SQU Med J, May 2011, Vol. 11, Iss. 2, pp. 230-235, Epub. 15th May 11
Submitted 27th Nov 10
Revision ReQ. 2nd Feb 11, Revision recd. 17th Feb 10
Accepted 2nd Mar 10

Department of Cardiology, College of Medicine, King Khaled University, Abha, Saudi Arabia.
*Corresponding Author email: aassiri@yahoo.com

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 300
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 



:مفتاح الكلمات

aBstract: Objectives: This study aimed to investigate the clinical and therapeutic profiles of heart failure (HF) 
cases admitted to Aseer Central Hospital (ACH), Saudi Arabia. Methods: A retrospective cohort of 300 consecutive 
patients admitted with the diagnosis of HF to ACH from 1 June 2007 to 31 May 2009 were included in the study. 
Data on demographic variables, aetiologic factors, risk factors, and therapeutic profiles of patients with HF were 
collected and analysed. Results: The patients’ mean age was 67.4 ± 13.7 years and 68.7% of them were male. The 
commonest aetiologies for HF were ischaemic heart disease (IHD) and hypertension in 38.3% and 33.3% of patients, 
respectively. A total of 61.3% of patients were diabetics. Other risk factors for HF included renal failure in 9.7%, atrial 
fibrillation in 13%, and anaemia in 48.3% of patients. Echocardiography was performed in 98.7% of cases: the average 
ejection fraction (EF) was 33% ± 17. Angiotensin converting enzyme inhibitors (ACEI) or angiotensin 2 receptor 
blockers were used in 68.3% of cases, β-blockers in 51.6% of cases and digoxin in 28.3% of cases. Conclusion: The 
major causes of HF in our study were IHD and hypertension. Diabetes and anaemia were common risk factors. The 
cohort constituted an intermediate HF risk group (ejection fraction (EF) 33%). Important therapeutic agents like 
angiotensin converting enzyme inhibitor I, β-blockers and digoxin were underutilised. Fostering such therapy in 
practice will lead to a better outcome in the management of HF patients. Anaemia was a significant risk factor in 
our HF patients and should be managed properly.

Keywords: Heart failure; Therapeutics; Saudi Arabia

Clinical and Therapeutic Profiles of Heart 
Failure Patients admitted to a Tertiary Hospital, 

Aseer Region, Saudi Arabia
Abdullah S Assiri

CLINICAL & BASIC RESEARCH

Advances in Knowledge 
1. This study provides information on the pattern and aetiology of heart failure in Saudi Arabia and the pattern of risk factors for heart 

failure in Saudi population.
2. It highlights the underutilisation of important drug therapies in heart failure for Saudi patients. 



Abdullah S Assiri

Clinical and Basic Research | 231

Heart failure (HF) is defined as a complex syndrome resulting from inability of the heart to meet peripheral 
tissues metabolic demands at a normal filling 
pressure.1 It is a common final pathway of many 
chronic disorders namely hypertension, diabetes, 
and ischaemic  heart disease (IHD).2 The global 
prevalence of heart failure varies from 2.3% to 
3.9% per annum.3-5Annually, an estimated 23 
million people have heart failure worldwide and 
2 million new cases are diagnosed each year. Due 
to therapeutic improvement in the treatment of 
acute myocardial infarction and hypertension and 
improved survival, the incidence of heart failure has 
increased and become a real public health issue.2,6-7 

It is characterised by decreased quality of life with 
high morbidity and mortality. The HF mortality 
rate is approximately 25% within one year of initial 
diagnosis.3-5,8 

The aetiology of HF varies from different reports 
around the world, but ischaemic heart disease, 
hypertension, rheumatic heart disease and to a 
lesser extent cardiomyopathy and anaemia are the 
leading causes of HF. Ischaemic  heart disease is 
becoming a major leading cause of heart failure in 
developed countries, where more than two thirds of 
HF cases are due to IHD.9,10 Despite clear evidence 
of the beneficial effect of certain therapeutic agents 
like angiotensin converting enzyme inhibitors 
(ACEI,) β-blockers and K-sparing diuretics on 
survival, these agents continue to be underutilised 
globally.11

The Aseer Region (population 1,200,000) is 
located in the southwest of Saudi Arabia covering 
an area of more than 80,000 km2. The region 
extends from the high mountains of Sarawat (with 
an altitude of 3,200 m above the sea level) to the 
Red Sea. Health services delivery in Aseer region 
is provided by a network of 244 primary health 
care centers, 16 referral hospitals and one tertiary 
hospital, Aseer Central Hospital (ACH). ACH, 
with 500 beds, is run by the Ministry of Health and 
the College of Medicine of King Khalid University 
(KKU), Abha.

We aimed in this study to analyse the 
demographic data, clinical and therapeutic profiles 
of patients admitted with the diagnosis of heart 
failure to Aseer Central Hospital (ACH) and to 
find out how close we were to the recommended 
international standards of management of heart 
failure.

Methods
A retrospective cohort of all consecutive patients 
admitted to Aseer Central Hospital (ACH) with 
the diagnosis of heart failure according to medical 
records, during the two-year period 1 June 2007 to 
31 May 2009, were included in this study. Approval 
of the local medical ethical committee was obtained. 
Demographic data, underlying aetiologies, risk 
factors for heart failure (diabetes, hypertension, 
anaemia, atrial fibrillation and renal failure), 
echocardiographic features and ejection fraction 
(EF) values were collected. Conventionally patients 
with EF < 30% were labelled as having severe left 
ventricular dysfunction, 30–44 % as moderate left 
ventricular dysfunction, and 45–54% as mild left 
ventricular dysfunction.12  

Records on all medications used conventionally 
for treatment of heart failure were collected. 
The main angiotensin converting enzyme (ACE) 
inhibitor agent used was captopril, and the target 
recommended dose was considered to be one 50 
mg tablet taken three times a day, with any lower 
dose considered to be below the target dose.13 The 
main β-blocker agent used was carvedilol and the 
target recommended dose was considered to be one 
25 mg tablet taken twice daily, with any lower dose 
considered to be below the target dose.14

Data were analysed using the Statistical Package 
for the Social Sciences (SPSS) software package 
(Version 15.0). Frequency, percentage, mean, 
standard deviation and median were used to present 
the data.

Application to the patient care
1. This study highlights the need to improve the use of proven important drug therapies for heart failure.
2. Physicians should recognise and address the problem of drug underutilisation in heart failure management.
3. The study also provides information on important risk factors for heart failure development and how to improve their prevention.



Clinical and Therapeutic Profiles of Heart Failure Patients Admitted to a Tertiary Hospital, Aseer Region, Saudi Arabia

232 | SQU Medical Journal, May 2011, Volume 11, Issue 2

Results
The present study included 300 patients with the 
diagnosis of heart failure. The age ranged from 26 to 
101 years with an average 67.4 ± 13.7 years. A total 
of 206 patients (68.7%) were male. The commonest 
aetiology for heart failure was IHD in 38.5% of 
cases followed by hypertension in 33.3 % of cases. 
Other aetiologies included dilated cardiomyopathy 
in 10% and valvular heart disease in 3% of patients. 
The commonest risk factors were diabetes in 61.3%, 
hypertension in 59% and anaemia in 48.3% of 
patients. Other risk factors were atrial fibrillation 
in 13% and renal failure in 9.7% of patients. Table 1 
shows the demographic and clinical characteristics 
of heart failure patients in Aseer region, Saudi 
Arabia.

Echocardiography was performed in 98.75% of 
patients and the average EF was 33% ± 17 for the 
study group. Our patients lay in the moderate left 
ventricular dysfunction group. Table 2 shows the 
distribution of heart failure patients according to 
their ejection fraction values. Table 3 shows the 
frequency of types of treatment used in HF patients 
in the study cohort. 

The use of ACEI or angiotensin 2 receptor 
blockers (A2RB) was reported in 68.3% of patients, 
and among patients on ACEI, the majority (91.85%) 
were on lower than the target dose, thus only 8.15 % 
of patients were on the recommended target dose. 
Captopril was the main ACEI agent used in this 
cohort.

The rate of use of β-blockers in our study was 
51.6%. Among those patients prescribed this 
treatment, 82% were on lower than the target dose, 
thus only 18% were on the recommended target 
dose. Carvedilol was the main β-blocker agent used 
in this cohort.

Other heart failure medications used were 
digoxin for 28.3% of patients; loop diuretics for 87%; 
K-sparing diuretics for 45.3%; vasodilator therapy 
(hydralazine or calcium channel blockers) for 13%; 
warfarin for 16%, and amiodarone for 1.3%. 

Discussion 
The literature on clinical and therapeutic profiles of 
heart failure patients in Saudi Arabia is scarce. This 
makes it difficult to plan policies for the prevention 
and management of heart failure in Saudi Arabia. 
The only study in neighbouring countries was the 
Omani study which included 1,164 patients with 
symptomatic heart failure and showed a prevalence 
of heart failure in an Arab population to be 
5.17/1,000 population.15  

In our series, the mean age was 67.4 years which 
is similar to the Framingham series of a Western 
population, where the most susceptible age for the 
onset of HF was 60 years and older.16 In our cohort, 
more than two thirds of patients were older than 
60 years. 

IHD and hypertension were the commonest 
aetiology of heart failure in our series, this concurs 
with similar findings both the Framingham16 and 
the Omani study.15   

Among risk factors for heart failure, we found 
the incidence of diabetes in our group to be high 
(61.3%); this data corroborates well with Al-Nozha’s 
findings of a high prevalence of diabetes in Saudi 
society.17

An important relevant finding in our study 

Table 1: Demographic and clinical characteristics of 
heart failure patients in Aseer Region, Saudi Arabia

Demographic/clinical characteristic No ( % )

Age, ( Mean ± SD) 67.4 ± 13.7

≥ 60 years, No (%) 228 (76%)

Male gender 206 (68.7%)

Aetiology

Ischaemic  cardiomyopathy
Hypertensive heart disease
Dilated cardiomyopathy
Valvular heart disease              

115 (38.3%)
100 (33.3%)

30 (10%)
9 (3%)

Risk Factors

Diabetes
Hypertension
Anaemia
Atrial fibrillation
Renal failure              

184 (61.3%)
177 (59%)

145 (48.3%)
39 (13%)
29 (9.7%)

Table 2: Distribution of heart failure patients by ejection 
fraction value

Type of LVD No (%)

Mild LVD (EF 45-54%) 29 (9.7%)

Moderate LVD (EF 30-44%) 83 (27.7%)

Severe LVD (EF < 30%) 141 (47%)

Normal (EF ≥ 55%) 43 (14.3%)

Echocardiography was not done 4 (1.3%)

Legend: LVD = left ventricular dysfunction; EF = ejection fraction



Abdullah S Assiri

Clinical and Basic Research | 233

is the high prevalence of anaemia (defined as 
haemoglobin level less than 12 gm/dl in females and 
less than 13 gm/dl in males according to the WHO 
definition).18  In our series, anaemia was detected in 
48.3% of patients with heart failure. Evidence from 
previous studies showed that anaemia is a long term 
predictor of poor prognosis in patients with severe 
heart failure.19 This group of patients requires 
special attention as correcting their anaemia will 
improve their clinical and haemodynamic status. 
The reasons for this relatively high prevalence of 
anaemia in our cohort could be due to different 
factors among them the fact that the Assir region is 
considered to be one of the major pockets of sickle 
cell genes in Saudi Arabia.20 Other important risk 
factors for heart failure include atrial fibrillation 
and renal failure which we found in our series (13% 
and 9.7% respectively); similar incidences of these 
two disorders were reported in other studies.7 These 
disorders were found to contribute to a high need 
of hospitalisation for elderly patients with heart 
failure.21,22 

The rate of echocardiography performance 
was adequate in our series where the vast majority 
of heart failure patients (98.7%) underwent 
echocardiographic assessment.

The majority of our patients were in the moderate 
risk group according to the EF value categorisation.   

In large trials, ACEI was clearly found to 
improve survival, functional capacity and to reduce 
the need for hospitalisation when given to heart 
failure patients.23-25 Despite these studies, the drugs 

are underutilised and, when used, the optimal dose 
is not achieved.24-28 In the current study, only 68.3% 
of heart failure patients were prescribed ACEI, and 
the majority of them were not on the recommended 
target dose. In contrast to this finding, in the USA 
ACEI is used in 89% of patients with heart failure.29 

This low rate of use in our cohort can be due to 
several factors: 1) lack of awareness of the important 
role of ACEI in improving mortality in HF patients; 
2) inappropriate broadening of the scope of the 
contraindications by clinicians; 3) lack of adherence 
to the recommended guidelines; 4) patient’s poor 
compliance with medications, or the economic cost 
of prescribing multiple medications to heart failure 
patients.

Similar findings regarding the underutilisation 
of ACE inhibitors in heart failure patients was 
observed in other studies and multiple factors 
were found to contribute to such a practice; among 
these were the older age of patients, the presence 
of renal dysfunction, the presence of only diastolic 
dysfunction, and the substandard quality of care 
given to heart failure patients.30  

β-blockers were found to reduce mortality and 
frequency of hospital admissions when given to 
patients with heart failure.14,31-32 The meta analysis 
of 21 trials showed that β-blockers improve left 
ventricular ejection fraction by 25%.33 In our study, 
we found only 51.6% of HF patients were prescribed 
β-blockers, and the majority of those were not on 
the recommended target dose. The same reasons 
postulated for ACEI underutilisation can be applied 
to the underutilisation of β-blockers.

Digoxin was found to decrease the need for 
admissions, but did not reduce mortality when 
given to patients with heart failure.34-36 Digoxin was 
used in only 28.3% of our cohort which is lower than 
the rate reported in the USA (50%).29 This low rate 
in our series could be due to clinicians giving more 
priority to drugs that reduce mortality only and less 
importance to drugs that only improve morbidity.

The use of oral anticoagulation warfarin in HF 
patients, especially those with severe left ventricular 
dysfunction, was found to reduce stroke, sudden 
death, and myocardial infarction.37 In large HF trials 
like SOLVD (Study of Left Ventricular Dysfunction), 
oral anticoagulation warfarin was used in 12% 
of patients.38 In our series, it was used in 16% of 
patients which is close to the international figure.

Amiodarone was found to reduce arrhythmia, 

Table 3: Frequency of types of drugs used in treatment 
of heart failure patients

Drugs No (%)

Loop Diuretics 261 (87%)

ACEI (angiotensin converting enzyme 
inhibitor) or A2RB (angiotensin 2 
receptor blockers) 

205 (68.33%)

β-Blockers 155 (51.7%)

K-Sparing Diuretics 136 (45.3%)

Nitrates 91 (30.3%)

Digoxin 85 (28.3%)

Warfarin 48 (16%)

Hydralazine 21 (7%)

Amplodipine 18 (6%)

Amiodarone 4 (1.3%)



Clinical and Therapeutic Profiles of Heart Failure Patients Admitted to a Tertiary Hospital, Aseer Region, Saudi Arabia

234 | SQU Medical Journal, May 2011, Volume 11, Issue 2

but not mortality, in HF patients.39 The rate of 
amiodarone use in large HF trials was 14.4%.38 
which is clearly higher than our rate of 1.3%. The 
reason for such a discrepancy is not obvious. 

The observed underutilisation of different 
evidence-based therapeutic agents for the treatment 
of heart failure patients in our cohort was also 
reported in other larger studies such as the Euro 
Heart survey on heart failure.40

Conclusion
In conclusion, we believe that this study shed some 
light on the clinical and the therapeutic profile of 
HF patients treated in the tertiary hospital in Aseer 
Region, Saudi Arabia. It has shown that IHD and 
hypertension were the leading causes of HF in this 
cohort. Diabetes is a highly prevalent risk factor and 
anaemia is a significant problem in our HF patients 
and should be corrected. Furthermore, this study 
showed underutilisation of the important treatment 
modalities used for HF, mainly ACEI, β-blockers 
and digoxin, and when used, the doses were not 
optimal. Awareness of this data will contribute to 
improvement in management of HF patients and 
encourage clinicians to adhere to the recommended 
guidelines for HF management. This study also calls 
for an urgent need to establish a national registry 
for heart failure in Saudi Arabia in order to evaluate 
the economic burden of such a common medical 
disorder and therefore plan a better health care 
system. 

c o n f l i c t o f i n t e r e s t
The author reported no conflict interest.

a c k n o w l e d g m e n t s

The author would like to thank the following 
colleagues from the College of Medicine, Abha, 
Saudi Arabia for their assistance with this paper: 
Dr Ahmed A. Mahfouz, Professor of Epidemiology, 
Department of Family & Community Medicine 
for statistical consultation and Dr. Awad Ahmed 
El-Mekki, Department of Medicine for English 
language revision.

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