ASEAN Heart Journal

Intended for healthcare professional

Original Article

ASEAN Heart Journal

December 2014, 22:16

First online: 10 December 2014

Original Article

Physicians’ Perception of the Patient Care Pathway for Acute Heart Failure in Asian Countries: Implications for Resource Allocation, Preventive Strategies and Clinical Trial Design

Elvira Zenaida Lansang MD,1 David Horsburgh,1 Yun Ning Lee,1 Adeline Sng,1 Ralph Moussalli MSc,1 Karen Wai MBBCh, MBA,1 Inder Anand MD, PhD, FRCP,2 Shu Zhang MD, PhD, FHRS,3 Wataru Shimizu MD, PhD, FJCC,4 Calambur Narasimhan MD, DM, AB,5 Sang Weon Park MD, PhD,6 Cheuk-man Yu MD, FRCP, FACC,7 Tachapong Ngarmukos MD,8 Razali Omar MBBS, M.MED, FHRS,9 Eugene B. Reyes MD, FPCP, FPCC,10 Bambang Budi Siswanto MD, PhD,11 Arthur Mark Richards MD, PhD, FRACP, FRCP, FRSNZ,12 Carolyn S.P. Lam MBBS, MRCP, MS12
Open Access
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  • Summary
  • Supplementary Material
  • References
  • About this Article



Heart failure (HF) is a growing epidemic in Asia. However, data are scarce regarding the patient care pathway of HF in Asia. We aimed to investigate the HF patient pathways in Asia using a questionnaire-based survey.

Methods and Results

Seventy physicians in 12 Asian countries were surveyed using standardized questionnaires regarding patient source, precipitating factors, clinical presentation, referral pattern, and discharge plans for patients with Acute Heart Failure (AHF). Direct self-referral was reported as the most common source of admission. Majority (70%) of patients presented at the emergency department for worsening of chronic HF, with acute coronary syndrome being the most common precipitating factor, and acute pulmonary edema the most common presentation. Patients spent an average of 10 hours in the Emergency Department and majority were admitted to Cardiology Wards. HF with reduced ejection fraction (HFrEF) were the majority of cases except in Hong Kong and Japan. Most patients were discharged home and only 13-15% were enrolled in outpatient HF programs.


This survey highlights the heterogeneity of AHF patient pathways in Asian countries. These findings underscore the need for prospective studies to validate physicians’ reports, evaluate these differences and guide resource allocation and design of AHF clinical trials.

​ Keywords

Cardiovascular - Emergency - Congestive - Referral

Open Access: This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

Supplementary Material



1. Sakata Y, Shimokawa H. Epidemiology of HF in Asia. Circ J 2013;77:2209–2217. PubMed  CrossRef

2. Mosterd A, Hoes AW. Clinical epidemiology of HF. Heart 2007;93:1137–1146. PubMedCentral  PubMed  CrossRef

3. Forouzanfar MH, Moran A, Phillips D, Mensah G, Ezzati M, Naghavi M, et al. Prevalence of HF by cause in 21 regions: global burden of diseases, injuries and risk factors - 2010 Study. J Am Coll Cardiol 2013;61(10_S).

4. Lam CSP, Donal E, Krainer EK, Vasan RS. Epidemiology and clinical course of HF with preserved ejection fraction. Eur J Heart Fail 2011;13(1):18–28. PubMedCentral  PubMed   CrossRef

5. Yang YN, Ma YT, Liu F, Li XM, Huang Y, Tang Q, et al. Incidence and distributing feature of chronic heart failure in adult population of Xinjiang. Zhonghua Xin Xue Guan Bing Za Zhi. 2010:38(5):460–4. PubMed

6. Ng TP, Niti M. Trends and ethnic differences in hospital admissions and mortality for congestive heart failure in the elderly in Singapore, 1991 to 1998. Heart. 2003;89:865–870. PubMedCentral  PubMed CrossRef

7. Lee S, Khurana R, Leong KTG. Heart failure in Asia: the present reality and future challenges. Eur Heart J Suppl 2012;14(suppl A):A51–A52. CrossRef

8. Lansang EZ, Tang V, Ranade S, Caveney E, Ng N, Saldanha LM, et al. The patient care pathway for type 2 diabetes mellitus in Asian countries: implications on target physician group for diabetes clinical trials. J Diabetes Metab 2014;5:331.

9. Adams KF Jr., Fonarow GC, Emerman CL, LeJemtel TH, Constanzo MR, Abraham WT, et al. Characteristics and outcomes of patients hospitalized for HF in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the acute decompensated HF national registry (ADHERE). Am Heart J 2005;149(2):209–216. PubMed  CrossRef

10. Atherton JJ, Hayward CS, Ahmad WAW, Kwok B, Jorge J, Hernandez AF, et al. Patient characteristics from a regional multicenter database of acute decompensated HF in Asia Pacific (ADHERE International - Asia Pacific). J Card Fail 2012;18(1):82–88. PubMed  CrossRef ​

11. Maggioni AP, Dahlstrom U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, et al. EURObervational research programme: the HF pilot survey (ESC-HF Pilot). Eur J Heart Fail 2010;12(10):1076–1084. PubMed  CrossRef

12. Zannad F, Mebazaa A, Juilliere Y, Cohen-Solal A, Guize L, Alla F, et al. Clinical profile, contemporary management and one-year mortality in patients with severe acute HF syndromes: the EFICA study. Eur J Heart Fail 2006;8:697–705. PubMed  CrossRef

13. Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP, et al. EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute HF patients: description of population. Eur Heart J 2006;27:2725–2736. PubMed  CrossRef

14. Spinar J, Parenica J, Vitovec J, Widimsky P, Linhart A, Fedorco M, et al. Baseline characteristics and hospital mortality in the acute HF database (AHEAD) main registry. Crit Care 2011;15:1–13. CrossRef

15. Hamaguchi S, Kinugawa S, Tsuchihashi-Makaya M, Goto K, Yamada S, Yokoshita A, et al. Loop diuretic use at discharge is associated with adverse outcomes in hospitalized patients with HF: a report from the Japanese cardiac registry of HF in cardiology (JCARE-CARD). Circ J 2012;76:1920–1927. PubMed  CrossRef

16. Sato N, Kajimoto K, Keida T, Mizuno M, Minami Y, Yumino D, et al. Clinical features and outcome in hospitalized HF in Japan (from the ATTEND registry). Circ J 2013;77:944–951. PubMed  CrossRef

17.Youn YJ, Yoo BS, Lee JW, Kim JY, Han SW, Jeon ES, et al. Treatment performance measures affect clinical outcomes in patients with acute systolic failure: report from the Korean Heart Failure Registry. Circ J 2012;76:1151–1158. PubMed  CrossRef

18. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middleincome countries. Curr Probl Cardiol. 2010:35(2):72–115.P a href="">PubMedCentral   PubMed  CrossRef ​

19. Ambrosy AP, Fonarow GC, Butler J, Chioncel O, Greene SJ, Vaduganathan M, et al. The global health and economic burden of hospitalizations for HF: lessons learned from AHF registries. J Am Coll Cardiol. doi:10.1016/j.jacc.2013.11.053. Published online ahead of print 27 January 2014.

20. O’Connor CM, Miller AB, Blair JEA, Konstam MA, Wedge P, Bahit MC, et al. Causes of death and rehospitalization in patients hospitalized with worsening HF and reduced left ventricular ejection fraction: results from efficacy of vasopressin antagonism in HF outcome study with tolvaptan (EVEREST) program. Am Heart J 2010;159:841–849. PubMed CrossRef

21. Maggioni AP, Dahlstorm U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, et al. EURObservational research programme: regional differences and 1-year follow-up results of the HF pilot survey (ESC-HF Pilot). Eur J Heart Fail 2013;15:808–817. PubMed CrossRef

22. Nieminen MS, Bohm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, et al. Executive summary of the guidelines on the diagnosis and treatment of acute HF. Eur Heart J 2005;26:384–416. PubMed  CrossRef

23. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al. Factors identified as precipitating hospital admissions for HF and clinical outcomes: findings from OPTIMIZE - HF. Arch Intern Med 2008;168:847–854. PubMed CrossRef

24. Kannel WB, Gordon T. Evaluation of cardiovascular risk in the elderly: the Framingham study. Bull N Y Acad Med 1978;54:573–591. PubMedCentral PubMed

25. Patients overly reliant on emergency services: NHIA. Taipei Times. 2014 Apr 7; p 3.

26. Rainer T. Why are Hong Kong’s emergency departments so understaffed? Emergency Physicians international. Issue 11.

27. Komindr A, Baugh CW, Grossman SA, Bohan JS. Key operational characteristics in emergency department observation units: a comparative study between sites in the United States and Asia. International Journal of Emergency Medicine 2014;7:1–8. CrossRef

28. Teerklink JR, Cotter G, Davison BA, Felker GM, Filippatos G, Greenberg BH, et al. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomized, placebo-controlled trial. Lancet 2013;381:29–39. CrossRef

29. Cowie M, Bell D, Butler J, Dargie H, Gray A, McDonagh T, et al. Acute heart failure - a call to action. Br J Cardiol 2013;20(suppl 2):S1–S11.

30. Collins SP, Levy PD, Pang PS, Gheorghiade M. The role of the emergency department in acute HF clinical trials - enriching patient identification and enrollment. Am Heart J 2013;165:902–909. PubMed  CrossRef

32. Chatterjee K, Massie B. Systolic and diastolic HF: differences and similarities. J Card Fail 2007;13:569–576. PubMed  CrossRef

32. [homepage on the Internet]. Available from: http://​data.​worldbank.​org/​indicator/​SP.​POP.​65UP.​TO.​ZS/​countries?​display=​default/​. Accessed April 25, 2014.

33. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of HF with preserved ejection fraction. N Engl J Med 2006;335:251–259. CrossRef

34. Borlaug BA, Paulus WJ. Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J; doi:10.1093/eurheartj/ehq426. Published online ahead of print 7 December 2010

35. Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive HF discharged from acute hospital care. Arch Intern Med 1998;158:1067–1072. PubMed  CrossRef

36. Wang SP, Lin LC, Lee CM, Wu, SC. Effectiveness of a selfcare program in improving symptom distress and quality of life in congestive HF patients: a preliminary study. J Nurs Res 2011:19:257–266. PubMed  CrossRef

37. Makaya MT, Kato N, Chishaki A, Takeshita A, Tsutsui H. Anxiety and poor society support are independently associated with adverse outcomes in patients with mild HF. Circ J 2009;73:280–287. CrossRef

38. Blair JEA, Zannad F, Konstam MA, Cook T, Traver B, Burnett JC Jr, et al. Continental differences in clinical characteristics, management, and outcomes in patients hospitalized with worsening HF. J Am Coll Cardiol 2008;52:1640–1648. PubMed  CrossRef

39. Butler J, Subacius H, Vaduganathan M, Fonarow GC, Ambrosy AP, Konstam MA, et al. Relationship between clinical trial site enrollment with participant characteristics, protocol completion and, outcomes. J Am Coll Cardiol 2013;61:571–579. PubMed  CrossRef

About this Article

Physicians’ Perception of the Patient Care Pathway for Acute Heart Failure in Asian Countries: Implications for Resource Allocation, Preventive Strategies and Clinical Trial Design

Open Access
Available under Open Access

Journal >> 22:1

Online Date
21 November 2019


Online ISSN

ASEAN Federation of Cardiology

Additional Links Cardiology


Author Affiliations
1. Quintiles East Asia, Singapore, Singapore
2. VA Medical Center, Minneapolis, United States
3. Fuwai Hospital, Beijing, China
4. National Cerebral and Cardiovascular Center and Nippon Medical School, Osaka, Tokyo, Japan
5. CARE Hospital, Hyderabad, India
6. Korea University Anam Hospital, Seongbuk-gu, Korea
7. Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
8. Ramathibodi Hospital, Mahidol University, Nakhon Pathom, Thailand
9. Institut Jantung Negara, Kuala Lumpur, Malaysia
10. Manila Doctors Hospital, Manila, Philippines
11. National Cardiovascular Center University Indonesia, Jakarta, Indonesia
12. Cardiovascular Research Institute, Singapore, Singapore

Correspondence to:
Carolyn S.P. Lam,