This document summarizes the findings of the Makkah Heart Failure Registry (MHFR) which included 993 heart failure patients treated at King Abdullah Medical City between October 2018 and June 2021. The average age was 56.9 years and 75.7% were male. Etiologies included ischemic (43.1%), dilated (35%), and other causes (21.8%). Patients were divided into three groups: Group I (33.1%) received sacubitril and had more severe disease, Group II (59%) received standard medical therapy, and Group III (7.8%) were patients evaluated during Hajj in 2019. The registry provides insights into the demographics, characteristics, treatments, and outcomes of

1. MHFR
Makkah Heart Failure Registry
Patients Demoghraphy and clinical characteristics
32nd Saudi Heart Association Virtual
Conference 7th October 2021
DR Asadullah Soomro, Dr Burai Adlan , Dr Abdullah Ghabashi , Dr Fatima Aboul Enein
Dr Najeeb , Dr Hassan Ali, Dr Nadeem Raja, Dr Nazir, Dr Mini, Dr Zainab, Dr Maha, Dr Jawed ,
Dr Jamal, Dr Ghada, Dr shereen , Dr Muntasir , Dr Leila Alkhalifa ,Ebtihal & Others.
Adult Cardiology department King Abdullah Medical City Holy Makkah.
Email: hssbasadsoomro@gmail.com

3. Introduction
64
million
HF is a global pandemic affecting 64 million patients worldwide
( 1-2% of the global population ). 65 to 70% in stage A & B heart Failure
By 2025 30% of the global population will have heart failure.
Frequent
9 of
10
Progressive
Mostly its incurable syndrome, can be reversible
Patients have symptoms despite treatment .
HF is associated with reduced quality of life .
Mortality
Exceeds Most
Cancers
Deadly ,Complex syndromes
77%
5 year mortality of HF exceeds prostatic
cancer./AIDS. >10% die during De-Novo
hospitalization, decline in survival with
recurrent hospitalization
Economic burden of HF is 108
Million dollars worldwide
( 2017) 92,990 high income
and 15,130 in low income
countries.
About 387 million dollars
/year in KSA
Costly ,especially admission and
readmissions ( 30-50% in 6 months )

4. KAMC History of HF Clinic
Heart Failure clinic at KAMC existed since 2014,
We reactivated non functional HF clinic on Tuesday
2nd October 2018.
Our first out patient HF was registered on 9th october
2018 and was switched to ARNI.
Intradepartmental HF consultation service was started and
first inpatient ( ADCHF ) was registered on 15th October 2018
and was switched to ARNI.
Subsequently we introduced early post discharge heart
failure service ( PDHFC ) in November 2019 and Rapid Access
heart failure service ( RAHFC ) in March 2020.

5. MHFR Background
Heart Failure imposes an enormous financial
burden on health care system.
To initiate HF research & development of HF
specialized ( CCPC ) program,King Abdullah Medical
City (KAMC) appropriately design prospective /
observational short ( 30 days hajj 2019 /long term
33 months out patient and in patient heart failure
registry to collect and analyse data of patients who
were referred to KAMC with heterogeneous heart
failure syndromes.

6. MHFR Methods
The data was collected from patients on
specialized proforma .
It included age, gender, LVEF and
Underlying etiology of 993 consecutive
patients who were evaluated & treated
in KAMC for heart failure during
October 2018 to June 2021.

7. MHFR ( Makkah Heart Failure Registry)
Saudi Heart Association Virtual Conference 7th October 2021
Patients Demoghraphy and clinical characteristics
Over all Average age of = 993
56.9 + _ 13.2 Years
18 To 45 years 46 to 65 years Above 65 years
Group I
330 Patients
On Sacubitril
average age =53.9 yr
Group II
586 Patients
Without Sacubitril
Average Age 57.7 Yrs
Group III ,77 Patients
Hajj 2019 ,Average =63.8 yr
71 11 161 33 46 8
77 32 227 73 120 57
2 3 27 13 18 11
Age Distribution
Men Women Men Women Men Women
196 ( 19.7 % ) 537 ( 54.0% ) 260 ( 26.1% )
Total = 993 Patients
150 46 417 119 185 76
82
109
194
300
54
177
41 31
Men,752/993
( 75.7 % ) Age range 19 to 91
Women, 241/993
(24 .2% ) Age range 24 to 85

8. MHFR Makkah Heart Failure Registry
“Sacubitril& Non Sacubitril Audit “
Men = 702
( 76.6%)
Women = 214
(23.3%)
Total Patients 916/993
Clinical Presentation of Heart Failure
Chronic Compensated
Heart Failure > 3 months
FC 1 – 11
543 ( 59.2% )
Evaluated and managed in out
patient ( Heart failure / Screening
clinic )
Acute Decompensation of
Chronic Heart Failure (ADCHF)
+ Advanced HF syndromes
210 ( 22.9 % )
FC 111,1V
Seen while In patient / at early
post discharge HF clinic .
Acute De-Novo Heart
failure FC 11 to 1V
With in 3 months of
HF symptoms
163 ( 17.7 %)
With mild to moderate
symptoms evaluated at
RAHFC/ Screening clinic

9. MHFR
Heart Failure Death Audit
“Those who did not die by sword,
Died any how.
Causes of death are many
But the result is one.”
Iben alsaadi Baghdad Iraq 941

10. MHFR Makkah Heart Failure Registry
“HF Death Audit “
Men = 71/993
( 78.8%)
Women = 19/993
( 21.1%)
Total Patients 90/993
( 9.0% )
Men death average age
60.1 years
Women death average age
63.8 years
Over all death average age =
60.9 years
Age classification Total deaths = 90 Men Deaths =71 ( 78.8 ) Women = 19 ( 21.1 % )
18 to 45 years 11 ( 12.2% ) 9 2
46 to 65 years 50 ( 55.5% ) 40 10
> 65 years 29 ( 32.2% ) 22 7
Group I 23 /330 ( 6.9% ) 18 to 45 Years 5 ( M , 4 F , 1 ) 46 to 65 Years 13 ( M ,11 F , 2 > 65 Years 5 ( M 3 , F 2 )
Group II 52 /586 ( 8.8% ) 6 ( M , 5 F , 1 ) 27 ( M, 22 F , 5 19 ( M ,15 F ,4
Group III 15/77 ( 19.4% ) 000000 10 ( M , 7 F , 3 5 ( M , 4 F , 1
Men death 71 /752
( 9.4 % )
Women death
19/241
( 7.8 % )

11. MHFR ( Makkah Heart Failue Registry)
Saudi Heart association Virtual conference 7th October 2021.
Patients Demoghraphy and clinical characteristics
KAMC Classification of Ischemic HF Syndromes. 428/993 ( 43% )
HF Groups
I - III
Type I
72 ( 17%)
( HF with Acute MI)
Type II
162 ( 37.8%)
( HF with old MI )
Type III
17 ( 4%)
( HF with Angina, no MI )
Type IV
101 ( 24% )
( Primary HF ,no MI,no
angina )
Type V
76 ( 18%)
( HF with Old CABG )
Group I
128/330
( 38.7%)
04 ( 3.1% ) 63 ( 49.2% 3 ( 2.3% ) 31 ( 24.2%) 27 ( 21%)
Group II
250/586
( 42.6% )
31 ( 12.4%) 96 ( 38.4% 12 ( 4.8%) 65 ( 26.%) 46 (18.4%)
Group III
50/77 (64.9%)
37 (74%)
28 STEMI
9 NSTEMI
03 ( 06%) 02 (0 4%) 05 ( 10%) 03 ( 06%)

12. MHFR ( Makkah Heart Failure Registry)
Saudi Heart association conference 7th October 2021.
Patients Demoghraphy and clinical characteristics
KAMC Classification of Non Ischemic HF Syndromes. 565/993 ( 56.8% )
HF Groups
I - III
Idiopathic
210/565
( 37.1%)
Valvular
125/565
( 22.1%)
Captagon
DCM
56/565
(9.9%)
Chemotherapy
DCM
35/565
( 6.1% )
Miscellanous
139/565
( 24.6%)
Group I
202/330
( 61.2%)
99/ 202
( 49.0% )
15/202
( 7.4%
33/202
( 16.3% )
11/202
( 5.4%)
44/202
( 21.7%)
Group II
336/586
( 57.3% )
111/336
( 33.%)
95/336
( 28.2%
23/336
( 6.8%)
24/336
( 7.1 %)
83/336
(24.7%)
Group III
27/77 (35.0%)
None 15/27
( 55%)
None None 12/27
( 44.4%)

13. KAMC Heart Failure Registry
“An Sacubitril Audit “
Captagon
Strangely most patients did not know cardiovascular adverse effects of captagon, Bit neglected population, from families, single
/divorced, even neglected by physicians for advanced therapies. They used drug for different reasons, long route drivers during
Hajj and Ramdan umrah, Sex drive, some just want to be awake, etc. It cause excessive thrombo emboloism, LV thrombus,
stroke, pulm embolism,systemic emboli ,coronary spasm, Severe mostly irreversible systolic dysfunction ,valve regurgitation.
Captagon ( Amphetamine) Induced Cardiomyopathy with severe LV systolic
Dysfunction.( Mainly Captagon + Alcohol & Hashish )
Total No of Captagoninduced HF Patients on Sacubitril = 33/330 ( 10% )All Men
Age Range 19 years to 63 years
Average Age 43 years
Severe LV systolic Dysfunction
Ejection Fraction EF < 25% = 78.9%
EF > 25% < 35% 21%
Etiologically
26 ( 78.7% ) Dilated Cardiomyopathy
7 ( 21.2% ) Ischemic with Old MI ( coronary spasm) .
Ischemic type 1V without MI and no angina.
Please do not ignore
them. They are equally
responsive to
treatment
Majority Patients
Tolerate ( GDMT)
Sacubitril 200mg
bid

14. MHFR ( Makkah Heart Failure Registry)
Saudi Heart Association Virtual Conference 7th October 2021
Patients Demoghraphy and clinical characteristics
Echocardiogram & LV Ejection fraction ( Done in 98% )
MHFR
Average LVEF 29+_ 12.3%
LVEF < 40% LVEF > 40 to 50 > 50% No Echo
330/330
100%
Excluded Excluded Excluded
401 / 586
68%
( 17 Patients
EF 35-40% )
58 /586
9.8%
108/586
18.4%
19/586
3.2%
53/77
68.8%
10/77
12.9%
14/77
18.1%
************
784/993
78.9%
Group I
330 Patients on ARNI
Average EF 23.2+_ 7.4%
Group II
586 Patients without ARNI
Average EF 31.7+_ 13.4%
Group III
77 Patients Hajj 2019
Average EF 33.8 +_ 0.4%
Total Patients
993
248 / 330 75% EF < 25%
384/586 65.5% EF < 35%
In 78.9% Patients LVEF was < 40%

15. MHFR Results
Registry includes 993patients; average age 56.9 ±13.2 year; 75.8% were
males; average LVEF of 29 ±12.3%. Aetiologically : 43.1 % ischemic, 35%
dilated, and 21.8 % miscellaneous.
4.9% had ICD and 5.2% had CRTD implantation .
Group I , comprise 330 patients (33.1%) were treated with
Sacubitril/valsartan. Average age 53.9 ±12.3 year; 83.5% males; average LVEF
of 23.2 ±7.4%. Aetiology: 128 ( 38.7% ) ischemic, 202 ( 61.2 % ) were non
ischemic. 172 (52.1%) reached target dose of 200 within 4.2±2.7 months.
Group II , comprise 586 patients (59%) were treated with optimal medical
treatment, average age 57.7 ±13.5 year; 72.2% are males; average LVEF of 31.7
±13.4%. Aetiology: 250 ( 42.6% ) were ischemic, 299 ( 51.0% ) were non
ischemic 37 ( 6.3 % ) were miscellaneous with out Coronary angiogram .
Group III , 77 patients (7.8%) were Hajji in 2019, average age 63.8 ±10.8 year;
64.9% males; average LVEF of 33.8 ±0.4%. Aetiology: 50 ( 64.9% ) ischemic, 27
( 35% ) non ischemic ( 15 55.5 % Valvular , and 12 ( 44.4% ) miscellaneous.

16. MHFR ( Makkah Heart Failure Registry)
Saudi Heart Association Conference 7th October 2021
Total Patients 993 Average Age 56.9 + _ 13.2 years ( Men 752 ( 75.7% ) Women 241( 24%
Patients Demoghraphy and clinical characteristics
Registry groups &
No of Patients
Location of registry
Type of Registry
Average Age
Men/ Women %
Ischemic Etiology
Valvular Etiology
On Target Dose
Of Sacubitril
Average LVEF %
HF in Saudis
Deaths = 90
Group I = 330 ( 33.2% ) Group II = 586 ( 59% ) Group III = 77 ( 7.7% )
Acute & chronic HF KAMC Cardiac
Center ( October 2018 to june 21)
Acute & Chronic HF KAMC Cardiac
Center ( October 2018 to June 21 )
Acute HF KAMC Cardiac Center
30 Days ,August Hajj 2019
Sacubitril Registry EF < 40% Non Sacubitril Registry
Both systolic and Perserved EF
Non Sacubitril Registry
Both Systolic & Perserved EF
53.9 +_ 12.3 Years 57.7 + _ 13.5 Years 63.8 + _ 10.8 Years
Men 278 ( 83.5 % ) Women 52 ( 15.7% ) Men 424 (72.2 % ) Women 162 ( 27.6%) Men 50( 64.9 % ) Women 27 ( 35% )
128/330 ( 38.7% ) 250/586 ( 42.6% ) 50/77 ( 64.9% )
15/202 non ischemic ( 7.4% ) 95/ 314 ( Non ischemic ) 30.2% 15/27 ( Non ischemic ) 55.5%
172/ 330 ( 52.1% ) Not Prescribed Not Prescribed
23.2 + _ 7.4% 31.7 + _ 10.8 % 33.8 + _ 0.4%
290/330 ( 87.8% ) 524/685 ( 89.4% ) 2/77 ( 2.5 % )
23 /330 ( 6.9% ) M = 18, F = 5 52/586 ( 8.8 % ) M = 42 F = 10 15/77 ( 19.4% ) M = 11, F = 4

17. Summary & Recommendations
Heart failure is common & complex public health
problem all over, and in Holy Makkah indeed.
KAMC being advanced Heart failure center has
honor to establish ( MHFR ) Makkah Heart
Failure registry of 993 HF patients during October
2018 to June 2021.
Looking at the magnitude of HF in Makkah region,
weekly tiny heart function clinic for regular HF
patients is not sufficient to improve heart failure
services for people of Makkah.

18. Summary& Recommendations
Currently heart failure services are fragmented .
To overcome problem, we need to establish a state of art
multidisciplinary heart failure program and HF network indeed (
Grade 1 to 111 Community HF and advanced HF services in
existing Makkah health care cluster )
Our patients are 10 to 15 years younger than western HF
population, HF problems will further grow because of
awareness and advancement in revascularization , CHD
correction in childhood, Valve surgery and expansion of
advance therapies ( CRTD,ICD LVAD& Valve implants) .

19. Summary & Recommendations
Heart Failure ist admission and readmission are two different
syndromes.
 77% of HF expenditure is on hospitalization, to
overcome complex situation there is a dire need to
implement model of multidisciplinary HF project .
We need to have HF services under one umbrella ( out
patient, Inpatient, Emergency HF and Community HF
services) .
Establishment of Regular rapid Access HF clinic
( RAHFC ) ,post discharge HF clinic ( PDHFC) , Nurse led HF clinic
and last not the least very complex advanced heart failure
clinic indeed .

20. Summary & recommendations
This game changer revolutionary heart failure
medication of the current century ( ARNI ),
must be used at least in centers with availability of
Heart function clinic ,if not heart failure program
indeed.
GDMT & recommended dose titration must be tried
before consideration of expensive device therapies
( ICD,CRTD,LVAD and MV Clip).
ARNI monitoring through out HF journey
( even low dose ) and dose titration to 200 mg is
cornerstone to achieve good outcomes.

21. MHFR ( Makkah Heart Failure Registry )
Saudi Heart Association conference 7th October 2021
Patients Demoghraphy and clinical characteristics
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