Heart Failure: Organization of Care after Hospitalization at the Abidjan Cardiology Institute ()
1. Introduction
Heart failure (HF) is the inability of the heart to provide, the blood flow necessary for the metabolic and functional needs of the various organs under normal conditions, with unincreased upstream venous pressures. It is the complication of many cardiovascular diseases. It is a public health problem.
Over the last three decades, major advances in the drug (renin-angiotensin-aldosterone system and the sympathetic system blocking) and non-drug (electrical, interventional and surgical treatment) management of HF have contributed to a reduction in overall morbidity and mortality [1] . Well-structured follow-up programmes (cardiovascular rehabilitation, telemedicine) have led to a reduction in rehospitalization and improved quality of life for patients in Europe [2] . However, in sub-Saharan Africa, post-hospital follow-up seems unstructured. Yet, HF is a frequent reason for hospitalization [3] , and particularly in Côte d’Ivoire. Also, in our daily practice, we are witnessing a recrudescence of rehospitalisation whose factors seem unknown.
In this context of frequent rehospitalization of HF patients at the Abidjan Heart Institute (AHI), this study was conducted to analyse the quality of post-hospitalization health care follow-up during heart failure at the Abidjan Heart Institute.
2. Methods
We conducted a prospective descriptive study of patients hospitalised for heart failure in the medicine department of the Abidjan Heart Institute from January 1st to December 31, 2015.
The HF Patients included were over 18 without sex distinction, had been hospitalised for heart failure in the medicine department and discharged during the study period; had a clinic and paraclinic check-up (chest X-ray, ECG, echocardiography, biology); followed up as an outpatient for at least two years. Patients who did not give informed consent and patients who died in hospital prior to outpatient follow-up were not included.
For each patient, after verbal informed consent, data was collected using a standardised survey form developed with Epi Data 3.1 software. We recorded consecutively the socio-demographic, clinical, paraclinic, therapeutic and the post-hospital follow-up data. We analysed socio-demographic parameters, consultations, clinic and paraclinic data, rehabilitation program (therapeutic education and exercise training) and titration program (Angiotensin-converting enzyme: ACEI, Angiotensin receptor blockers: ARBs, Beta-blockers). Death rates are at 6 months, 9 months, 12 months and 24 months.
The consultation was said to be regular, when the patients respected the periodicity of the appointments fixed by the doctor. It was said to be irregular when the patients did not respect the periodicity of the appointments fixed by the doctor. A person “lost to follow-up” was a patient for whom we had no information after at least one consultation despite reminders.
Data entry was performed using Epi Data 3.1 software and statistical analysis by Stata 12.0 software. Quantitative variables were expressed as mean ± standard deviation. While qualitative variables were expressed as a proportion or percentage, survival curves were compared according to Kaplan Meier.
3. Results
3.1. Prevalence
During the study period 396 heart failure patients were identified out of 1127 admissions to the medical department. The frequency of HF was 35% for the one year.
3.2. Socio-Demographic Characteristics
The average age of the patients after hospitalization was 57.4 ± 16.4 years with the extremes of 18 and 91 years.
The population aged over 50 represented two third of the patients (67.2%). There was a male predominance (59.3%) with a sex ratio of 1.5.
The study revealed that 48% of the patients had a secondary education level and 34.3% had an academic level.
The working population represented 56.8% of the patients. Patients residing in Abidjan represented 73.5% of the cases. The most common risk factor for heart failure was hypertension (49%), followed by smoking (16%) and diabetes (15%; Table 1).
3.3. Clinic
The majority of patients had a history of hospitalization for HF (45%). The study revealed that 36.1% of the patients had systolic blood pressure (SBP) ≥ 140 mmHg and 43.4% had diastolic blood pressure (DBP) ≥ 90 mmHg. Tachycardia was observed in 74% of our patients. Polypnea was present in 53% of cases (Table 1). Obesity was found in 36.9% of patients and overweight was recorded in 28.3% of patients. The frequent mode of decompensation on admission was the global HF (61.9%), followed by the right HF (23.5%) and the left HF (14.6%). In descending order, the frequent triggering factors were infectious syndrome (27.8%), therapeutic non-compliance (25.2%), rhythm disorders (17.7%), pulmonary embolism (6.8%) and myocardial ischemia (6.1%, Table 1).
3.4. Paramedical Assessment
Cardiomegaly was found in 98.3% with a mean of 0.7 ± 0.4.Sinus rhythm (56.1%) and sinus tachycardia (44.9%) was frequently reported. The most
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Table 1. Socio-demographic, clinical, echocardiographic, therapeutic and evolutionary parameters.
important supra-auricular disorder was atrial fibrillation (23.7%) and the predominant supra-ventricular disorder was ventricular extrasystols (23%). The study population had atrioventricular block 1 (AVB1) in 10.3%.
Bundle branch block was most represented by Incomplete Right Bundle-Branch block (IRBBB) (27.4%) followed by complete Right Bundle-Branch block (CRBBB) (22.2%).
Left ventricle telediastolic diameter (LVTDD) and Left ventricule telesystolic diameter (LVTSD) were elevated in 55% and 59.1% of cases respectively. LVEF was impaired in Simpson biplane (55.5%) and Tm (84.5%) respectively. Among the underlying heart diseases, dilated cardiomyopathies predominated (36.1%) followed by hypertensive (21.7%), ischaemic (16.2%) and valvular (9.8%) heart diseases (Table 1).
The biology showed hyponatremia (37.7%), hypokalemia (8.7%) and hyper creatinin (1.9%). The blood level of NT-proBNP was high in 95% of cases.
3.5. Treatment
The main drugs prescribed were furosemide (91.2%), ACE inhibitors (72.2%) or ARBs (8.6%), beta-blockers (46.2%) and Mineralocorticoid receptor antagonists: MRAs (11.6%). Associated treatment included Calcium Channel inhibitors (7.1%), statins (18.9%), nitrates (22.7%), aspirin (25.8%) and curative anticoagulant therapies (31.6%, Table 1).
3.6. Post-Hospitalization
1) Follow-up consultations
During the posthospital heath care follow-up, more than half of the patients (74.1%) were non-compliants. The majority of patients (58.2%) were not followed up by the usual practitioner (Table 2).
2) Titration session
Patients who completed the post-hospital titration sessions achieved optimal doses of ACE inhibitors, ARBs and Beta-blockers in 54.1%, 7.3% and 38.5% of cases respectively.
3) Cardiovascular rehabilitation
In cardiovascular rehabilitation, 94 patients had completed their program, 21.3% of whom had received exercise training and 78.7% therapeutic education.
4) Imaging and biological parameters
The ECG was monitored in 14 outpatients. The chest X-ray and cardiac Doppler ultrasonography were requested in 5 and 25 of the outpatients respectively. Biological monitoring was rarely performed during the post-hospital follow-up (Table 2).
3.7. Evolution
At 2-years post-hospitalization heath care follow-up, rehospitalized patients
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Table 2. Post-hospital follow-up parameters.
represented 49.5%, the number of decompensations was 77.3% and deaths were estimated at 30.2% of cases.
During the first year of follow-up, the mortality was 48.2%, 67% and 72.3% at 6 months, 9 months and 1-year at 6 months, 9 months and 1-year respectively.
The probability of survival was higher in patients regularly monitored than in irregularly monitored (Figure 1).
4. Discussion
4.1. Limitations of Study
This work is of scientific and pragmatic interest because of its originality on the one hand and on the other hand, the significant data concerning the care pathway of heart failure patients in our context.
4.2. Prevalence
The hospital prevalence of HF in our study was 35%. This prevalence varies from 27.3% to 41% in some African series [4] [5] [6] . However, the prevalence of heart failure varies between 0.4% and 2% for the general population in Europe [7] . This difference in prevalence could be explained by the better management of coronary syndromes, which are the main cause of heart failure in the west. In Côte d’Ivoire, however, it is the complications of hypertension. The low socio-economic level makes access to health care difficult in our population.
4.3. Epidemiological Characteristics
The majority of patients in this study were aged over 50 (67.2%). The mean age of the patients was 57.4 ± 16.4 years. The average age generally observed in
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Figure 1. Comparison of survival of regular and non-regular post-hospitalization patients using Kaplan-Meier plan.
sub-Saharan Africa is around 55 years [8] [9] . In contrast, the average age was higher in the West at around 75 years [7] [10] . This age difference between African and Western data could be explained by the longer life expectancy in Europe. This condition contributes to lower life expectancy in our country in particular and in Africa in general.
The HF occurs in Africa in adults in their fifties or older, whereas in the West it is later in life, around the current septuagenarians.
Male predominance seems to be constant [8] . However, some African authors [11] and the ADHERE study [10] noted a female predominance in 56%, 59.6% and 52% respectively. A plausible explanation could be due to the better control of cardiovascular diseases in women who are traditionally known for better health behaviour leading to fewer complications such as HF.
4.4. Clinical Aspects
Congestive heart failure (61.9%) was the common clinical presentation in this study, followed by right heart failure (23%) and left heart failure (14.6%). Kheyi [6] in Morocco found that left heart failure was predominant (63%). Congestive heart failure was the predominant clinical presentation in sub-Saharan Africa [5] [12] [13] [14] . This would probably be justified by the delay in consultation, the insufficiency or even absence of financial means and the inappropriate therapeutic itineraries, which would explain the delay in consultation and the evolution towards severe forms.
4.5. Post-Hospital Care
After discharge from hospital, our patients were followed up on an outpatient basis for 2 years. This stage was marked by the high number of patients with very poor compliance (74.1%) and irregular consultations (15.1%) after 2 years of follow-up. This finding was the same in the N’cho-Motto prospective observational study carried out in the same department [16] . The author found 60.3% poor compliance with follow-up appointments. Indeed, this study reported that patients resorted to traditional medicine and prayers for healing, which led to poor compliance with therapeutics [16] . This attitude could be related to a low socio-economic status. More than half of our patients were retired or unemployed. This was a handicap for an adequate therapeutic follow-up in our context of lack of health insurance. Usually, their healthcare is provided by a third party or the family.
In addition to this primary difficulty, which would explain the lost of follow-up, there is also the lack of patient compliance. This situation has a negative impact for improving doctor-patient relationship. This disruption of the doctor-patient relationship was significant. Nearly two third of the patients were not followed up by the usual practitioner. This could explain the number of patients lost to follow-up and the irregular consultations in our study. The trust that develops in the doctor-patient relationship usually motivates patients to consult their practitioner and avoids discordant discourse, attitudes and practices of practitioners. Awareness-raising actions aimed at the actors must be undertaken.
The titration of certain therapies such as Beta-blockers, ACE inhibitors and ARBs is a necessary therapeutic objective for the optimisation of patients’ treatment. During this follow-up period, only 59 patients had received from titration sessions. It was significant for betablockers (81%) and ACE inhibitors (67.6%). At optimal doses, ACE inhibitors or ARBs and betablockers have been shown to be effective in reducing morbidity and mortality in HF [1] . This optimal tolerated dose is not often reached at discharge because of low arterial blood pressures [19] . Thus, post-hospitalization follow-up turns out to be an opportunity for complicity between the doctor and the patient in the search for the target dose. However, we noted that few of the regular patients in the study underwent it. Lack of time and sufficient doctors, episodes of decompensation and sometimes contraindications were noted as obstacles to the regularity of titration sessions.
This study also revealed that cardiovascular rehabilitation, including exercise training and therapeutic education, if necessary, in the post-hospitalization follow-up, was poorly practised, exposing a quantitative and qualitative insufficiency in the management of HF [10] . These beneficial effects have been demonstrated in several clinical trials [20] [21] [22] [23] . Giallauria, et al. [20] observed an improvement in peak of VO2, the 6-minute walk test and the quality of life of heart failure patients. Belardinelli [21] in a 10-year study showed an improvement in peak VO2, a decrease in resting heart rate, an improvement in LVEF and a reduction in the VE/VCO2 slope in patients admitted to an exercise training programme. He also reported a reduction in the rate of death and rehospitalizations in exercise-retrained HF patients [21] .
Therapeutic education, leads to improved adherence and compliance, a reduction in the number of rehospitalizations and the cost of management, and an improvement in quality of life and survival [22] [23] .
The lack of such operational cardiovascular rehabilitation facilities being in sub-Saharan Africa would certainly explain the high rates of rehospitalization and mortality in HF [1] [8] . However, cardiovascular rehabilitation was in its infancy and the additional costs faced by patients with low-income would explain the low proportion of participants in exercise training and therapeutic education sessions. Awareness of the benefits should allow us to overcome this difficulty.
Post-hospitalization follow-up is reinforced by paraclinical check-ups. These tests allow us to check the effectiveness and safety of the treatment and to look for secondary complications. This study showed that the request for ECGs, chest X-ray, cardiac echodoppler and biological control tests was weak. Also, NT-proBNP, which is a diagnostic, monitoring and prognostic marker, was only requested at admission. The NT-proBNP assay is only performed on admission for diagnosis. This relevant marker for follow-up and prognosis was neglected due to its high cost for outpatient with low income in Africa. The level of NT-proBNP at discharge predicts the prognosis of HF [24] . This test remains costly in our practice setting and would represent one third of the minimum wage. This could be explained by the low rate of patients regularly followed up in post-hospitalization and the lack of planning of the demand for these examinations. In addition, the low socio-economic level of our patients makes it impossible to carry out these examinations in the majority of cases. It becomes difficult to monitor occurrence of complications and decompensation factors. The most common found decompensation factors of HF were bronchopulmonary infection (32.1%), treatment non-compliance (29%) and rhythm disorders (20.5%). Other authors found the same factors but in different proportions. Our results confirmed those of Soya [15] which were: non-compliance with treatment (48.7%), bronchopulmonary infections (33%), non-compliance with diet (23.7%), rhythm disorders (16.2%) and anaemia (11.8%). In our context, the factors of poor compliance with treatment, recourse to traditional therapy, non-compliance with consultations, poor therapeutic compliance and lack of social security coverage have also been identified [16] . These factors are the source of frequent rehospitalizations and the poor quality of life of heart failure patients. Oyoo and Ogola in Kenya [17] had identified irregularity of treatment (27.4%), arrhythmia (20.9%), infection (17.6%), and anaemia (13.2%) as triggering factors. The direct pathophysiological mechanism according to Dike [18] was severely elevated blood pressure.
In total, the decompensating factors are very diverse, including infection, rhythm disorders and non-adherence to therapy, which seem to be presentin almost all series. This is why therapeutic follow-up must systematically integrate relapse and the prevention of these triggering factors.
4.6. Post Hospital Outcome
Inadequate post-hospital follow-up and socio-economic factors in this study would explain the rehospitalization rate (40.5%). Indeed, the probability of survival was high in the regularly followed up patients compared to the non-observant group. We regretted 30.2% of deaths during follow-up over the period of this study. Our results are in agreement with those of some authors. In Europe, the EFICA registry noted 50% of deaths at one year. Zannad found 46.5% of mortality at one year [25] . On the other hand, Siirila-Waris found 27.4% after 12 months of evolution [26] . All these results showed a high mortality rate at one year of follow-up for heart failure patients. In Europe, this could be explained by the ageing of the population, making advanced age a poor prognostic factor. In Africa, it is a source of high morbidity and mortality among young people, leading to a drop in productivity.
This study also showed that this mortality rate had reached 30.2% at 2 years of follow-up. It is higher in non-regularly followed up patients. Favouring factors would probably be the low socio-economic level, the irregularity of consultations, the lack of patient loyalty, the absence of therapeutic education and effort re-training.
5. Conclusion
The organisation of care and coordination between professionals should be structured or planed. Therapeutic strategies need to be intensified in order to optimise their long-term benefits.