Background: Cardiovascular disease is the leading cause of death globally, with approximately 80% of these deaths occurring in low- and middle-income countries. Sex differences in cardiovascular disease are well described in high-income countries but limited in low- and middle-income countries. Objectives: This study sought to evaluate the sex differences in clinical presentation, cardiovascular risk profile, diagnosis, treatment, and outcomes among patients in the Kenya Heart Registry. Methods: Data were prospectively collected from 3 tertiary hospitals, including patients with heart failure, acute coronary syndrome, venous thromboembolism, and atrial fibrillation. Primary outcomes were in-hospital and 6-month mortality, as well as sex-specific differences in clinical presentation, cardiovascular risk factors, diagnosis, and treatment. Results: Among 1,687 participants, 51.3% were women. Of these, 1,241 were admitted, while 446 were managed as outpatients. Women were younger (50.9 vs 54.2 years; P < 0.001), had lower monthly income, higher left ventricular ejection fraction, higher rates of heart failure with preserved ejection fraction, venous thromboembolism, and atrial fibrillation, and lower rates of acute coronary syndrome than men. No sex difference was observed in diagnostics or treatment or adherence to guideline-directed therapies. In-hospital and 6-month all-cause mortality were 7.4% and 14.7%, respectively, and were similar by sex (women 8.0% and 14.8% vs men 6.9% and 14.5%; P = 0.449 and P = 0.881, respectively). Conclusions: Significant sex differences exist in clinical profiles, but management and outcomes are similar. Scaling up evidence-based interventions is urgently needed to reduce the high mortality in this population.

BACKGROUND:Timely identification of outpatients with heart failure with reduced ejection fraction (HFrEF) transitioning toward advanced heart failure (HF) is challenging, and the prevalence of advanced HF in this population is unknown. METHODS:Outpatients with chronic HF, left ventricular ejection fraction ≤30%, and New York Heart Association class II-III symptoms despite medical therapy were identified from 9 HF clinics by the prescreening of electronic health records. Eligible patients were invited to undergo screening for features of advanced HFrEF, defined as (1) left ventricular ejection fraction ≤30%; (2) N-terminal pro-B-type natriuretic peptide >2000 pg/mL; and (3) a cardiopulmonary exercise test with peak oxygen uptake <12 or 14 mL/kg/min or 6-minute walk distance <300 m. A subgroup underwent right heart catheterization. Logistic regression models were used to identify markers of advanced HF and hemodynamic compromise, defined as cardiac index <2.2 L/min/m2 and pulmonary capillary wedge pressure >12 mm Hg. RESULTS:Among 1020 identified patients, 424 accepted investigator contact, and 300 (median age 64 years, 21% women) were screened. Features of advanced HFrEF were identified in 19 patients (6.3%; 95% confidence interval 3.9%-9.7%). Hemodynamic compromise was present in 30% of the patients, including 83% and 23% of those meeting and not meeting the clinical advanced HF criteria, respectively. Lower systolic blood pressure, Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS), maximal workload, hemoglobin, and estimated glomerular filtration rate (eGFR) were associated with features of advanced HFrEF. A history of ventricular tachycardia or fibrillation, greater N-terminal pro-B-type natriuretic peptide, lower peak oxygen uptake, KCCQ-OSS, and eGFR were associated with hemodynamic compromise. CONCLUSIONS:Screening outpatients with an ejection fraction ≤30% and mild-to-moderate symptoms identifies previously unrecognized features of advanced HFrEF in approximately 6%. Nearly one-third of the screened patients had hemodynamic compromise irrespective of whether they exhibited features of advanced HFrEF. Simple clinical markers such as eGFR, hemoglobin, or KCCQ-OSS may refine the screening process.

INTRODUCTION:To assess how national income level influences global variation in the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). METHODS:A web-based survey on HFpEF diagnosis and treatment was distributed worldwide from May to July 2023 through email, scientific societies, and social networks. Respondents provided demographic information and details on diagnostic practices, resource availability, and treatment approaches. Countries were categorized according to the 2023 World Bank income classifications: high-income countries (HICs), upper-middle-income countries (UMICs), lower-middle-income countries (LMICs), and low-income countries (LICs). RESULTS:1459 physicians from 91 countries completed the survey (median age 42 years; 61% male). Income level influenced the type of clinician managing HFpEF, with cardiologists more frequently involved in UMICs and LMICs/LICs than HICs. Respondents in HICs reported a higher proportion of HFpEF among their HF patients (40% vs 30% elsewhere; P < .001). Use of natriuretic peptides varied significantly across settings, as did the availability of echocardiographic parameters required for HFpEF assessment, which was highest in HICs. Screening for coronary artery disease in new HFpEF cases ranged from 22% in LMICs/LICs to 40% in UMICs. Availability of ACE inhibitors, ARBs, MRAs, and loop diuretics showed clear income-related differences, while SGLT2 inhibitors were widely available across all groups (88%). Multi-disciplinary HF programmes were most common in HICs (62%) and least common in LMICs/LICs (24%; P < .001). CONCLUSION:National income level is associated with major differences in diagnostic testing, medication access, specialist involvement, and multi-disciplinary care for HFpEF. These disparities highlight the need for scalable, resource-adapted strategies to optimize HFpEF care globally.

Soud Seif,1 Jasmit Shah,1,2 Mohamed Jeilan,1 Anders Barasa,1 Harun A Otieno,1 Felix Ayub Barasa,3 Bernard Gitura,4 Mzee Ngunga11Department of Medicine, Aga Khan University Hospital, Nairobi, Kenya; 2Brain and Mind Institute, Aga Khan University, Nairobi, Kenya; 3Department of Cardiology, Moi Teaching and Referral Hospital, Eldoret, Kenya; 4Department of Cardiology, Kenyatta National Hospital, Nairobi, KenyaCorrespondence: Soud Seif, Department of Medicine, Aga Khan University Hospital, P.O. Box 30270-00100, Nairobi, Kenya, Email soudykudi7@gmail.comBackground: Venous thromboembolism (VTE) encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE) poses a significant burden despite advances in diagnostic and therapeutic options. The risk factors and clinical outcomes of VTE are dynamic, highlighting the need for more comprehensive studies, especially in sub-saharan Africa. This study aimed to identify risk factors and clinical outcomes in three major tertiary centers in Kenya.Methodology: The HEART Registry was developed in 2021 and recruited patients with VTE prospectively over three years from three facilities in Kenya. Patients’ demographics, risk factors for VTE, hospital course, and clinical outcomes over six months were obtained. Descriptive statistics were used to summarize the data, presenting the findings as frequencies, percentages, medians, and interquartile ranges. No pre-specified inferential or comparative analyses were planned, consistent with the descriptive registry design.Results: A total of 422 patients with VTE were prospectively enrolled. The median age was 46.5 years notably younger than typically reported in Western populations. DVT was the most common presentation (54%) followed by PE (38.4%). A substantial proportion of patients (49.5%) did not have any identifiable risk factors (unprovoked VTE). The most common acute-phase treatment was low molecular weight heparin (57.5%), followed by warfarin (28.6%). Direct oral anticoagulants recommended as first line therapy by current international guidelines were available but underutilized reflecting access constraints. Only 1.7% of participants received thrombolytic therapy. The median length of hospital stay was eight days. In the acute phase, 10.4% (n=31) of admitted participants died. At six-month follow-up, death occurred in an additional 39 patients.Conclusion: A substantial proportion of VTE patients in Kenya had no identifiable risk factors which is a pattern consistent with global data on unprovoked VTE. This highlights the need for caution in attributing VTE solely to preventable causes. VTE associated acute and six month mortality was high, driven predominantly by underlying comorbidities. Preventing VTE in acute medical conditions remains a major area of concern and future prospective studies are needed to identify novel population specific risk factors and optimize outcomes in this setting.Keywords: venous thrombosis, pulmonary embolism, deep vein thrombosis, anticoagulation, Kenya, sub-Saharan Africa, HEART Registry, risk factors, outcomes

Introduction:cardiovascular disease is a growing concern in Africa, with coronary artery disease emerging as a leading cause of mortality. Despite strong evidence and international guidelines recommending secondary prevention therapy post-acute coronary syndrome (ACS)-including antiplatelet agents, statins, beta blockers, and angiotensin-converting enzyme (ACE) inhibitors-suboptimal use remains a concern, especially in low- and middle-income countries. This study aimed to quantify the use of guideline-recommended secondary prevention medications after ACS in Kenya using the data from the Kenya Heart Registry study. Methods:a cohort study was conducted using data from the Kenya Heart Registry across three hospitals in Kenya from 2019 to 2023. Adult patients (≥18 years) diagnosed with ACS (ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), or unstable angina (UA)) were included. Clinical and sociodemographic data were extracted, including pharmacotherapy at presentation and discharge. Descriptive statistics and multivariate logistic regression (odds ratio (OR) and 95% confidence intervals) were used to assess patterns and predictors of medication use at discharge. Results:a total of 247 patients were included (168 STEMI, 79 NSTEMI/UA). Majority, 77.7%, were males and 39.3% were above the age of 65 years. More than 70% of the patients were overweight or obese. Use of secondary prevention therapy was low at home but increased significantly during hospitalization and remained high at discharge. At discharge, 91.4% of STEMI and 89.9% of NSTEMI/UA patients received aspirin; 88.3% and 84.8%, respectively, received statins. The odds of receiving a beta blocker at discharge were higher among patients with diabetes (OR=2.59) and dyslipidemia (OR=2.46), while patients with hypertension had higher odds of receiving ARB (OR=5.28). Conclusion:despite better in-hospital and discharge prescribing patterns, suboptimal pre-hospital medication use and underutilization of certain agents like ticagrelor at discharge highlight gaps in care. Tailored interventions such as provider training, patient education, and strengthened transition-of-care protocols are needed to improve long-term adherence to guideline-directed medical therapy after ACS in Kenya, particularly among high-risk groups.

Introduction:atrial fibrillation is increasingly diagnosed in Kenya due to the persistence of rheumatic heart disease and the rising burden of cardiovascular risk factors. We aim to describe the baseline, clinical, treatment characteristics, and six-month outcomes of patients diagnosed with atrial fibrillation in Kenya. Methods:a retrospective observational cohort study design was employed. Data were obtained from three Kenyan referral hospitals, including public and private institutions. Baseline and six-month data were collected. Depending on the type of variable, data were summarized descriptively. Results:two hundred forty participants were enrolled, with a median age of 59.0 (IQR: 42.0-75.8). Women made up 54.4% (n=123) of the cohort. The median body mass index was 24.8 kg/m2(IQR: 21.1-29.2), and 62.8% (n=142) of participants were hospitalized at enrollment. Non-valvular atrial fibrillation (AF) was the predominant type, accounting for 77.4% (n=175) of cases, with persistent AF being the most common subtype (60.5%, n=137). At baseline, 77% (n=174) of participants were on anticoagulation therapy. The proportion with high-risk HAS-BLED and CHA2DS2-VASc scores at baseline was 10 (4.4%) and 62 (28.8%), respectively. Hypertension was the most prevalent comorbidity, affecting 39.4% (n=89) of participants. Nearly half (48.6%) had a preserved left ventricular ejection fraction. At the six-month follow-up, all participants remained on anticoagulation therapy. Mortality occurred in 17.7% (n=40) of participants, with cardiovascular causes accounting for 45.0% of these deaths. Conclusion:the predominant type was non-valvular atrial fibrillation. Enhancing screening for comorbidities and adopting a holistic approach to atrial fibrillation care could lead to better patient outcomes in Kenya.

BACKGROUND:TAP-IT (Thoracentesis to Alleviate Cardiac Pleural Effusion-Interventional Trial) investigated the effect of therapeutic thoracentesis in addition to standard medical therapy in patients with acute heart failure and sizeable pleural effusion. METHODS:This multicenter, unblinded, randomized controlled trial, conducted between August 31, 2021, and March 22, 2024, included patients with acute heart failure, left ventricular ejection fraction ≤45%, and non-negligible pleural effusion. Patients with very large effusions (more than two-thirds of the hemithorax) were excluded. Participants were randomly assigned 1:1 to upfront ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard medical therapy or standard medical therapy alone. The primary outcome was days alive out of the hospital over the following 90 days; key secondary outcomes included length of admission and 90-day all-cause mortality. All outcomes were analyzed according to the intention-to-treat principle. RESULTS:A total of 135 patients (median age, 81 years [25th; 75th percentile, 75; 83]; 33% female; median left ventricular ejection fraction, 25% [25th; 75th percentile, 20%; 35%]) were randomized to either thoracentesis (n=68) or standard medical therapy (n=67). The thoracentesis group had a median of 84 days (77; 86) alive out of the hospital over the following 90 days compared with 82 days (73; 86) in the control group (P=0.42). The mortality rate was 13% in both groups, with no difference in survival probability (P=0.90). There were no differences in the duration of the index admission (control group median, 5 days [3; 8]; thoracentesis group median, 5 days [3; 7], P=0.69). Major complications occurred in 1% of thoracenteses performed during the study period. CONCLUSIONS:For patients with acute heart failure and pleural effusion, a strategy of upfront routine thoracentesis in addition to standard medical therapy did not increase days alive out of the hospital for 90 days, all-cause mortality, or duration of index admission. The current findings lay the groundwork for future research to confirm the results. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT05017753.

AIMS:The EMAIL-HF trial aims to evaluate whether a digital guideline implementation strategy can increase and accelerate initiation of sodium-glucose co-transporter 2 (SGLT2) inhibitors in patients with heart failure (HF). METHODS AND RESULTS:EMAIL-HF is a pragmatic, registry-based, randomized controlled trial including patients with a diagnosis of HF within the last 10 years, residing in the Capital Region of Denmark and the municipality of Roskilde (~2 million inhabitants). A total of 5996 eligible patients not already treated with SGLT2 inhibitors were identified from nationwide health registries and randomized 1:1 to either receive a digital letter providing information on SGLT2 inhibitors with an invitation for evaluation (intervention group: 2979 patients), or to usual care without the letter (control group: 3017 patients). The median age was 73 years (intervention) vs. 74 years (control), with 67.4% and 66.5% males, respectively. The primary outcome is the proportion of patients initiating SGLT2 inhibitor therapy within 6 months after randomization. The secondary outcome is a composite of time to first HF hospitalization or all-cause mortality. Additional exploratory outcomes include adherence, clinical events, healthcare utilization and subgroup analyses. Full baseline characteristics and clinical outcomes will be reported after completion of event accrual. CONCLUSIONS:EMAIL-HF will determine whether a population-wide digital strategy can increase and accelerate guideline-based initiation of SGLT2 inhibitors in patients with chronic HF. This trial may offer a scalable model to improve implementation of novel therapies in routine clinical practice.

Background Diastolic dysfunction (DD), a precursor to heart failure with preserved ejection fraction (HFpEF), is associated with significant morbidity and mortality. Data on DD in Sub-Saharan Africa (SSA) remain limited. This study aimed to determine the prevalence and describe the clinical and echocardiographic characteristics of DD in a cohort of adult patients at a tertiary referral facility in Kenya. Methods In this prospective cohort study, we reviewed 1,205 echocardiographic examinations performed in a six-month period in 2020 at the Aga Khan University Hospital, Nairobi, Kenya. Diastolic function was assessed based on the 2016 ASE/EACVI guidelines. Patients with preserved left ventricular (LV) systolic function (Left Ventricular Ejection Fraction [LVEF] ≥ 50%) and evidence of diastolic abnormalities were evaluated, and those meeting guideline criteria for DD were included in the final analysis. Results Among the 1,205 echocardiograms reviewed, 43.1% (n = 519) showed at least one diastolic abnormality, and 32.1% (n = 387) met the inclusion criteria. Of these, 53.2% (n = 206) were classified as having severe DD, while 46.8% (n = 181) had borderline DD. The mean age of participants was 62.8 ± 12.3 years. The most common symptoms were dyspnea (54.8%), chest pain (31.5%), and fatigue (27.1%). Hypertension was affecting 78.6%. Multivariate analysis identified the following independent predictors of severe DD: chronic kidney disease (OR: 8.07, 95% CI: 3.25–19.99), preexisting heart failure (OR: 6.04, 95% CI: 3.26–11.17), atrial fibrillation (OR: 5.43, 95% CI: 1.57–18.83), pacemaker implant (OR: 4.95, 95% CI: 1.09–22.5), dyspnea (OR: 3.39, 95% CI: 1.76–6.55), anemia (Hb < 10 g/dL) (OR: 2.04, 95% CI: 1.24–3.36), hypertension (OR: 2.04, 95% CI: 1.22–3.43), advanced age (OR: 1.02, 95% CI: 1.01–1.04), and elevated NT-proBNP (OR: 18.52, 95% CI: 3.36–101.9). Echocardiographic parameters associated with severe DD included LV hypertrophy (OR: 2.67, 95% CI: 1.61–4.4), abnormal global longitudinal strain (OR: 1.66, 95% CI: 1.009–2.74), and low-normal LV systolic function (OR: 1.64, 95% CI: 1.06–2.53). Conclusion This study shows that a third of patients referred for echocardiography at a tertiary referral hospital in Kenya have diastolic dysfunction, the majority severe. Traditional cardiovascular risk factors: hypertension and chronic kidney disease, were strongly associated with severe DD. These findings underscore the importance of early detection and aggressive management of cardiovascular risk factors to prevent the onset and progression of HF in Sub-Saharan Africa.

Background Cardiovascular disease is the leading cause of death globally, with approximately 80% of these deaths occurring in low- and middle-income countries. Sex differences in cardiovascular disease are well described in high-income countries but limited in low- and middle-income countries. Objectives This study sought to evaluate the sex differences in clinical presentation, cardiovascular risk profile, diagnosis, treatment, and outcomes among patients in the Kenya Heart Registry. Methods Data were prospectively collected from 3 tertiary hospitals, including patients with heart failure, acute coronary syndrome, venous thromboembolism, and atrial fibrillation. Primary outcomes were in-hospital and 6-month mortality, as well as sex-specific differences in clinical presentation, cardiovascular risk factors, diagnosis, and treatment. Results Among 1,687 participants, 51.3% were women. Of these, 1,241 were admitted, while 446 were managed as outpatients. Women were younger (50.9 vs 54.2 years; P < 0.001), had lower monthly income, higher left ventricular ejection fraction, higher rates of heart failure with preserved ejection fraction, venous thromboembolism, and atrial fibrillation, and lower rates of acute coronary syndrome than men. No sex difference was observed in diagnostics or treatment or adherence to guideline-directed therapies. In-hospital and 6-month all-cause mortality were 7.4% and 14.7%, respectively, and were similar by sex (women 8.0% and 14.8% vs men 6.9% and 14.5%; P = 0.449 and P = 0.881, respectively). Conclusions Significant sex differences exist in clinical profiles, but management and outcomes are similar. Scaling up evidence-based interventions is urgently needed to reduce the high mortality in this population.

Heart failure (HF) poses a significant and growing public health challenge in Kenya, largely driven by the increasing prevalence of hypertension, diabetes mellitus, and obesity. The condition disproportionately affects younger adults and is primarily linked to non-ischemic causes. Despite the existence of evidence-based treatment options, major barriers remain—particularly in timely diagnosis, access to care, and long-term management—leading to high rates of hospital readmission and mortality. Additionally, the absence of robust national data limits the development of effective policies and optimized HF care strategies. This study aimed to describe the clinical and demographic characteristics, underlying etiologies, management practices, and short-term outcomes—including in-hospital and six-month mortality—of HF patients in Kenya, utilizing data from the National Research Fund (NRF) Registry on Cardiovascular Diseases. This was a prospective observational study, conducted at three tertiary hospitals in Kenya—Kenyatta National Hospital, Moi Teaching and Referral Hospital, and Aga Khan University Hospital—representing public and private sectors from December 2021 to December 2022. Adults (≥ 18 years) with clinically and objectively confirmed heart failure were enrolled from both inpatient and outpatient settings. Data were managed via REDCap and analyzed using Stata 17.0. Descriptive statistics were used to describe the population. Logistic regression was used to assess survival and predictors of mortality. Statistical significance was set a P value < 0.05. A total of 795 HF patients were enrolled across three tertiary hospitals in Kenya. The mean age was 52.3 years (SD 18.4), 51.7

Cardiac amyloidosis (CA) is still an underdiagnosed cause of heart failure (HF) and early disease recognition and timely disease-modifying therapy (DMT) administration translate to better outcomes. We aimed to assess CA screening and management approaches for patients with HF preserved ejection fraction (HFpEF) among physicians worldwide. An independent academic web-based survey was distributed worldwide between May 2023 and July 2023. Overall, 1,460 physicians (61% were men, median age was 42 [34 to 49] years) from 95 countries completed the survey. A total of 2/3 of respondents had experience diagnosing CA and reported having 10% of patients with CA in patients with HFpEF. Systematic screening for CA of all patients with HFpEF was performed by 10% of responders, whereas 24% did not consider the screening. Most responders (39%) used left ventricular hypertrophy as a screening criterion. Serum protein electrophoresis with immunofixation of free light chain and urine protein electrophoresis or cardiac magnetic resonance were selected by half of the responders as a first-line diagnostic tool. The combination of serum protein electrophoresis with immunofixation free light chain, urine protein electrophoresis, and bone scintigraphy was considered by 32% of the participants. CA DMT was available for 48% of the physicians. About 82% of responders would administrate HF to patients with HFpEF with CA, with the most preferable drugs being diuretics, sodium-glucose cotransporter-2 inhibitors, and renin-angiotensin-aldosterone system inhibitors. In conclusion, the results reveal the uncertainties among physicians worldwide regarding the need for CA screening of patients with HFpEF. CA remains a disease with very heterogeneous management, particularly, in the screening and diagnostic workup. The HF community should aim to educate on CA and improve access to DMT.

Heart failure with reduced ejection fraction is a syndrome consisting of symptoms (dyspnoea, fatigue, swelling) and/or signs of congestion (pulmonary crackles, oedema). It is caused by structural and/or functional pathologies, most commonly ischaemic heart disease, entailing elevated cardiac filling pressures and can result in low cardiac output. Medical treatment has evolved during the recent decades as outlined in this review, and a 4-pillar treatment strategy is recommended including a renin-angiotensin-aldosterone system blocker or sacubitril/valsartan, a betablocker, a mineralocorticoid antagonist, and an SGLT2 inhibitor.

Background: Inflammation is a key driver of heart failure with preserved left ventricular ejection fraction. AZD4831 inhibits extracellular myeloperoxidase, decreases inflammation, and improves microvascular function in preclinical disease models. Methods and Results: In this double-blind phase 2a study (Safety and Tolerability Study of AZD4831 in Patients With Heart Failure [SATELLITE]; NCT03756285), patients with symptomatic heart failure, left ventricular ejection fraction of >= 40%, and elevated B-type natriuretic peptides were randomized 2:1 to once-daily oral AZD4831 5 mg or placebo for 90 days. We aimed to assess target engagement (primary end point: myeloperoxidase specific activity) and safety of AZD4831. Owing to coronavirus disease 2019, the study was terminated early after randomizing 41 patients (median age 74.0 years, 53.7% male). Myeloperoxidase activity was decreased by more than 50% from baseline to day 30 and day 90 in the AZD4831 group, with a placebo-adjusted decreased of 75% (95% confidence interval, 48, 88, nominal P < .001). No improvements were noted in secondary or exploratory end points, apart from a trend in Kansas City Cardiomyopathy Questionnaire overall summary score. No deaths or treatment-related serious adverse events occurred. AZD4831 treatment-related adverse events were generalized maculopapular rash, pruritus, and diarrhea (all n = 1). Conclusions: AZD4831 inhibited myeloperoxidase and was well tolerated in patients with heart failure and left ventricular ejection fraction of 40% or greater. Efficacy findings were exploratory owing to early termination, but warrant further clinical investigation of AZD4831.

AbstractAimsThis study aims to evaluate the worldwide variations in the diagnosis and treatment of heart failure with preserved ejection fraction (HFpEF), using an HF survey distributed internationally to physicians, including both cardiologists and non‐cardiologists.Methods and resultsA group of HF specialists designed an independent, academic web‐based survey focusing on HFpEF care and diagnosis, which was distributed via scientific societies and various social networks between 1 May 2023 and 1 July 2023. The survey included 1459 physicians (1242 cardiologists and 217 non‐cardiologists) from 91 countries, with a mean age of 42 (34–49) years and 61% male. Most physicians (89.2%) defined HFpEF as left ventricular ejection fraction ≥50%. Significant regional variations were observed in HFpEF management (P < 0.001 for all comparisons unless stated otherwise). Cardiologists managed 63.1% of HFpEF patients overall, with significant variability across regions (P < 0.001). The estimated HFpEF prevalence was highest in Eastern Asia and Western Europe and lowest in Africa and South America. Diagnostic practices varied: natriuretic peptide use ranged from 70%–74% in Africa to 95%–97% in Southern/Western Europe. Echocardiographic parameters showed regional differences, with diastolic stress testing used most in South‐Eastern Asia (47% vs. 13–36% elsewhere). HFpEF scoring systems were most common in South‐Eastern Asia (78%) and least in Africa (30.1%). Coronary artery disease screening approaches differed, with Eastern Asian physicians more likely to always perform routine angiograms (52%) compared with Northern Europeans (12%). Treatment preferences also varied regionally. Sodium glucose co‐transporter‐2 inhibitors (SGLT2i) was the preferred first‐line treatment (45%–70% across regions), followed by diuretics. In an ideal setting, 52% would primarily use SGLT2i, 33% loop diuretics, and 22% beta‐blockers. Drug availability differed significantly: SGLT2i was most available (88% overall), while ARNI was least available (61%). South America and Middle Eastern/Northern Africa reported lower availability of guideline‐directed therapies. Multidisciplinary HF programmes were most common in Asia (70%) and least in Africa (24%). The perceived benefit of atrial flow regulator devices also showed significant regional differences.ConclusionsThere are considerable global variations in the diagnosis and management of HFpEF. Most physicians favour SGLT2i despite regional disparities in health care resources and guideline adherence. Harmonized practices and improved access to comprehensive care can enhance outcomes of HFpEF patients worldwide.

Introduction Pleural effusion is present in half of the patients hospitalised with acute heart failure. The condition is treated with diuretics and/or therapeutic thoracentesis for larger effusions. No evidence from randomised trials or guidelines supports thoracentesis to alleviate pleural effusion due to acute heart failure. The Thoracentesis to Alleviate cardiac Pleural effusion Interventional Trial (TAP-IT) will investigate if a strategy of referring patients with acute heart failure and pleural effusion to up-front thoracentesis by pleural pigtail catheter insertion in addition to pharmacological therapy compared with pharmacological therapy alone can increase the number of days the participants are alive and not hospitalised during the 90 days following randomisation.Methods and analysis TAP-IT is a pragmatic, multicentre, open-label, randomised controlled trial aiming to include 126 adult patients with left ventricular ejection fraction ≤45% and a non-negligible pleural effusion due to heart failure. Participants will be randomised 1:1, stratified according to site and anticoagulant treatment, and assigned to referral to up-front ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard pharmacological therapy or to standard pharmacological therapy only. Thoracentesis is performed according to local guidelines and can be performed in participants in the pharmacological treatment arm if their condition deteriorates or if no significant improvement is observed within 5 days. The primary endpoint is how many days participants are alive and not hospitalised within 90 days from randomisation and will be analysed in the intention-to-treat population. Key secondary outcomes include 90-day mortality, complications, readmissions, and quality of life.Ethics and dissemination The study has been approved by the Capital Region of Denmark Scientific Ethical Committee (H-20060817) and Knowledge Center for Data Reviews (P-2021–149). All participants will sign an informed consent form. Enrolment began in August 2021. Regardless of the nature, results will be published in a peer-reviewed medical journal.Trial registration number NCT05017753.

Aim: We aimed to describe the clinical course of patients with heart failure with reduced ejection fraction (HFrEF) after discharge from the heart failure clinics (HFC). Patients & methods: We reviewed the hospital's records of 610 patients that were discharged between 2013 and 2018 from the HFC at a single centre. Patients with no recurrent contact to ambulatory cardiac care were invited to an echocardiographic assessment. Results: Of the survivors, 72% were re-referred after discharge. Nearly 30% of the patients with no recurrent contact with ambulatory cardiac care had persistent HFrEF and further therapeutical optimizations were indicated in half of them. Conclusion: This highlights the importance to identify high-risk patients that would benefit from extended management in the HFC.

In symptomatic patients with heart failure and reduced ejection fraction (HFrEF), recent international guidelines recommend initiating four major therapeutic classes rather than sequential initiation. It remains unclear how this change in guidelines is perceived by practicing cardiologists versus heart failure (HF) specialists.