiology. Cardiol Croat. 2011;6(11):289–301.
    7. 7.
      Gheorghiade M. S. Colucci W, Swedberg K. Beta-blockers in chronic heart failure. Circulation. 2003;107(12):1570–5.DOI
    8. 8.
      Elliott PM, Anastasakis A, Borger MA, et al. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. The Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(39):2733–79.DOI
    9. 9.
      Duraković Z, Duraković MM, Skavić J. Hypertrophic cardiomyopathy and sudden cardiac death due to physical exercise in Croatia in a 27-year period. Coll Antropol. 2011;35(4):1051–4.PubMed
    10. 10.
      Kuck KH, Hindricks G, Padeletti L, Raatikainen P, Arnar DO. The EHRA White Book 2014: the current status of cardiac electrophysiology in ESC Member countries.Link
    11. 11.
      Bušić M. Darivanje i presađivanje organa „Hrvatski model“. Medix. 2011;17(92/93):144-8.Link