Outcomes of patients with hypertensive heart disease and heart failure with reduced ejection fraction (HFrEF) at a tertiary centre in South Africa

Introduction. Hypertension is endemic in Sub-Saharan Africa and has been shown to be the leading cause of heart failure (HF) on the continent. Clinical observation suggests that hypertensive heart disease (HHD) is potentially reversible with medical therapy and that baseline characteristics and outcomes differ from other causes of HF. Method. This was a single centre, retrospective hospital-based observational study of patients diagnosed with HF with reduced and mid-range ejection fraction (HFrEF and HFmrEF) secondary to HHD, seen at the Cardiomyopathy Clinic at Groote Schuur Hospital over a threeyear period. Ethics approval was obtained (HREC REF 677/2018). Results. A total of 59 patients were included, with an equal representation of both genders [female 49.2%]. The majority of patients were of mixed race [57.6%] and black African [39%] ethnicity. The mean age at presentation was 44 ±12.0 years. At baseline, 71.7% of patients had effort intolerance [NYHA Class II, 36.2%; Class III, 32.8%; Class IV, 1.7%] and the most common symptoms were dyspnoea [65.5%], pedal oedema [34.5%] and orthopnoea [29.3%]. A pre-existing diagnosis of hypertension was present in 66.8%, 30,5% had other comorbidities (HIV, 5 [8.5%]; diabetes mellitus, 5 [8.5%]; chronic kidney disease, 5 [8.5%]) and 62% of women presented in the peripartum period. At baseline, the mean systolic and diastolic blood pressures were 130±20.1 and 81±12.8mmHg, respectively. Congestive HF was observed in 40.7% of cases despite being on medical therapy (loop diuretics [88.5%]; ACE-I [88.5%]; beta blocker [84.6%]; MRA [51.9%]). Atrial fibrillation [3.5%] and LBBB [10.5%] were infrequent. Left ventricular hypertrophy (LVH) was noted in 54.4% on ECG, and the mean QTc was prolonged [466±35ms]. On echocardiogram, mean wall thickness was normal [IVSd 1.0 [0.9-1.2]; LVPWd 1.1 [0.8-1.3], however, left atrial [4.4±0.9cm] and LV end-diastolic dimensions [LVEDD 6.4±0.8cm] were increased. LV ejection fraction (EF) was markedly impaired [29.9±10.4%]. At follow up, there was a significant (p< 0.001). Recovery of LVEF was observed in 86.5% patients where repeat imaging was done [LVEF ≥ 50% in 45.9%; LVEF improved ≥10% in 40.5%]. 1- and 3-year transplant-free survival was 98.3% and 90.5%, respectively. Conclusion. Most patients with HHD and impaired LVEF have a pre-existing history of hypertension and present with effort intolerance, congestion and mildly elevated or ‘pseudonormal' blood pressures. Concentric LVH was not a prominent feature on echocardiogram and AF was infrequent. Despite severely impaired LVEF at baseline, mortality was lower than expected for HF patients and improvement in LVEF on therapy was observed in the majority of patients