ajay article final (except ref).docx https://doi.org/10.22502/jlmc.v10i1.495 Original Research Article Clinical Profile and Short-term Outcome of Heart Failure Patients in a Tertiary Hospital in Kaski, Nepal: A Cross-sectional Study Ajay Adhikaree,a,c Arjun Kumar Budha,b,c Gobind Rawat,b,c Choodamani Nepal,b,c Umesh Dhungana,b,c Suwas Chandra Gautam,b,c Prayas Bidarib,c ABSTRACT: Introduction: Heart failure is one of the leading causes of hospitalization. The aim of this study was to evaluate the epidemio-clinical profile and short-term outcome of hospitalized heart failure patients in a tertiary care hospital. Methods: This descriptive cross-sectional study was conducted at Pokhara Academy of Health Sciences, Kaski, Nepal from October 1, 2021 to January 31, 2022. All the hospitalized heart failure patients aged 18 years or above were included. Relevant history, examination, laboratory and pertinent findings were noted. Descriptive statistics were used for qualitative and quantitative data. Paired t-test was used for comparison of pre-and post-hospitalization data. A p-value <0.05 was taken for statistical significance. Results: There were a total of 116 patients (65.5% females) with a mean age of 64.20 ± 16.35 years. Most of them had shortness of breath (97.4%) and orthopnea (72.4%) and presented with pedal/sacral edema (81.9%) and bilateral basal crepitations (69.8%) in the chest. Heart failure with preserved ejection fraction was the most prevalent (61.2%) type and dilated cardiomyopathy (27.6%) was the commonest etiology of heart failure. The median duration of hospitalization was five days and the in-hospital mortality was 2.6%. Loop diuretics and vasodilators (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker) were the most commonly used medications. Conclusions: Dilated cardiomyopathy was the most common etiology and heart failure with preserved ejection fraction was the predominant type of heart failure. With a short length of stay and low in-hospital mortality, the short-term outcome was good. Keywords: Clinical profile, Heart failure, Hospitalization. Submitted: 27 July, 2022 Accepted: 09 October, 2022 Published: 20 October, 2022 a: Assistant Professor, Department of Internal Medicine b: MD Resident, Department of Internal Medicine c: Pokhara Academy of Health Sciences, Pokhara, Kaski, Nepal Corresponding Author: Ajay Adhikaree Assistant Professor Devdaha Medical College and Research Institute, Bhaluhi-9, Devdaha Municipality, Rupandehi, Nepal e-mail: ajay.bijay@gmail.com ORCID: https://orcid.org/0000-0001-5125-7365 INTRODUCTION: State of the art heart failure (HF) diagnostics and therapeutics have increased both the prevalence and longevity in HF, making frequent HF hospitalization a universal health concern [1,2,3] and it is expected to rise in How to cite this article: Adhikaree A, Budha AK, Rawat G, Nepal C, Dhungana U, Gautam SC, Bidari P. Clinical Profile and Short-term Outcome of Heart Failure Patients in a Tertiary Hospital in Kaski, Nepal: A Cross-sectional Study. Journal of Lumbini Medical College. 2022;10(1):14 pages. DOI: https://doi.org/10.22502/jlmc.v10i1.495 Epub: 2022 October 20 J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 https://doi.org/10.22502/jlmc.v10i1 https://orcid.org/0000-0001-5125-7365 Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients coming days.[4,5] Erewhile in low- and middle income countries, valvular heart diseases were frequent. However, in prevailing time due to shift of paradigm in epidemiology, ischemic heart disease takes humongous share.[6,7] Few publications only mention sparsely the commonest cause, different risk factors, outcome of those heart failure hospitalizations in our setting.[6,7,8,9,10,11,12,13] Hence this study was conducted to evaluate the epidemio-clinical profile of heart failure patients and their short-term outcome in our setting. METHODS: This descriptive cross-sectional study was carried out at Pokhara Academy of Health Sciences (PoAHS) from 1st October 2021 to 31st January 2022 after approval from the Institutional Review Committee, PoAHS (Ref. No. 68/078). All hospitalized patients aged 18 years or above with the diagnosis of heart failure were enrolled. The patients who could not undergo cardiac evaluation including necessary investigations and post operative patients ( ≤ 3 months of surgery) were excluded. The sample size was calculated using the formula: Minimum sample size (n) = Z2pq/ e2. Taking prevalence (p) as 7.5% from the study of Sharma et al.[8], Z=1.96 at 95% confidence interval and e=5%, the minimum sample size was calculated to be 107. Recent European Society of Cardiology guidelines for diagnosis and treatment of acute and chronic heart failure (2021) were adopted for defining, classifying and diagnosing heart failure.[1] Patients data were collected from medical history sheets acquired during admission, stay and discharge from the hospital. A comprehensive history, essential physical examination and obligatory laboratory investigations were noted in a working proforma which was formulated after discussion with all the team members and after careful review of various literatures. Quantitative N-Terminal Pro Brain Natriuretic Peptide (NT-Pro BNP) estimation was processed using the Chemiluminescence Immunoassay (CLIA) approach. A focused systemic cardiovascular assessment along with Chest X-Ray (CXR), Electrocardiogram (ECG) and echocardiogram were carried out. Antero-posterior view CXR was repeated to postero-anterior view whenever feasible and cardiomegaly was labeled only when cardiothoracic ratio was > 50% in postero-anterior view. Updated guideline on standardization and interpretation of ECG laid by respective heart rhythm society was exercised for calibration and other technicalities of ECG.[14] Recent European Association of Cardio-Thoracic Surgery protocol (2020) was followed for identifying atrial fibrillation.[15] American College of Cardiology and American Heart Association diagnostic criteria were adopted for detecting bundle branch block pattern and translating other ECG abnormalities.[16] Likewise, recent instructions of American Society of Echocardiography and the European Association of Cardiovascular Imaging were preferred for summarizing echocardiographic results.[17] European Society of Cardiology working group classification of the cardiomyopathies (2008) guideline was used for defining cardiomyopathies.[18] All these data were noted in Statistical Package for Social Sciences (SPSS) for further analysis. Quantitative data were expressed in terms of number, percentage, mean ± standard deviation. Pre- and post hospitalization data were compared using paired t-test. A p value < 0.05 was designated significant. RESULTS: There were a total of 116 patients with female J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients Table 1: Baseline Characteristics, Clinical Presentations and Risk Factors (n=116) Characteristics Frequency (%) Sex Female 76 (65.5%) Male 40 (34.5%) Symptoms SOB: NYHA 3 51 (44%) NYHA 4 62 (53.4%) PND/Orthopnoea 84 (72.4%) Chest Pain 54 (46.6%) Palpitation 54 (46.6%) Sweating 38 (32.8%) Epigastric Pain 32 (27.6%) Pre-Syncope 16 (13.8%) Clinical Signs Edema (pedal/sacral) 95 (81.9%) B/l basal crepitations 81 (69.8%) Distended neck veins 56 (48.3%) Raised JVP 35 (30.2%) S3 30 (25.9%) Hepatomegaly 14 (12.1%) Risk Factors Tobacco (Smoking/Chewing) 83 (71.6%) HTN 44 (37.9%) COPD 42 (36.2%) DM-II 22 (19.0%) Anemia 17 (14.7%) Past history of heart failure 15 (12.9%) Obesity 13 (11.2%) Arrhythmia (excluding sinus arrhythmia) 12 (10.3%) Renal disease 06 (5.2%) CAD/PCI/CABG 03 (2.6%) Note: Bilateral (B/L), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Bypass Graft (CABG), Coronary Artery Disease (CAD), Diabetes Mellitus-type II (DM-II), Hypertension (HTN), Jugular Venous Pressure (JVP), New York Heart Association (NYHA) grading for dyspnoea, Paroxysmal Nocturnal Dyspnoea (PND), Percutaneous Coronary Intervention (PCI), Shortness of Breath (SOB), Third Heart Sound (S3). J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients predominance of 65.5% and mean age of 64.20 ± 16.35 years. Most of them presented with shortness of breath (SOB). Tobacco consumption (71.6%) either in the form of smoking or chewing was the most common risk factor. These baseline findings are depicted in more detail in Table 1. Table 2: Investigations findings in the study population (n=116) Laboratory Parameters Mean ± Standard Deviation Haemoglobin (g/dl) 12.72 ± 2.22 Urea (mg/dl) 36.68 ± 26.69 Creatinine (mg/dl) 1.31 ± 1.26 Sodium (meq/L) 136.84 ± 4.57 Potassium (meq/L) 4.11 ± 0.66 Random Blood Sugar (mg/dl) 134.66 ± 63.48 NT Pro-BNP* (pg/ml) 4946.47 ± 454.21 NT Pro-BNP in HFpEF** (pg/ml) 4235.72 ± 388.90 NT Pro-BNP in HFrEF*** (pg/ml) 7171.54 ± 549.74 *N-Terminal Pro Brain Natriuretic Peptide, **Heart Failure with preserved Ejection Fraction ***Heart Failure with reduced Ejection Fraction The mean values of hemoglobin, creatinine and random blood sugar are shown in Table 2. The mean serum N-terminal pro brain natriuretic peptide (NT-Pro BNP) level was 4946.47 ± 454.21 pg/ml. Chest x-ray (CXR) showed pleural effusion in 65.5% and cardiomegaly in 36.2% of the patients. The most common ECG abnormalities were sinus tachycardia (91.38%) followed by ST/T changes (62.06%). Echocardiography demonstrated distinctive left ventricular diastolic dysfunction (LVDD) in 87.9%, followed by tricuspid regurgitation (78.4%). Table 3 highlights various investigation findings of those patients. Almost all heart failure hospitalizations were from the emergency department (96.6%). The most common cause of heart failure was dilated cardiomyopathy (27.6%). Table 4 illustrates all these heart failure hospitalization parameters in detail. Clinical variables like Heart Rate (HR), Respiratory Rate (RR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), and body weight mean values were significantly reduced when compared between pre- and post hospitalization (Table 5). J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients Table 3: Investigations findings in the study population (n=116) Laboratory Parameters Number (%) Chest X-Ray Findings: Pleural Effusion U/L 23 (19.8%) B/L 53 (45.7%) Cardiomegaly 42 (36.2%) Electrocardiographic Findings: Sinus Tachycardia 106 (91.38%) ST/T changes 72 (62.06%) LBBB 35 (30.17%) A. Fib. 15 (12.93%) RBBB 12 (10.34%) LAFB 05 (4.31%) Echocardiographic Findings: LVDD 102 (87.9%) TR 91 (78.4%) MR (excluding trace MR) 71 (61.2%) AR 48 (41.4%) LVSD 45 (38.8%) PR 31 (26.7%) Pericardial Effusion 17 (14.7%) Note: Aortic Regurgitation (AR), Atrial Fibrillation (A. Fib.), Bilateral (B/L), Left Anterior Fascicular Block (LAFB), Left Bundle Branch Block (LBBB), Left Ventricular Diastolic Dysfunction (LVDD), Left Ventricular Systolic Dysfunction (LVSD), Mitral Regurgitation (MR), Pulmonary Regurgitation (PR), Right Bundle Branch Block (RBBB), Tricuspid Regurgitation (TR), Unilateral (U/L). J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients Table 4: Heart failure hospitalization parameters (n=116) Parameters Frequency (%) Admission ED 112 (96.6%) OPD 4 (3.4%) Diagnosis HFpEF (LVEF ≥ 50%) 71 (61.2%) HFmEF (LVEF: 41-49%) 11 (9.5%) HFrEF (LVEF ≤ 40%) 34 (29.3%) Etiology DCM (including PPCM) 32 (27.6%) Cor Pulmonale with RHF 27 (23.3%) HTN 21 (18.1%) VHD (including RHD, IE) 19 (16.4%) CAD 13 (11.2%) Structural Heart Disease (ASD) 02 (1.7%) Arrhythmia 02 (1.7%) Median length of stay (days) Ward 4.0 ICU (n=15) 3.0 Status of patient Discharged 111 (95.7%) Death 03 (2.6%) Referred 02 (1.7%) Medications Loop Diuretics 76 (65.5%) ACEI/ ARB 55 (47.4%) β-Blocker 44 (37.9%) Bronchodilator 39 (33.6%) Aspirin 35 (30.2%) MRA 23 (19.8%) Statin 19 (16.4%) CCB 16 (13.8%) ADA (including Insulin) 08 (6.9%) Digoxin 07 (6.0%) Penicillin 04 (3.5%) Antibiotics (Other than Penicillin) 03 (2.6%) Note: Angiotensin Converting Enzyme Inhibitor (ACEI), Angiotensin Receptor Blocker (ARB), Anti-Diabetic Agents (ADA), Atrial Septal Defect (ASD), Beta Blocker (β-Blocker), Calcium Channel Blocker (CCB), Coronary Artery Disease (CAD), Dilated Cardiomyopathy (DCM), Emergency (ED), Heart Failure with mildly reduced Ejection fraction (HFmEF), Heart Failure with preserved Ejection fraction (HFpEF), Heart Failure with reduced Ejection fraction (HFrEF), Hypertension (HTN), Infective J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients Endocarditis (IE), Intensive Care Unit (ICU), Mineralocorticoid Receptor Antagonist (MRA), Outpatient department (OPD), Peripartum Cardiomyopathy (PPCM), Rheumatic Heart Disease (RHD), Right Heart Failure (RHF), Valvular Heart Disease (VHD) Table 5: Pre- and Post- hospitalization clinical parameters Parameters Pre-Hospitalization (Mean ± SD) Post-Hospitalization (Mean ± SD) p value* Systolic blood pressure (mm Hg) 121.03 ± 20.19 113.53 ± 21.15 0.001 Diastolic blood pressure (mm Hg) 78.28 ± 13.66 72.84 ± 13.50 <0.001 Body weight (Kg) 58.00 ± 9.59 54.97 ± 9.67 <0.001 *Paired t test DISCUSSION: Heart failure is a hyperonym for any deterioration of ventricular filling and ejection fraction of the heart and consists of a myriad of symptoms and signs with diverse clinical presentations and ranges of laboratory and radiological changes. Multitude criteria and algorithms have been formulated for diagnosis and management. However, paucity of resources compels rigorous integrated algorithm- based management of heart failure inapplicable especially in low- and middle income countries. Moreover, keeping abreast with recent heart failure guidelines, gross pragmatic evaluation and management is practiced universally. This study tried to highlight some of these issues. The mean age of the patients in this study was 64.20 ± 16.35 years which was similar to recent national studies done by Shrestha et al.[9] (63.7 years) and Adhikari et al.[10] (62.8 years). However, compared to preceding studies done in Nepal, this was slightly an elder age which illustrated accelerated epidemiological transition towards longevity. [4,6,7,9,13] When these data were compared to international database studies, Kyoto congestive heart failure registry [19] had mean age of 80 years, Japanese diagnosis procedure combination database [20] had mean age of 79 years, China PEACE retrospective heart failure study [21] had mean of 73 years and BIOSTAT- CHF study [2] had mean of 68 years. The mean age of our study was comparatively less which is consistent with low national life expectancy. Female to male ratio in this study was 1.9, suggesting possibility of higher prevalence of heart failure in female which was also consistent with previous national publications.[4,6,9,11,12.13] The patients presented with the gamut of complaints of which shortness of breath (SOB) was present in almost all of the cases J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients (97.4%). Patients with decompensated heart failure presented with either New York Heart Association (NYHA) Class III or IV symptoms possibly suggesting higher threshold for inpatient admission of high-acuity patients and a trend of seeking medical attention at late stage because of lack of medical awareness or limited access to health facility or health insurance policy. Orthopnoea and paroxysmal nocturnal dyspnoea (PND) were also in substantial frequency in this study. Antecedent studies showed various severity of SOB including orthopnea and PND.[7,9,10,12] Congestion is regarded as one of the cardinal features of heart failure. Edema (pedal and/or sacral) was present in four-fifths of the patients compared to bilateral basilar crepitations which was present in about two-third of the patients. Both the signs of systemic as well as pulmonary venous congestion were profound in this study. Contrary to this, frequent pulmonary congestion was observed in other studies.[7,21] Raised JVP, third heart sound (S3) and tender hepatomegaly were also present in conspicuous extent in this study. Tobacco consumed in any form; either smoking or chewing, was the most common associated risk factor in this study. Tobacco is considered one of the major health burdens of developing nations. Tobacco is a traditional cardiovascular risk factor and shares fellowship with other conventional risk factors like hypertension, diabetes, coronary artery disease and atrial fibrillation, all of which have equal potential of decompensating heart failure. Nicotine, a noxious compound found in tobacco, thereby activating the sympathetic nervous system, increases the heart rate and blood pressure and by virtue of increasing myocardial demand results into heart failure. Generation of reactive oxygen species, accumulation of unhealthy lifestyle and unhealthy feeding habits in tobacco consumers lead to structural changes in the heart ensuing heart failure.[22] Available national literatures also have suggested that tobacco, anemia and chronic obstructive pulmonary disease (COPD) are predominant risk factors associated with heart failure.[4,10,12,13] This inculpable finding needs a large sample randomized control trial study for validation. Hypertension (HTN) and diabetes mellitus type-II (DM-II) were present in 37.9% and 19% of the patients respectively in this study. There was a striking difference in prevalence of HTN and DM-II in international studies where HTN was the most common associated comorbidity. In a Japanese database cohort study,[20] the prevalence of HTN and DM-II was 76.7% and 38.3% respectively. The China PEACE study [21] showed a prevalence of 53.8% for HTN and comparable prevalence of 19.9% for DM-II. This shift in trend in risk factors from developing to developed nations is the root cause for emergence of cardiovascular disease epidemics. Heart failure and COPD can coexist together and is thought to be a dangerous liaison. Resemblance in clinical presentations, sharing same risk factors and association with similar comorbidities make the picture complicated. More than one-third (36.2%) of the patients in this study had COPD. Similar reports were narrated in previous studies. Similarly, heart failure is more common in patients with atrial fibrillation (A. Fib) and is related with unfavorable outcomes including mortality and longer stay in hospital. The prevalence of A. Fib in this study was 12.93% which was much less compared to Japanese database cohort study [20] (41.8%), Kyoto registry [19] (41%), and the China PEACE study [21] (35.9%). This difference was postulated to occur due to difference in age group and other associated risk factors between our patients and those registries. J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients There were only 12.9 % of patients having past history of heart failure which was much lower compared to around 60% reported in the China, Europe and the United States.[21,23,24] As many of our patients were from rural community with limited access to health services, there is a possibility that many of them remained undiagnosed or there may be incomplete documentation regarding previous admission or outpatient department visits. Additionally, as our patients were younger, they have less chance of having heart failure in the past compared to international registries. The strength of this study was inclusion of biomarker N terminal pro-brain natriuretic peptide (NT Pro-BNP) in the diagnostic algorithm of heart failure. These high levels of NT Pro-BNP observed in this study definitely vowed for worsening/severe heart failure and ruled out confounding errors resulting from elderly age, anemia, renal failure, infection or arrhythmia. The level of NT Pro-BNP noted in this study was similar to other studies. [2,19,21,24,25] Incorporation and interpretation of all investigatory modality in heart failure is novelty of this study. Pleural effusion was visible in almost two-third of the chest x-ray (CXR) in this study. Pleural effusion is the result of pulmonary venous congestion. Similarly, cardiomegaly was noticed only in one-third of the patients. The study done by Shrestha et al.[9] had illustrated a higher percentage for cardiomegaly compared to pleural effusion. This flip flop in percentages may be due to inclusion of severely symptomatic patient in this study and large number of patients with echocardiography proven dilated left ventricle on Shrestha et al.[9] The most common electrocardiographic (ECG) findings observed was sinus tachycardia (91.38%) followed by ST segment and T wave (ST/T) changes, which was observed in almost two-thirds of the patients. Atrial fibrillation and bundle branch block (BBB) were present in varying proportions in this study. Various arrhythmia and blocks are characteristics of heart failure. These ECG changes are a consequence of counter-regulatory neuro-endocrine and maladaptive sympathetic over activation of the heart. Risk factors like HTN, COPD, anemia and various other etiology of heart failure including myocardial ischemia, associated features like electrolyte disturbances or structural changes in the heart can contribute to ECG changes. Similar ECG findings were noted in antecedent researches.[4,12] Echocardiography remains one of the cornerstones in diagnosis and management of heart failure. In this study, left ventricular diastolic dysfunction (LVDD) was the most common (87.8%) echocardiographic finding which was then followed by valvular regurgitation. Similar echocardiographic profiling was documented in previous studies.[12,25,26] Contrary to that, left ventricular systolic dysfunction (LVSD) was present only in about one-third of the patients in this study. These findings later explain the predominant prevalence of heart failure with preserved versus reduced ejection fraction in this study. Pericardial effusion is recognized as a yardstick for presence of heart failure. Pericardial effusion was noted in a considerable number of patients in this study. As most of the patients in this study were hospitalized with severe symptoms, almost all (96.6%) patients landed up in ED while only a few showed up in OPD. Categorically, about two-third of the patients were diagnosed as heart failure with preserved ejection fraction (HFpEF) while remaining one-third were classified as heart failure with reduced ejection fraction (HFrEF). This study found that dilated cardiomyopathy (DCM) was the J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients most common cause of heart failure similar to few previous studies.[4,10] Cor pulmonale with right heart failure was placed in second position elaborating the fact that COPD and its consequences are still the predominant deciding factor in heart failure. Valvular heart disease (VHD) including rheumatic heart disease (RHD) was also a contributing cause for heart failure in some percentage of patients but not as much in that frequency as explained in literatures.[6,11,13] Coronary artery disease (CAD) accounted for only a small percentage (11.2%) of heart failure in this study which is in contrast to few national[7,9,12] and other international studies where CAD was the dominant etiology. The diverse etiology of heart failure observed in those previous national studies corresponds to different time frames of those studies and different medical services those hospitals provide including comprehensive cardiac services. The median length of hospital stay was 5 days with a stay of 3 days in intensive care unit (ICU) for a few patients. International registries had documented longer duration of stay for heart failure hospitalization.[25,26,28] This could be due to financial constraints, high bed occupancy rate indicating crisis of bed in government hospitals, lower age of the patient, low prevalence of comorbidities. Compared to the available data and other disease admission rates, the length of stay documented in this study denotes that guideline directed medical therapy for heart failure has prompt response resulting in shorter stay in hospital. The in-hospital mortality of 2.6% documented in this study was lower compared to international data and registries.[21, 27] Most of the patients (95.7%) were discharged out from the hospital in this study. Reason for this could be many but less number of worsening or advanced failure in this study compared to those registries. Loop diuretics were the most common medications used. Diuretics by relieving congestion produce symptomatic relief as well as maintain hemodynamic harmony. This balanced hemodynamics makes way for other heart failure medications to act effectively. Use of angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), beta-blocker and mineralocorticoid receptor antagonist (MRA) were in increasing trend compared to previous study but suboptimal compared to international registries suggesting that there is still a long way to go.[2, 10,11,13, 19-21, 28] There is still a huge potential regarding application of novel therapy like angiotensin receptor neprilysin inhibitor (ARNI) and sodium glucose cotransporter-2 (SGLT2) inhibitor. Several limitations ought to be considered. Because of the design of the study, its data could not be generalized; neither can it be extrapolated to find causal relationship of heart failure with any other entities. As patients included in this study were symptomatic, the other half of heart failure, i.e., asymptomatic and compensated heart failure patients was not taken into consideration. Limited sample size and inability to look for other parameters of short term outcome were also its limitations. CONCLUSION: Dilated cardiomyopathy was the most common etiology and heart failure with preserved ejection fraction dominated heart failure hospitalization. This shift of paradigm in epidemics of heart failure resulted due to accumulation of risk factors like tobacco consumption, hypertension and diabetes. Moreover, the length of stay was short and the short term outcome of hospitalized heart failure patients was good, representing the favorable response of anti-heart failure medications. However, to achieve optimal J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients response, use of novel as well as adequate anti-heart failure medications is desired. Conflict of interest: None declared. Source of Fund: No funds were available. REFERENCES: 1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur eart J. 2016;37(27):2129-2200 PMID: 27206819. DOI: https://doi.org/10.1093/eurheartj/ehw128 2. Ferreira JP, Metra M, Mordi I, Gregson J, Maaten JMT, Tromp J, et al. Heart failure in the outpatient versus inpatient setting: findings from the BIOSTAT-CHF study. Eur J Heart Fail. 2019;21(1):112-20 PMID: 30338883 DOI: https://doi.org/10.1002/ejhf.1323 3. Fonarow GC, Abraham WT, Albert NM, Gattis WA, Gheorghiade M, Greenberg BH, et al. Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF): rationale and design. Am Heart J. 2004;148(1):43-51 PMID: 15215791. DOI: https://doi.org/10.1016/j.ahj.2004.03.004 4. Bhattarai M, Shah RK, Sainju NK, Bhandari B, Keshari S, Karki DB. Etiological spectrum of heart failure in a tertiary health care facility of Central Nepal. Nepalese Heart Journal. 2019;16(2):23-8 DOI: https://doi.org/10.3126/njh.v16i2.26313 5. Gheorghiade M, Abraham WT, Albert NM, Greenberg BH, O’Connor CM, She L, et al. Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure. JAMA. 2006;296(18):2217-26 PMID: 17090768 DOI: https://doi.org/10.1001/jama.296.18.2217 6. Regmi SR, Maskey A, Dubey L. Heart Failure Study: Profile of Heart Failure Admissions in Medical Intensive Care Unit. Nepalese Heart Journal. 2017;6(1):32-4 DOI: https://doi.org/10.3126/njh.v6i1.18452 7. Dubey L, Sharma SK, Chaurasia AK. Clinical profile of patients hospitalized with heart failure in Bharatpur, Nepal. J Cardiovasc Thorac Res. 2012;4(4):103-5 PMID: 24250996 DOI: https://doi.org/10.5681/jcvtr.2012.025 8. Sharma D, Kafle RC, Alurkar VM. Pattern of cardiovascular disease among admitted in tertiary care teaching hospital. J Nepal Health Res Counc. 2020;18(46):93-8 PMID: 32335600 DOI: https://doi.org/10.33314/jnhrc.v18i1.2156 9. Shrestha UK, Alurkar VM, Baniya R, Barakoti B, Poudel D, Ghimire S. Profiles of heart failure in the western region of Nepal: prognostic implications of the MELD-XI score. Internal Medicine Inside. 2015;3(0):1 DOI: http://dx.doi.org/10.7243/2052-6954-3-1 10. Adhikari S, Gajurel RM, Poudel CM, Shrestha H, Thapa S, Devkota S, et al. Precipitating factors leading to decompensation of heart failure in patients attending a tertiary care centre of Nepal. Nepalese Heart Journal. 2020;17(1):17-21 DOI: https://doi.org/10.3126/njh.v17i1.28798 11. Shareef M, KC MB, Raut R, Hirachan A, KC B, Agarwal AK, et al. Etiology of heart failure in the emergency department of a tertiary cardiac centre of Nepal. Nepalese Heart Journal. 2017;14(2):1-4 DOI: https://doi.org/10.3126/njh.v14i2.18494 12. Dhungana SP, Chaparia A, Sharma SK. Prevalence of co-morbid conditions in J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/27206819/ https://doi.org/10.1093/eurheartj/ehw128 https://doi.org/10.1093/eurheartj/ehw128 https://pubmed.ncbi.nlm.nih.gov/30338883/ https://pubmed.ncbi.nlm.nih.gov/30338883/ https://doi.org/10.1002/ejhf.1323 https://doi.org/10.1002/ejhf.1323 https://pubmed.ncbi.nlm.nih.gov/15215791/ https://pubmed.ncbi.nlm.nih.gov/15215791/ https://doi.org/10.1016/j.ahj.2004.03.004 https://doi.org/10.1016/j.ahj.2004.03.004 https://doi.org/10.3126/njh.v16i2.26313 https://doi.org/10.3126/njh.v16i2.26313 https://pubmed.ncbi.nlm.nih.gov/17090768/ https://pubmed.ncbi.nlm.nih.gov/17090768/ https://doi.org/10.1001/jama.296.18.2217 https://doi.org/10.1001/jama.296.18.2217 https://doi.org/10.3126/njh.v6i1.18452 https://doi.org/10.3126/njh.v6i1.18452 https://pubmed.ncbi.nlm.nih.gov/24250996/ https://pubmed.ncbi.nlm.nih.gov/24250996/ https://doi.org/10.5681/jcvtr.2012.025 https://doi.org/10.5681/jcvtr.2012.025 https://pubmed.ncbi.nlm.nih.gov/32335600/ https://pubmed.ncbi.nlm.nih.gov/32335600/ https://doi.org/10.33314/jnhrc.v18i1.2156 https://doi.org/10.33314/jnhrc.v18i1.2156 http://dx.doi.org/10.7243/2052-6954-3-1 http://dx.doi.org/10.7243/2052-6954-3-1 https://doi.org/10.3126/njh.v17i1.28798 https://doi.org/10.3126/njh.v17i1.28798 https://doi.org/10.3126/njh.v14i2.18494 https://doi.org/10.3126/njh.v14i2.18494 Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients Heart failure: an experience at tertiary care hospital. Journal of Nobel Medical College. 2018;6(2):35-41 DOI: https://doi.org/10.3126/jonmc.v6i2.19568 13. Monib AK, Dhungana SP, Nepal R, Ghimire R. Clinical Profile of Patients with Heart Failure in Eastern Part of Nepal: a Hospital based study. Journal of Nobel Medical College. 2019;8(1):48-52 DOI: https://doi.org/10.3126/jonmc.v8i1.24477 14. Kligfield P, Gettes LS, Bailey JJ, Childers R, Deal BJ, Hancock EW, et al. Recommendations for the standardization and interpretation of the electrocardiogram: part I: The electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2007;115(10):1306-24 PMID: 17322457 DOI: https://doi.org/10.1161/circulationaha.106. 180200 15. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498 PMID: 32860505 DOI: https://doi.org/10.1093/eurheartj/ehaa612 16. Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances A Scientific Statement From the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol.2009;53(11):976-81 PMID: 19281930 DOI: https://doi.org/10.1016/j.jacc.2008.12.013 17. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14 PMID: 25559473 DOI: https://doi.org/10.1016/j.echo.2014.10.003 18. Elliott P, Andersson B, Arbustini E, Bilinska Z, Cecchi F, Charron P, et al. Classification of the cardiomyopathies: a position statement from the European Society Of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2008;29(2):270-6 PMID: 17916581 DOI: https://doi.org/10.1093/eurheartj/ehm342 19. Yaku H, Ozasa N, Morimoto T, Inuzuka Y, Tamaki Y, Yamamoto E, et al. Demographics, management, and in-hospital outcome of hospitalized acute J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np https://doi.org/10.3126/jonmc.v6i2.19568 https://doi.org/10.3126/jonmc.v6i2.19568 https://doi.org/10.3126/jonmc.v8i1.24477 https://doi.org/10.3126/jonmc.v8i1.24477 https://pubmed.ncbi.nlm.nih.gov/17322457/ https://doi.org/10.1161/circulationaha.106.180200 https://doi.org/10.1161/circulationaha.106.180200 https://doi.org/10.1161/circulationaha.106.180200 https://pubmed.ncbi.nlm.nih.gov/32860505/ https://doi.org/10.1093/eurheartj/ehaa612 https://doi.org/10.1093/eurheartj/ehaa612 https://pubmed.ncbi.nlm.nih.gov/19281930/ https://pubmed.ncbi.nlm.nih.gov/19281930/ https://doi.org/10.1016/j.jacc.2008.12.013 https://doi.org/10.1016/j.jacc.2008.12.013 https://pubmed.ncbi.nlm.nih.gov/25559473/ https://doi.org/10.1016/j.echo.2014.10.003 https://doi.org/10.1016/j.echo.2014.10.003 https://pubmed.ncbi.nlm.nih.gov/17916581/ https://pubmed.ncbi.nlm.nih.gov/17916581/ https://doi.org/10.1093/eurheartj/ehm342 https://doi.org/10.1093/eurheartj/ehm342 Adhikaree A, et al. Clinical Profile and Short-Term Outcome of Heart Failure Patients heart failure syndrome patients in contemporary real clinical practice in Japan-observations from the prospective, multicenter Kyoto Congestive Heart Failure (KCHF) registry. Circ J. 2018;82:2811-9 PMID: 30259898 DOI: https://doi.org/10.1253/circj.cj-17-1386 20. Mitani H, Funakubo M, Sato N, Murayama H, Rached RA, Matsui N, et al. In-hospital resource utilization, worsening heart failure, and factors associated with length of hospital stay in patients with hospitalized heart failure: A Japanese database cohort study. J Cardiol. 2020;76(4):342-9 PMID: 32636125 DOI: https://pubmed.ncbi.nlm.nih.gov/32636125 / 21. Yu Y, Gupta A, Wu C, Masoudi FA, Du X, Zhang J, et al. Characteristics, Management, and Outcomes of Patients Hospitalized for Heart Failure in China: The China PEACE Retrospective Heart Failure Study. J Am Heart Assoc. 2019;8(17):e012884 PMID: 31431117 DOI: https://doi.org/10.1161/jaha.119.012884 22. Aune D, Schlesinger S, Norat T, Riboli E. Tobacco smoking and the risk of heart failure: A systematic review and meta-analysis of prospective studies. Eur J Prev Cardiol. 2019;26(3):279-88 PMID: 30335502 DOI: https://doi.org/10.1177/2047487318806658 23. Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP, et al. Euro Heart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J. 2006;27(22):2725-36 PMID: 17000631 DOI: https://doi.org/10.1093/eurheartj/ehl193 24. Steinberg BA, Zhao X, Heidenreich PA, Peterson ED, Bhatt DL, Cannon CP, et al. Trends in patients hospitalized with heart failure and preserved left ventricular ejection fraction: prevalence, therapies, and outcomes. Circulation. 2012;126(1):65-75 PMID: 22615345 DOI: https://doi.org/10.1161/circulationaha.111.0 80770 25. Al-Tamimi MA-A, Gillani SW, Abd Alhakam ME and Sam KG. Factors Associated With Hospital Readmission of Heart Failure Patients. Front Pharmacol. 2021;12(0):732760 PMID: 34707497 DOI: https://doi.org/10.3389/fphar.2021.732760 26. Amran IM, Alias SA, Shahril NS, Basuki HF, Salleh AZZ, Khalil FA, et al. Heart Failure Admissions and its Associated Factors, Complications and Treatment. International Journal of Cardiology. 2019;297(Suppl):22-23 DOI: https://doi.org/10.1016/j.ijcard.2019.11.062 27. Cleland J, Dargie H, Hardman S, McDonag T, Mitchell P. National Heart Failure Audit, April 2012-March 2013. London: National Institute For cardiovascular Outcomes research (NICOR), Institute of Cardiovascular Science, University College; 2013 Nov. 86p. (Accessed on: 25th July 2022) Available from: http://www.wales.nhs.uk/sitesplus/docume nts/862/National%20Heart%20Failure%20 Audit%20April%202012-March2013.pdf 28. Lawson CA, Zaccardi F, Squire I, Ling S, Davies MJ, Lam CSP, et al. 20-year trends in cause-specific heart failure outcomes by sex, socioeconomic status, and place of diagnosis: a population-based study. Lancet Public Health. 2019;4(8):e406-e420 PMID: 31376859 DOI: https://doi.org/10.1016/s2468-2667(19)301 08-2 J. Lumbini. Med. Coll. Vol 10, No 1, Jan-June 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/30259898/ https://doi.org/10.1253/circj.cj-17-1386 https://doi.org/10.1253/circj.cj-17-1386 https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/31431117/ https://doi.org/10.1161/jaha.119.012884 https://doi.org/10.1161/jaha.119.012884 https://pubmed.ncbi.nlm.nih.gov/30335502/ https://pubmed.ncbi.nlm.nih.gov/30335502/ https://doi.org/10.1177/2047487318806658 https://doi.org/10.1177/2047487318806658 https://pubmed.ncbi.nlm.nih.gov/17000631/ https://pubmed.ncbi.nlm.nih.gov/17000631/ https://doi.org/10.1093/eurheartj/ehl193 https://doi.org/10.1093/eurheartj/ehl193 https://pubmed.ncbi.nlm.nih.gov/22615345/ https://pubmed.ncbi.nlm.nih.gov/22615345/ https://doi.org/10.1161/circulationaha.111.080770 https://doi.org/10.1161/circulationaha.111.080770 https://doi.org/10.1161/circulationaha.111.080770 https://pubmed.ncbi.nlm.nih.gov/34707497/ https://doi.org/10.3389/fphar.2021.732760 https://doi.org/10.3389/fphar.2021.732760 https://doi.org/10.1016/j.ijcard.2019.11.062 https://doi.org/10.1016/j.ijcard.2019.11.062 http://www.wales.nhs.uk/sitesplus/documents/862/National%20Heart%20Failure%20Audit%20April%202012-March2013.pdf http://www.wales.nhs.uk/sitesplus/documents/862/National%20Heart%20Failure%20Audit%20April%202012-March2013.pdf http://www.wales.nhs.uk/sitesplus/documents/862/National%20Heart%20Failure%20Audit%20April%202012-March2013.pdf http://www.wales.nhs.uk/sitesplus/documents/862/National%20Heart%20Failure%20Audit%20April%202012-March2013.pdf https://pubmed.ncbi.nlm.nih.gov/31376859/ https://pubmed.ncbi.nlm.nih.gov/31376859/ https://doi.org/10.1016/s2468-2667(19)30108-2 https://doi.org/10.1016/s2468-2667(19)30108-2 https://doi.org/10.1016/s2468-2667(19)30108-2