Heart Failure in Oman: Current Statistics and Recommendations.

This review aims to explore the status of heart failure (HF) practice and research in Oman. Extensive search of databases (Arab World Research Source, EBSCOhost, Medline, and Google Scholar) yielded eight published literatures in the last two decades in Oman. The escalation of HF among older adults in Oman has been documented across the two decades. Ischemic heart disease continues to dominate as the cause for HF among the Omani population. Recent researchers have highlighted that acute coronary syndrome and noncompliance with medications are factors which precipitate an acute HF. One-year follow-up of HF patients in Oman has estimated their mortality rate at 25%. Our knowledge of HF is very limited by the few published research and data sets. However, the prevalence of HF is increasing, and is expected to dramatically increase with the rise in the Omani population in hypertension and diabetes. More research is needed in the area of HF on the Omani population. Copyright:

INTRODUCTION

Dr. Braunwald was the first to single out heart failure (HF) as an emerging epidemic of the 21st century.[1] Today, there is no doubt that HF has reached epidemic proportions globally.[2] In 2014, there were 26 million HF patients worldwide. The prevalence of HF in North America, Europe, and Australia ranges between 1.3% and 2.2% of the total population.[34] In Asia, it ranges from 1.3% in China to as high as 6.7% in Singapore and in Africa. The average prevalence of HF is around 30%.[34]

Based on the Framingham Heart Study, 10% of HF patients die within 30 days of their diagnosis and as many as 60% of HF patients die within 5 years of the date of their diagnosis.[5] HF treatment developments have improved the mortality rates, however, it still considered high.[67] The wide range of physical and psychological symptoms experienced by HF patients affects the quality of life and increases the risk of hospitalization and death.[8] Furthermore, HF patients have comorbidities such as diabetes mellitus (DM), hypertension (HTN), and other cardiac and noncardiac-related conditions.[9]

The burden of HF is a substantial medical and economic problem globally as well as in Oman. This short review aims to describe the published research on HF in Oman and discuss current statistics available and recommendations.

METHODS

The key search terms included for this literature review were “heart failure or congestive cardiac failure,” “cardiovascular disease,” “ischemic heart disease,” “acute coronary syndrome,” “cardiac surgery,” “Oman,” and “Middle East.” Interdisciplinary databases (Arab World Research Source, EBSCOhost, and Medline) and gray literature sources (Google Scholar) were explored. Peer-reviewed, full-texted research studies and reviews in English language were included if they met the following criteria: (a) the population under empirical analysis were with HF, (b) the study/review included data pertaining to Oman, and (c) the study/review had HF as a variable or outcome. There was no limitation placed on time or defining criteria for HF. Studies/reviews from the Middle East countries from which the data for Oman were not exclusive, and studies/reviews on other cardiovascular diseases or comorbid diseases with no exclusive data for HF, were excluded. The flow diagram [Figure 1] displays the process of literature search, including the reasons for excluding the articles.

Figure 1

The process of literature search

The first level of sifting involved the removal of duplicates by organizing them on a Microsoft Excel spreadsheet. The titles and abstracts of the sifted articles were then screened for relevancy. The full text of the relevant abstract was evaluated by two authors independently for eligibility against the inclusion criteria. The information from the articles which met the inclusion criteria was organized using a review matrix, which included author, year, purpose, geographical, methodological, and content-specific variables.

RESULTS

Tables 1 and 2 summarize the methodological and content-related variables recorded from the extracted literature. Studies included in this review were published over the past two decades (2001–2018). They included prospective observational and retrospective studies, a few focused on statistical associations between HF patients and their length of inpatient hospital stay,[10] outcomes at discharge, and prognosis.[11] The design adopted in four of the selected studies was a prospective survey. Two studies were drafted on a retrospective review of strategic information.

Table 1

Methodological variables

Author, year	Design	Aim	Location	Population (n)	Time frame
Agarwal, 2001	Prospective	To determine the prevalence and etiologies of symptomatic HF in an indigenous Arab population over a 3-year period	Al-Dakhiliyah region of Oman	1164 heart failure patients aged above 13 years, admitted to secondary care hospitals	1992-1994
Panduranga, 2010	Prospective	To assess the prevalence, risk factors, presenting features, and inhospital outcomes of ACS patients ≤40 years of age from Oman	Oman	579 consecutive ACS inpatients from Oman	2006-2007
Al-Rasadi, 2011	Retrospective	To evaluate inhospital outcomes of ACS patients with MetS in Oman	Oman	1392 consecutive inpatients admitted with a diagnosis of ACS to 15 tertiary care hospitals	2006-2007
Al-Shamiri, 2013	Literature review	To review the etiology, diagnosis, treatment, and prognosis of HF patients in the Middle East	Middle East	.	.
ALZadjali, 2014	Literature review based on MoH annual health report in 2010	To describe the current situation of HF in Oman	Oman	15,671 inpatients admitted to MoH hospitals	.
Almashrafi, 2016	Observational retrospective	To identify factors influencing prolonged postoperative LOS following cardiac surgery and to devise a predictive model for prolonged LOS in the CICU	Oman	600 patients who underwent cardiac surgery at a major referral hospital in Oman	2009-2013
Pandurnga, 2016	Prospective	To describe the demographics, clinical characteristics, management, and outcomes of patients in Oman with AHF	Oman	988 consecutive patients admitted to 12 hospitals	2012
Alharrasi M., 2018	Prospective	To examine self-care and HRQL in Oman	Oman	105 patients with HF, outpatient clinic in a tertiary care institution in Northern Oman	2016-2018

MetS: Metabolic syndrome, LOS: Length of stay, CICU: Cardiac intensive care unit, HF: Heart failure, AHF: Acute HF, HRQL: Health-related quality of life, MoH: Ministry of Health, ACS: Acute coronary syndrome

Table 2

Content-specific variables

Author, year	HF defining criteria	Prevalence/incidence	Dominant age, mean±SD or n (%)	Dominant gender	Etiology	Precipitating factors	EF	Comorbidities	Treatment	Outcome
Agarwal, 2001	Left ventricular ejection fraction <50% and/or diastolic dysfunction	5.17/1000 population	55 and 64 (37.3%) years	Male 61.3%	Ischemic heart disease 51.7% Hypertensive heart disease 24.9% Idiopathic dilated cardiomyopathy 8.3%	.	Diastolic dysfunction (19.9%)	.	.	.
Panduranga, 2010	.	.	Patients aged 40 (27%) years and more experienced heart failure	.	.	Delayed presentation with STEMI	.	Hyperlipidemia Diabetes Hypertension	.	Inhospital mortality was 4.3% among patients aged ≥40 years
Al-Rasadi, 2011	.	.	.	.	.	.	.	High BP (SBP ≥130 mm Hg and DBP ≥85 mm Hg High blood sugar FBS ≥5.6 mmol/L	.	MetS was associated with increased risk of HF
Al-Shamiri, 2013	Echocardiograms and chest X-rays	.	10 years younger than their Western counterparts		IHD: 52% Valvular heart disease: 8.4% Idiopathic dilated cardiomyopathy: 8.3%		HF-REF: 80.1% HF-PEF: 19.9%	HTN: 25% Diabetes	ACEI/ARBs (86%) Beta-blocker (95%) Aldosterone antagonist (53%)	Inhospital mortality: 5.3% 30-day mortality: 7.5%
ALZadjali, 2014	.	8.9% of inpatients admitted in are with HF Highest bed occupancy was in Al-Dakhiliyah region	Prevalence increases with age 45-49 (3%) 55-59 (6%) >60 (34%)	Male: female ratio is 52:5/10,000 population admitted with HF	.	.	.	.	.	6.2% with circulatory problem died in the hospital
Almashrafi, 2016	.	26.3% admitted had HF	.	.	.	.	.	.	.	HF at admission was a significant predictor of the length of CICU stay
Pandurnga, 2016	ESC criteria	.	63.0 (12.0) years	Male 57%	Ischemic heart disease, idiopathic cardiomyopathy	Acute coronary syndrome Noncompliance with medication	36% (median)	Hypertension (72%) Coronary artery disease (55%) Diabetes mellitus (53%)	ACEI, beta-blockers, aldosterone agonists under prescribed	At 12-month follow-up 50% rehospitalized Mortality: 26.4%
Alharrasi M., 2018	….	…	61.58 (15.54) years	Female 52%	Ischemic 46 (43.81) Nonischemic 59 (56.19)	….	41.11 (13.72)	Number of comorbidities 3 (1.8)	…	HRQL reported to be high (65.02±20.31)

ESC: European society of cardiology, HF: Heart failure, STEMI: ST-segment elevation myocardial infarction, CICU: Cardiac intensive care unit, MetS: Metabolic syndrome, HRQL: Health-related quality of life, SBP: Systolic blood pressure, DBP: Diastolic blood pressure, BP: Blood pressure, HTN: Hypertension, ARBs: Angiotensin II receptor blockers, ACEI: Angiotensin-converting enzyme inhibitor, HF-REF: Heart failure with reduced ejection fraction, HF-PEF: Heart failure with preserved ejection fraction, IHD: Ischemic heart disease, EF: Ejection fraction, FBS: Fasting blood sugar

There were two reviews included as they drew attention to some facets of HF in Oman. Patients with HF have been the population in three of the eight studies. However, HF as an outcome variable has been estimated in the population of patients with acute coronary syndrome (ACS), metabolic syndrome, and among patients requiring cardiac surgeries. One study which estimated the hospitalized Omani patients with circulatory problems magnified the inpatient statistics of patients with HF.

The prevalence of HF in Oman reported by these studies has increased from 1164[12] to 1400.[13] In 2001, the prevalence of HF in Oman was estimated to be 0.5%.[12] The prevalence was doubled by 2018 and incidence was reported to be 1000 new cases per year.[12] The latest statistics show that currently we have 1751 HF cases admitted to hospitals in 2018 in Oman.[14] An estimate of HF with reduced ejection fraction was high at 56%.[15] The escalation of HF among older adults (>60 years of age) has been consistently documented across the two decades.

The diagnostic criteria for HF in the selected studies included the European Society of Cardiology, ejection fraction (<50%) and/or diastolic dysfunction, electrocardiograms, and chest X-rays. The median EF is reported as 36%. Most (five of the seven) of the studies, reflected that Omanis with HF were aged 55 years and above. The incidence of more men diagnosed with HF is also made manifest by this review.

Ischemic heart disease (IHD) is the most common etiology reported in the surveyed literature. Idiopathic cardiomyopathy is stated as an etiology in a tenth of the Omani population with HF. The factors which precipitate HF among the surveyed population are acute coronary syndrome, noncompliance with medications, and delayed presentations with STEMI. HTN, hyperlipidemia, coronary artery disease, and diabetes are stated as comorbidities endured by patients with HF in this region. Two of the studies reviewed stated that HF patients were prescribed angiotensin-converting enzyme inhibitors and beta-blockers. The prescription of aldosterone antagonists was seldom.

The inpatient mortality ranged between 4.3% and 6.2% among Omani patients with HF. The mortality rate had increased to 7.5% and 26.4% at 1-month and 12-month follow-up surveys, respectively. The reviewed studies also amplify that HF is a predictor of the length of stay in coronary intensive care units, and rehospitalization.

DISCUSSION

Two distinct findings appeared from the detailed introspection of the available literature on HF in Oman.

The morbidity pattern of heart failure in Oman

The characteristics of HF patients in Oman are made manifest from this literature review. These few studies have generated an epidemiological trend that puts Oman at a medical misfortune as HF was reported among patients at a younger age as compared to their Western counterparts with increasing rehospitalization and mortality at 1 year.[11] With regard to risk factors and etiology of HF in Oman, the primary comorbid conditions were HTN, coronary artery disease, and DM which were noted in other studies as well.[1617] IHD, hypertensive heart disease, and idiopathic cardiomyopathy were the most common etiologies of AHF in Oman as it is the case in other gulf countries.[1116181920]

Noncommunicable diseases have been estimated to account for most (68%–72%) death in Oman.[212223] This has been attributed to aging, rapid changes in the diet, and lifestyle changes due to urbanization, globalization, and economic growth taking place in the Arab Gulf countries.[24] These findings directly showcase the devastating effects of a modern lifestyle adopted by the country over the last few decades. There is a significant association between increased body mass index and decreased knowledge of CHD risk factors.[2526] The higher prevalence of metabolic syndrome and hyperlipidemia adds to the burden of HF in Oman.[27]

Noncompliance with medication was a common precipitating factor in the Oman CARE registry. Within 12-month follow-up, one in two patients were rehospitalized for AHF.[11] If patients’ attitudes and behaviors toward their own health care is not addressed, we are bound to see more cases of HF readmitted frequently to the hospitals. These complementing evidences guide the need for “health promotion and illness preventive” services as well.[11] This in line with the recent recommendation by the American College of Cardiology and American Heart Association guidelines on the primary prevention of cardiovascular disease.

The need for lipid-lowering, antihypertensive, antiplatelet, and blood glucose control therapies for the high-risk population is also exemplified in the authors’ article on contemporary guidance.

In addition, the occurrence of HF with other medical conditions makes it complicated to treat HF in Oman and thus contributes to its high mortality.[1617]

Another facet of morbidity pattern established through this review is the rapid progression of HF with age. Similar to that, a ten-fold increase in the prevalence of HF patients between patients in their 4th and 6th decades of life was recorded by AlZadjali.[13]

This review has also highlighted that 80% of patients with HF have reduced ejection fraction. All these factors contribute to increasing prevalence of HF with high morbidity and mortality.

Pharmacological management of HF was described in the OMAN CARE registry,[11] which showed that inhospital majority of patients received guideline-recommended treatment, however, at 1 year, the same dosages were continued. Even though inhospital mortality was low, 7% as in other countries, the 3-month mortality doubled and at 1 year it was high at 25% which is probably due to inadequate dosage of guideline-recommended medications. This calls for the initiation of HF clinics in Oman.

Nonpharmacological management is not well reported except for one study that has described self-care among HF patients in Oman which was found to be poor.[28]

The study found that there were subgroups within the HF patients that were mostly very poor on recognizing and managing their symptoms. Collectively, this rapid deterioration in patients with HF in Oman and the increasing prevalence signals the need for focused transitional care services. Care Transitional Intervention has been successful in bridging the gap between hospital and home care services for patients with HF.[29] It empowers individuals to manage their health in four domains: medication self-management, patient-centered record, follow-up, and early recognition of complications.[30]

The lack of dedicated research was the second theme which surfaced from this literature review. HF research in Oman is still low, with only eight published literatures in the past two decades [Table 1]. This translates into one study every 3 years which leaves the medical team with limited evidence to guide their clinical decision-making. The lack of precise inclusion criteria, HF diagnostic criteria, stronger empirical designs, and predictors of poor outcome is evident from the extracted literature. The updated and comprehensive evidence-based literature on the diagnosis, management, and utilization of available resources for HF outlines the New York Heart Association functional classification as the standard for HF classification.[31] The article states that structural and functional assessment with echocardiography and HF-specific laboratory tests with brain natriuretic peptide (BNP) are advocated for evaluating patients with higher possibility of HF.

The predictors of poor outcome and high mortality have been extolled as serum urea >15 mmol/L, systolic blood pressure >115 mmHg, serum creatinine >2.72 mg/dl, N-terminal pro-BNP >986 pg/ml, and left ventricular ejection fraction <45%. The wide spectrum of management and criteria for discharge are also detailed.[31] Empirical schemes based on such gold standard criteria are required. Longitudinal designs with follow-up inquiry and randomized control trials to establish standard protocols are recommended.

Future researches should focus on nonpharmacological management of HF in Oman and their effect on health outcomes such as morbidity and mortality.

Overall, early diagnosis, prompt treatment of acute HF, and other underlying comorbidities while incorporating intensive health promotion and lifestyle behavioral modification of the Omani population may reverse the high rehospitalization and very poor outcome observed in Oman among all AHF registries.

In addition, there is a need to increase public awareness on the risk factors. The use of social media, newspapers, extensive mass education, and free health screening stress should emphasize the importance of prevention in the diagnosis of CHD and HF.

CONCLUSION

A very limited number of researches are done in Oman with regard to HF. Multiple epidemiological or clinical statistics were not available except for the raw data published in the Ministry of Health website.

HF patients in Oman are a decade younger than Western countries and its prevalence is increasing over last two decades. Rehospitalization and mortality due to HF are very high in Oman compared to other countries. More epidemiological and clinical researches are needed in this group of patients. More epidemiological and clinical researches are needed in this group of patients, so that HF risk factors control, timely diagnosis of HF, and appropriate pharmacological and non-pharmacological management of HF is undertaken across all health centers in Oman.

Hopefully, establishing these parameters will help reduce mortality and morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.