What Are the Differences in HF Phenotype, Management and Outcomes in Asia?

Until recently, Asian patients were underrepresented in heart failure trials. A state-of-the-art paper published May 30 in JACC: Heart Failure examines the importance of including this population in heart failure studies and discusses how to improve future trials.

According to Robert J. Mentz, MD, and colleagues, while the prevalence of heart failure is lower in Asia than in the West, the large population in Asia means that there is a higher absolute burden of disease in these countries, with an estimated >20 million people with heart failure in Asia. Additionally, the at-risk population is increasing faster in Asia than other parts of the world due to an aging population and increases in coronary artery disease, tobacco use, diabetes and obesity. The median age of heart failure patients is lower in Asia than the U.S. and Europe, and also varies greatly between Asian countries. Compared with other regions where >50 percent of the population has ischemic heart failure, there is a lower prevalence in Asia. However, recent data suggest that ischemic heart failure is increasing in this region.

When it comes to heart failure management, intravenous (IV) diuretic therapy use is similar between Asian and Western populations, but IV inotrope use tends to be higher in Asia than in the U.S., the authors explain. For guideline-directed medical therapy, angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker was found to be similar, while the use of mineralocorticoid receptor antagonists was higher in Asia, and use of beta-blockers lower. Factors associated with underutilization of medications in Asia include rural residency, less-specialized health care providers, and fewer comorbid conditions. Trials have also found lower used of implantable cardioverter-defibrillators in Asia-Pacific than in other regions. In addition, heart failure mortality rates in Asia-Pacific were higher than in other regions, but hospitalization rates were lower.

When examining the representation of Asian populations in heart failure studies published between January 1994 and December 2015, the authors found that past large-scale outcome trials of heart failure with reduced ejection fraction did not routinely enroll Asian patients. While none of the landmark ACE inhibitor trials included patients from Asia, most trials examining mineralocorticoid receptor antagonists, ivabradine and LCZ-696 had Asian patient representation. Further, relatively few Asia-specific heart failure studies have been conducted.

Looking forward to future, Mentz and colleagues propose that early-phase pharmacokinetic and dose-ranging studies are needed in Asian populations. They also propose a developmental strategy in which trials are conducted in Asian countries simultaneously with efforts in other regions, rather than the historical model where Asian countries were included only after initial efforts in Europe and/or North America. "[Heart failure] trial development and conduct must acknowledge that Asia covers a diverse group of nations, each with unique patient, sociocultural and medical practice backgrounds that may affect trial design," the authors write.

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