Determinants of the survival benefit associated with statins in patients with acute heart failure

Temporal trends (2003-2018) of in-hospital and 30-day mortality in patients hospitalized with acute heart failure

BACKGROUND

Limited temporal data on in-hospital mortality trends of patients hospitalized with acute heart failure (AHF) have been reported. We evaluated whether, in AHF hospitalized patients, the rate of in-hospital and 30-day mortality, and 30-day re-hospitalization for AHF have changed in the past 15 years.

METHODS AND RESULTS

We examined administrative data from the Lombardy region, Italy and analysed data of all adults hospitalized for AHF from 2003 to 2018. Patients were stratified according to the hospitalization period: 2003-2006; 2007-2010; 2011-2014; 2015-2018. Primary endpoint was the comparison of in-hospital mortality rates among periods. Secondary endpoints were 30-day mortality rates and temporal trends of re-hospitalization for AHF. During this period, 414,164 hospitalizations with a primary diagnosis of AHF were identified, involving 286,028 patients aged 18 and older. In-hospital and 30-day mortality in the entire cohort showed a progressive increase over time (from 6.7 % to 8.5 % and from 12.4 % to 14.5 %, respectively). Thirty-day re-hospitalization for AHF was 2 %, showing a progressive decrease over the years. However, patient' age and complexity increased in the most recently hospitalized patients. After adjusting for major confounders, in-hospital and 30-day mortality risks were similar moving from one study period to the next (relative risk for trend 1.00 [95 % CI 0.99-1.01] and 1.00 [95 % CI 0.98-1.01], respectively), while that of 30-day AHF re-hospitalization decreased progressively (hazard ratio for trend 0.86 [95 % CI 0.84-0.88]).

CONCLUSIONS

In our study, the increasing age and complexity of patients largely accounted for the continued rise in early mortality observed in patients hospitalized with AHF.

Characteristics, Predictors, and Clinical Outcomes in Heart Failure With Reduced Ejection Fraction According to a 1-Year Left Ventricular Ejection Fraction Following Sacubitril/Valsartan Treatment

BACKGROUND

Optimal medical treatment can lead to improvement in left ventricular ejection fraction (LVEF) in patients with heart failure with reduced EF (HFrEF). We investigated the characteristics, predictors, and outcomes of HFrEF according to the 1-year LVEF following angiotensin receptor-neprilysin inhibitors therapy (ARNI).

METHODS AND RESULTS

Using the STRATS-HF-ARNI (Strain for Risk Assessment and Therapeutic Strategies in Patients With Heart Failure Treated With Angiotensin Receptor-Neprilysin Inhibitor) registry, we identified 1074 patients with HFrEF who took ARNI and underwent baseline and 1-year echocardiography. Patients were classified as HF with improved ejection fraction (HFimpEF) and persistent HFrEF (perHFrEF) (1-year LVEF >40% and ≤40%). The primary and secondary outcomes were all-cause and cardiac mortality from the 1-year follow-up. Among 1074 included patients, 498 (46.4%) had HFimpEF, and 576 (53.6%) had perHFrEF. Older age, male sex, and large LV end-diastolic volumes were positive predictors of perHFrEF, whereas atrial fibrillation and high systolic blood pressure were identified as inverse predictors. Patients with HFimpEF showed lower all-cause and cardiac mortality rates (both log-rank P<0.001). In the multivariable analysis, perHFrEF (hazard ratio, 2.402 [95% CI, 1.251-4.610]; P=0.008) was an independent predictor of poor outcomes. The risk of all-cause mortality decreased as the 1-year LVEF increased up to 40%; however, no additional risk reduction was observed beyond 40%. Compared with patients taking renin-angiotensin-aldosterone system inhibitors in the STRATS-AHF (Strain for Risk Assessment and Therapeutic Strategies in Patients With Acute Heart Failure) registry, those in the STRATS-HF-ARNI registry demonstrated better outcomes in both HFimpEF and perHFrEF.

CONCLUSIONS

Patients with HFimpEF had better prognosis than those with perHFrEF, and ARNI treatment in HFrEF could be more beneficial than renin-angiotensin-aldosterone system inhibitors for both HFimpEF and perHFrEF.

REGISTRATION

URL: https://www.who.int/clinical-trials-registry-platform; Unique identifier: KCT0008098.

Reduced Heart Failure and Mortality in Patients Receiving Statin Therapy Before Initial Acute Coronary Syndrome

BACKGROUND

There is uncertainty regarding the impact of statins on the risk of atherosclerotic cardiovascular disease (ASCVD) and its major complication, acute heart failure (AHF).

OBJECTIVES

The aim of this study was to investigate whether previous statin therapy translates into lower AHF events and improved survival from AHF among patients presenting with an acute coronary syndrome (ACS) as a first manifestation of ASCVD.

METHODS

Data were drawn from the International Survey of Acute Coronary Syndromes Archives. The study participants consisted of 14,542 Caucasian patients presenting with ACS without previous ASCVD events. Statin users before the index event were compared with nonusers by using inverse probability weighting models. Estimates were compared by test of interaction on the log scale. Main outcome measures were the incidence of AHF according to Killip class and the rate of 30-day all-cause mortality in patients presenting with AHF.

RESULTS

Previous statin therapy was associated with a significantly decreased rate of AHF on admission (4.3% absolute risk reduction; risk ratio [RR]: 0.72; 95% CI: 0.62-0.83) regardless of younger (40-75 years) or older age (interaction P = 0.27) and sex (interaction P = 0.22). Moreover, previous statin therapy predicted a lower risk of 30-day mortality in the subset of patients presenting with AHF on admission (5.2 % absolute risk reduction; RR: 0.71; 95% CI: 0.50-0.99).

CONCLUSIONS

Among adults presenting with ACS as a first manifestation of ASCVD, previous statin therapy is associated with a reduced risk of AHF and improved survival from AHF. (International Survey of Acute Coronary Syndromes [ISACS] Archives; NCT04008173).