Improving heart failure services for people in Holy Makkah. Part 1 is why to build up multidisciplinary heart failure program

1. Dr Asadullah Khan Soomro
Adult Cardiology department
Dr Awwad Albishri Hospital Holy Makkah.
MHFS
Why
Multidisciplinary
Heart failure
Programme
( MDHFP/CCPC ) in
KAMC holy Makkah
Part 1

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. Shocking Cost on Admission &
Readmission HF Syndromes
Out of 3.75 million HF patients in gulf region, an estimated 1.5 million patients are suffering from
heart failure in three countries.( UAE, KSA and Egypt ) . Highest number, (998 900) in Egypt only
Annual Per patient cost was highest in UAE ( USD ,14121 )
Followed by KSA ( USD 8404 ) Lowest ,yet ( USD 1105 ) in Egypt.
Total Estimated Cost for the MENA region is
USD 4.88 billion.
Highest in KSA
USD 2.63 billion
UAE
USD 1.25
Billion
Egypt
USD 994.96
Million
Major Cost associated on Inpatient care , on admission , readmission , & invasive procedures
Estimated Cost of 4 key HF medications per year = 3622 SR, ( Cost of sacubitril per year per patient 7665 SR )
9162 SR
4 HF Drugs
Per /Pt
Per/Yr
ARNI, MRA
B Blockers
& Diuretics

5. MHFS
Aims of the MDHFP
1) Establishment of the network of multidisciplinary Novel Heart failure Clinics in
Makkah healthcare cluster.( like CHFC , RAHFC, PDHFC, Advanced HF ,Nurse led HF, Virtual HF ,
regular HF clinic SDHFC ( same day for OPD based I/V diuretic & inotropes ) , Cardio-oncology &
Cardio-obstetric heart failure Clinic .
2) Implementation and monitoring of updated guidelines on heart failure diagnosis and
management.
3) To familiarize and encourage cardiology community to apply evidence based therapies and
discoveries to prevent or delay of development of pre-HF to overt heart failure to
advanced HF , and prevention of deaths before onset of symptoms .
4) To promote heart failure prevention by public education ,on healthy life style, HF symptom
awareness and self-care to prevent recurrent decompensation and HF hospitalization.
5) Introduction of heart failure rehabilitation and create a highly supportive habitat for
research in heart failure especially amongst disappearing breed of physician
scientists.

6. A
&
B
56
%
C
D
HF
Stage
Code

7. 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.

8. 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

9. 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

10. 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%)

11. 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%)

12. 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

13. 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%

14. 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

15. Improving Heart Failure
Services for people in Makkah
Building Multidisciplinary
Heart Failure Programme
( MDHFP ) and network
In Makkah Healthcare Cluster.
82
Public
Health
Centers
9
Public
Hospitals
KAMC
Iconic
Quaternary
Al-Noor
King Faisal
King A Aziz
Hira
Ajyad
MCH
Others

16. MHFS
Steps to build MDHFP
1) Establish the goals of ( MDHFP ) multidisciplinary heart failure
programme.
2) Develop referral criteria & publicize criteria within community.
3) Determine specific HF population ( Stage A to D ),and which patient to
be seen where ( level I to III ).
4) Assess physical location for the clinic, and type of HF patient ( RAHFC )
5) Appoint MDHFP director / Governor and HF clinic leaders/Co-ordinators.
6) Determine/appoint MDHFP staffing model, HF physician/dedicated medical
specialist interested in HF, Clinical/HF nurse. In addition , allied health
professionals ( Pharmacist, educationist/nurse, nutritionist, exercise
physiologist/physical therapist, psychologist/social worker, Financial/Admin
Coordinator.

17. MHFS
Steps to build MDHFP
7) Create clinic appointment structure, ( new patient, follow up, urgent ).
8) Develop clinical practice pathways & protocols ( Inpatient/outpatient)
9) Develop partnership with other relevant subspecialists ( Nephrology ).
10) Develop partnership with frequently used clinical services ( EKG, Echo, CMRI, CPET, Cath lab,
cardiac rehabilitation ,palliative care.)
11) Develop a technology and Virtual visit infrastructure .
12) Establish mechanism for patient follow-up .
13) Create hospital coverage plan.
14)Determine mechanism for quality improvement
15) Develop Business plan for HF clinic ( Value Based Model of HF )
16) Build research network
17) Obtain appropriate accreditation ( JCI, AHA,ACC )

18. 7 Stakeholders of Heart Failure
Programme & Network.
Key to success is 7 star HF education , education & education indeed “
1)
Patient Education
2) Family &
family Friends
Education
3) Paramedical
Personnel
Education
4) Physician /
medical students
Education
5) Payer organizations
Insurance Companies
Education
6) Admin directors
Policy Makers
Education
7) Pharmaceutical/ Devices and cardiac technological industry Education

19. MHFS
Classification of Makkah Heart Failure Network
Model 1, Community Heart Failure Clinics
Heart failure service with only ,out patient clinic capability
Admission
Model 2
Heart Failure service with OPD , emergency
and in patient capability but without cath Lab.
Model 4
All + Advanced Heart Failure service
With Intervention, LVAD and
Cardiac transplant Capability.
Level
I
To
IV
Model 3
Heart Failure service Model 2 +
Cath lab & PCI capability

20. Model of Heart Failure Programe
HEART FAILURE CLINICAL CARE PROGRAME ( CCPC )
RAHFC
( RAPID ACCESS HEART FAILURE CLINIC )
“Goal is same Day “
One stop fast track heart referral from, PHC/ER to
“Best Care “ when ever and where ever requires.
( Cardio-Oncology & Cardio-obstetric services).
IN PATIENT
HEART FAILURE
SERVICE
COMMUNITY
HEART FAILURE
SERVICE
OUT PATIENT
HEART FAILURE
Service
EMERGENCY
HEART FAILURE
SERVICE
Regular / Virtual
Heart Failure
Clinic
Post Discharge
Heart failure &
Cardiac Rehabilitation
Clinic
Nurse Led
Multi disciplinary
Heart Failure Clinic
Advanced
Heart Failure Clinic
4
2
1
3

21. MHFS
Network of Novel HF clinics in
Makkah Healthcare cluster
RAHFC
( Rapid Access Heart Failure Clinic )
Advanced Heart
Failure Clinic
Post Discharge Heart
Failure Clinic
CHFC
( Community Heart
Failure Clinic
VHFC
Virtual Heart Failure
Clinic
SDHFC
( same day Heart
Failure Clinic )
RHFC
( Regular HF clinic )
NLHFC
( Nurse led HF
Clinic )
Cardio-Oncology
&
Cardio-Obstetric
HF Clinic

22. MHFS
Network of Novel HF clinics in
Makkah Healthcare cluster
Rapid Access HF Clinic
Post Discharge HF
Clinic
Advanced HF Clinic
Community HF Clinic
Virtual HF Clinic
Regular HF Clinic
Same day HF Clinic
Nurse Led HF Clinic
Cardio-oncology &
Cardio-Obstetric Clinic
This Clinic is for new onset ( De-Novo ) HF patients with mild to moderate symptoms , or suspected heart failure
patients & those who left DAMA from ER, its walk in clinic . Target is all basic work up on same day.
This clinic is for those patients who were admitted & discharge from the ward ,CCU,ICU with diagnosis of ADCHF ( Acute
decompensation of chronic HF ) & New onset Heart Failure. ( Telephonic call on 3rd day and clinic appointment With in 10-15 days post discharge)
This clinic is for tiny group of complex ambulatory advanced heart failure stage D , not suitable for advanced therapies ( LVAD or OHT
) or waiting for advanced therapies & Post LVAD /Post heart transplant.
This community based HF clinic for care of stage A and stage B Heart failure , Early referral to RAHFC with mild to moderate new
onset HF patients & post discharge early follow up / HF education and self care Zone awareness.
This clinic is for Compensated HF patients who are living away from Makkah can follow on this clinic ,if need can be
reviewed on regular HF clinic. ( To save thousands of Km travel, petrol, time , leave and cost saving indeed )
This clinic is for compensated HF patients under follow up / GDMT dose titration until fulfill dispose criteria .
This clinic is for those patients who are in need of regular I/V diuretics & inotropes on OPD basis to avoid frequent
ER visits and readmissions. This can be utilized for ER patients who refuse admission/DAMA.
Its multidisciplinary clinic for HF education, clinical pharmacist medication ,Dietary education & miscellaneous
problems.
This clinic is exclusively for Cardio-oncological problems with heart failure evaluation & follow up.
Cardio-obstetric HF clinic is for pregnant and Peri-partum cardiomyopathy patients .

23. MHFS
Conclusion
In Heart Failure world ,we are facing with these
Tigers and Elephant heart with heterogeneous
prognosis.
We spent tons of money on care of heart failure ,yet
our services are Zigzag and fragmented.
We need to review our problem, and work on
organized care of heart failure for better outcome.

24. Conclusion
“ Zigzag/Disorganized”

25. THANK YOU
Living Longer, Living Well