Background: Heart failure is expected to increase in prevalence globally.(1) The increased incidence of metabolic disorders coupled with the increase in life expectancy in Singapore has contributed to this trend. Heart failure poses a great burden on patients, caregivers and the healthcare system.Previous European studies have suggested that patients managed by internists differ in baseline characteristics when compared to patients in clinical trials and patients managed by cardiologists.(2,3) These patients tend to be older, more incapacitated and have multiple comorbidities. They experience more side effects and are unable to tolerate the many guideline recommended medications. There are no known studies examining the characteristics of heart failure patients admitted to internal medicine in Singapore. This study aims to characterize these patients, to understand gaps in care and identify areas for improvement.
Methods: The study team conducted a single center pilot observational study in a tertiary hospital in Singapore. The study team reviewed clinical records of patients admitted to department of internal medicine for heart failure between 1 January and 31 March 2020.The data collected included age, gender, left ventricular ejection fraction (LVEF), NT-proBNP levels, readmission within 30 days, presence and control of comorbidities like hypertension, diabetes mellitus and chronic kidney disease. Medications prescribed for heart failure were also collected.
Results: A total of 132 patients were included in this study. The mean age in this group was 76, with a female predominance of 55%. 73% of patients in the group identified their ethnic group as Chinese ethnicity, with 14% of Indian ethnicity and 12% of Malay ethnicity. Echocardiography results were available in 83% of the cohort. 48% (n=64) were identified as heart failure with preserved ejection fraction (HFpEF); 10% (n=13) heart failure with mid-range ejection fraction (HFmrEF); and 24% (n=32) heart failure with reduced ejection fraction (HFrEF). It is also noted that 60% (n=79) of total studied subjects had concomitant diabetes mellitus and 57% (n=75) had chronic kidney disease. 27% of the total subjects (n=36) had been readmitted within 30 days of a prior admission.
Conclusions: In our study, patients admitted in internal medicine department at our center tend to be older, with a higher proportion of patient with HFpEF.(4,5) There is also a high proportion of patients with comorbidities like diabetes and chronic kidney disease. A significant proportion of patient experienced recurrent admissions. Due to advanced age and multiple comorbidities in this group, management of heart failure is made more challenging. This patients experience more adverse effects from polypharmacy. Many of the medications are also contraindicated in patients with significant renal impairment. Our pilot study highlighted differences in baseline characteristics for heart failure patients admitted to internal medicine. These differences will translate to differences in care needs, therapeutics, and care organization. We intend to conduct a bigger study in our center, to identify gaps in the current treatment of heart failure and areas for quality improvement. The major limitation in our study was the small number of subjects. The patients examined were also from a single center.