The document summarizes differences in characteristics and outcomes between Western and Korean patients with acute heart failure based on an analysis of registry data. It finds that compared to Western registries, Korean patients tended to be relatively younger (mean age 69 years old), with a higher rate of first-time heart failure presentations (52.1%) and lower rates of hypertension and coronary artery disease as the cause of heart failure. Korean patients also presented with lower blood pressures on admission. In-hospital mortality rates were similar at around 5%, though Korean patients had lower 90-day mortality. Factors like creatinine levels, blood pressure, BMI and sodium levels similarly predicted outcomes. Rates of beta blocker use at discharge were also lower for Korean

1. Byung Su Yoo, MD., PhD.
Division of Cardiology, Wonju College of Medicine,
Yonsei University, South Korea
Differences in clinical characteristics
and its effect for outcomes
between western and Korean patients
with ADHF :
ACC 2015: Advances in the care of patients with heart failure

2. Outlines : What’s difference ?
 Background
 Comparisons of Acute Heart Failure Registry
 Outcomes and other clinical analysis
 Summary

4. : the prevalence of heart failure has been rapidly increasing in worldwide and its
influence on mortality, morbidity and the cost of health care is growing fast.
Heart failure is epidemic in worldwide
Heart
Failure ↑
Aging
Society
Advanced
medical &
surgical
care
IHD, DM
etc.
Background

5. Comparisons of HF prevalence
Estimated Prevalence of heart failure by age group
(National Health Insurance Service’s sample cohort
database, 2010, Korea).
Prevalence of heart failure by sex and age (National
Health and Nutrition Examination Survey: 2009–
2012). Source: National Center for Health Statistics
and National Heart, Lung, and Blood Institute. USA
0.8
3.8
9.4
0.8
4.7
9.5
0
2
4
6
8
10
40-59 60-79 80+
Prevalence
Age
Men Women
0.2
1.5
6.6
10.6
0.6
1.2
4.8
13.5
0
2
4
6
8
10
12
14
16
20-39 40-59 60-79 80+
PrevalenceofPopulation
Age (Years)
Background

6. Trends of heart failure in Korea
Heart failure is rapidly increasing, especially in old age
2009 y 2010 y 2011 y 2012 y 2013 y
Total 94,421 100,480 109,588 114,393 115,063
Male 32,989 36,334 41,010 42,935 44,330
Female 61,432 64,146 68,578 71,458 70,733
(number of total HF patients)
Total 0-9 YO 10-19 YO 20-29 YO 30-39 YO 40-49 YO 50-59 YO 60-69 YO 70-79YO ≥80 YO
Male 176 3 3 8 25 70 338 462 1,179 2,744
Female 285 3 3 7 22 52 159 506 1,622 3,362
(number of HF patients per 100,000 population)
*In Korea, annually in average, 230 patients/100,000 population visit clinic or hospital due to any causes
**HF patients (≥ 80 YO) visit hospital 14 times frequently compared to general population
National Health Insurance database, 2014, Korea
Background

7. 0.0
0.5
1.0
1.5
2.0
2002 2003 2004 2005 2006 2007 2008 2009 2010
Prevalence(%)
Year
Men
Women
0.75%
1.06%
1990 2000 2010 2020 2030 2040 2050
Aging is global issue
Trends in aged population according to nation
2012. UN
Prevalence of heart failure by sex in 2002-
2010 (Source : National Health Insurance
Service’s sample cohort database)
0%
10%
20%
30%
40%
USA
Italy
India
China
Japan
Korea
Background

8. • Average age: 55-65 years vs. 65~70
• Women: 20-25% vs. 50%
• Ischemia etiology (CAD): ≈ 50% vs. ≈ 50%
• Renal insufficiency: usually excluded
(mean Cr 1.1-1.3) vs. 30%
• Preserved LV systolic function: usually excluded (LVEF usually <35-
40) vs. ≈ 50%
• Atrial fibrillation: < 25% vs. >30%
Characteristics of ADHF Patients
Enrolled in Clinical Trials vs. Registry
We need a registry data to evaluate characteristics, clinical profiles
and clinical outcomes of ADHF.
Comparisons of Acute Heart Failure Registry

9. Korean Acute Heart Failure Registries
Korean HF (KorHF)
Registry
Korean Acute HF
(KorAHF) Registry
Study duration 2004. 6 – 2009. 4 2011. 3 – 2014. 2
Sites 24 hospitals 10 hospitals
Patients 3,200 5,600
Sponsor
Korean Society
of Cardiology
Korea National
Institute of Health
(KNIH)
F/U duration
1.7 year (0.1-4.9
years)
> 3 years, expected
F/U rate 81% 95%
Publications 11 papers 1 design paper
In-hospital
mortality*
6.4% 6.1 %
Comparisons of Acute Heart Failure Registry
Eur J Heart Fail. 2014 Jun;16(6):700-8
* : including transplantation

10. KorAHF ATTEND ADHERE OPTIMIZE-HF EHFSII
Country Korea Japan USA USA Europe
Year 2011.3~2014.2 2007.5-(2012.9) 2001.9-2004.1 2003.3-2004.12 2004.10-2005.8
Sample size 5660 1110 (2009.6) 105388 48612/5791(330) 3580/2981
Follow-up duration >3.0 years 180 days N/A 60,90 days 3-, 12-month
Demographics
Age 68(15) 73 (14) 72 (14) 73 (14) 70 (13)
Male 53.3% 59 48 48 61
Comorbidities
Hypertension 59.2% 71 75 71 63
DM 35.6% 34 44 42 33
Stroke 15.2% 12 17 16 13
AF 27.5% 40 31 31 39
Cause of HF
Ischemia 37% 33 57 60 54
Hypertensive 3.9% 18 N/A 23 11
Summary of baseline data
Comparisons of Acute Heart Failure Registry
Eur J Heart Fail. 2014 Jun;16(6):700-8

11. KorAHF ATTEND ADHERE OPTIMIZE-HF EHFSII
Country Korea Japan USA USA Europe
Year 2011.3~2014.2 2007.5-(2012.9) 2001.9-2004.1 2003.3-2004.12 2004.10-2005.8
Sample size 5660 1110 (2009.6) 105388 48612/5791(330) 3580/2981
Follow-up duration >3.0 years 180 days N/A 60,90 days 3-, 12-month
Clinical status on admission
De novo HF 52.1% 63 24 13 37
Creatinine 1.48 (1.46) 1.4 (1.5) 1.8 (1.6) 1.8 (1.8) N/A
Heart rate 92.7 (27.1) 99 (30) N/A 87 (22) median 95
Systolci BP 131.1 (30.3) 147 (38) 144 (33) 143 (33) median 135
LVEF ≤40% 51.7% 57 47 48.8 46
Management
IV diuretics 74.9% 80 87 N/A 84
IV inotropes 31.3% 21 8 7 <29.8
IV vasodilators 41.0% 46 7 14 38
Outcome
Length of stay (median) 9.0 days 21 4.3 6.4 (mean) 9
in-hospital mortality 4.8% 7.7 3.8 3.8 6.7
Eur J Heart Fail. 2014 Jun;16(6):700-8
Summary of baseline data
Comparisons of Acute Heart Failure Registry

12. Total In-hospital mortality 4.76%
in-hospital mortality: 6.14% Urgent heart transplantation 1.38%
Hospital stay (median) 9 days
Medical cost 9,164,200 Korean won ( 7,968 US $)
Outcomes
After discharge,
90-day mortality: 4.2%
HF readmission rate: 12.9%
ADHERE
Outcomes and other clinical analysis
Circ Heart Fail. 2011 : from the Biomarkers in Acute Heart Failure (BACH)

13. Risk factors for in-hospital death
ADHERE, JAMA 2005 OPTIMIZE HF , JAMA 2006
LESS THAN GREATER THAN
2.68%
n=25,122
8.98%
n=7202
SYS BP 115
n=24,933
SYS BP 115
n=7150
6.41%
n=5102
15.28%
n=2048
2.14%
n=20,834
5.49%
n=4099
Cr 2.75
2045
12.42%
n=1425
21.94%
n=620
BUN 43
n=33,324
Highest to Lowest Risk Cohort
OR 12.9 (95% CI 10.4-15.9)
2.6
5.5
7.5
16.3
0
2
4
6
8
10
12
14
16
18
SBP > 100mm Hg
SCr < 2.0 mg/dL
(n=34,909)
SBP > 100mm Hg
SCr ≥ 2.0 mg/dL
(n=9780)
SBP ≤100mm Hg
SCr < 2.0 mg/dL
(n=2680)
SBP ≤100mm Hg
SCr ≥ 2.0 mg/dL
(n=1243)
In-HospitalMortality(%)
Outcomes and other clinical analysis

14. Predictors of in-hospital mortality
Multivariate analysis from KorHF KorAHF registry
Variables Adjusted OR(95% CI) p-value
Lung congestion 1.67 (1.06,2.64) 0.0274
Chronic renal disease in past medical Hx 2.01 (1.34,3.02) 0.0008
Newly detected DM at admission 2.23 (1.15,4.32) 0.0177
Newly detected renal failure
at admission (Cr > 2.0)
4.57 (3.02,6.92) <.0001
Q wave (ECG) 1.97 (1.35,2.87) 0.0005
RBBB (ECG) 1.95 (1.26,3.04) 0.0030
*Other aggravating factors 2.22 (1.44,3.43) 0.0003
BMI < 25kg/m2 2.09 (1.37,3.19) 0.0006
SBP < 100 mmHg 3.41 (2.41,4.82) <.0001
WBC ≥ 10,000 1.80 (1.30,2.50) 0.0004
Sodium < 135 mmEq/L 1.98 (1.42,2.74) <.0001
LVEF < 40% 1.82 (1.29,2.57) 0.0006
C-statistics 0.806
Variables Adjusted OR (95% CI) p-value
Lung congestion 2.38 (1.17,4.82) 0.016
SBP < 100 mmHg 4.45 (2.69,7.37) <0.001
ECG (Q wave) 1.98 (1.07,3.65) 0.029
ECG (RBBB) 2.68 (1.47,4.89) 0.001
Lab (WBC ≥10000/mm3
) 1.82 (1.12,2.96) 0.016
Lab (Sodium <135mmol/L) 2.06 (1.27,3.34) 0.003
Lab (Cr ≥2.0mg/dL) 2.83 (1.66,4.81) <0.001
LVEF <40% 1.88 (1.14,3.1) 0.014
Aggravating factor_others 3.17 (1.71,5.86) <0.001
Etiology of heart failure_valvular heart disease 2.12 (1.16,3.89) 0.015
C-statistics 0.807
Outcomes and other clinical analysis
Eur J Heart Fail. 2014 Jun;16(6):700-8

15. EventfreeSurvival
Hyponatremia
Log Rank P < 0.001
NN
HN
OPTIMIZE, HF Gheorghiade M. Eur Heart J 2007
Yoo BS et al. JKIM 2015
Outcomes and other clinical analysis
in-hopital mortality
in-hopital mortality

16. Baseline sBP in mortality
Heart 2009 95: 56-62 Yoo BS et al. (submitted to JCF)
Outcomes and other clinical analysis

17. Obesity paradox is a global phenomenon
N=6,142 patients from 12 prospective observational cohorts.
Primary outcome: All cause death.
Shah R et al. J Am Coll Cardiol. 2014;63:778-85.
Forest Plot of HR for Association of BMI With All-Cause MortalityAll-Cause Mortality 30 Days and 1 Year
Outcomes and other clinical analysis

18. Obesity paradox in KorAHF ;
similar result
Unpublished data from KorAHF
Adjusted for several factors
Outcomes and other clinical analysis
Shah R et al. J Am Coll Cardiol. 2014;63:778-85.
KorAHFGreat network

19. Quality of Care
Fonarow GC et al. Arch Intern Med 2005;165:1469-1477
Yoo BS, Oh JW, Kang SM, Choi DJ, PLoS ONE : 2014
Youn YJ, Yoo BS, Circ J. 2012 Apr 25;76(5):1151-1158
5.0
6.1
3.1
1.4
0.0
2.0
4.0
6.0
8.0
10.0
Length of Stay
(median)
Mortality
All P<0.0001
Lagging Centers Leading Centers
Outcomes and other clinical analysis

20. Drug adherence in systolic HF
67.6
41.1
58.8
65.7
49.5
44.7
84 83
21
0
10
20
30
40
50
60
70
80
90
100
ACEI/ARB BB AA
KorHF
KorAHF
ADHERE
(%)
Outcomes and other clinical analysis

21. Limitation
• Potential biases of registry data
- Selection bias
- Not consecutive patients
- Different socioeconomic status and health
care system

22. Summary : What’s difference?
1. Background :
– rapidly increasing prevalence of HF (esp. aging)
2. Compared with other registries
– relatively young (mean 69 years old)
– high rate of de novo HF: 52.1%
– low incidence of hypertension and CAD
– low BP at admission
3. Outcomes
– in-hospital mortality (≈5%) with low 90-day mortality rate
– Similar effect of Cr, SBP, BMI and serum sodium level
– low Use of BB at discharge.

23. Thanks to
• KorAHF Registry Investigator
(PI: BS Oh, and investigators)
• Korea Heart Failure Society Members
(Present: MC Cho and members)
• ACC and KSC

24. 15 (Fri) ~ 16 (Sat) April, 2016
Daegu, Korea