Temporal trends in mortality and readmission after acute heart failure: a systematic review and meta-regression in the past four decades

AIMS

Acute heart failure (AHF) is frequent and life-threatening disease. However, innovative AHF therapies have remained limited, and care is based on experts' opinion. Temporal trends and benefits of long-term oral cardiovascular medications on AHF outcomes remain uncertain.

METHODS AND RESULTS

This study is registered with PROSPERO (CRD42018099885). A systematic review ranging from 1980 to 2017, searched AHF studies with more than 100 patients that reported death and/or readmission. Primary outcomes were temporal trends, assessed by meta-regression, for 30-day or 1-year all-cause death and/or readmission rates. Secondary outcomes were temporal trends of oral cardiovascular therapies and their influence on primary outcomes. Among the 45 143 studies screened, 285 were included, representing 15 million AHFs. In the past decades, though mortality and readmission remain high, there was a decline in 30-day all-cause death [odds ratio (OR) for a 10-year increment: 0.74, 95% confidence interval (CI) 0.61-0.91; P = 0.004] that persisted at 1 year (OR 0.86, 95% CI 0.77-0.96; P = 0.007), while 30-day and 1-year all-cause readmission rate remained roughly unchanged. Trends of primary outcomes were linear and did not differ among continents. Decline in 1-year all-cause death rate correlated with high proportions of oral or beta-blockers, especially when combined with oral renin-angiotensin-aldosterone system inhibitors, but not with diuretics while trends in readmission remained unchanged with these therapies.

CONCLUSIONS

Although AHF outcomes remain poor, the present study revealed global favourable trends of survival after AHF episodes probably associated with greater use of oral neurohormonal antagonists. The present study urges to implement the combination of oral renin-angiotensin-aldosterone system inhibitors and beta-blockers in patients at risk of AHF.

Angiotensin Receptor Neprilysin Inhibitors in HFrEF: Is This the First Disease Modifying Therapy Drug Class Leading to a Substantial Reduction in Diuretic Need?

Despite significant advances in disease modifying therapy in heart failure (HF), diuretics have remained the cornerstone of volume management in all HF phenotypes. Diuretics, alongside their definite acute haemodynamic and symptomatic benefits, also possess many possible deleterious side effects. Moreover, questions remain regarding the prognostic impact of chronic diuretic use. To date, few data exist pertaining to diuretic reduction as a result of individual traditional guideline directed medical therapy in HF with reduced ejection fraction (HFrEF). However, diuretic reduction has been demonstrated with sacubitril/valsartan (angiotensin receptor-neprilysin inhibitor [ARNi]) from the PARADIGM study, as well as, post-marketing reports from our own group and others. Whether the ARNi compound represents the dawn of a new era, where effective therapies will have a more noticeable reduction on diuretic need, remains to be seen. The emergence of sodium glucose transport 2 inhibitors and guanylate cyclase stimulators may further exemplify this issue and potentially extend this benefit to HF patients outside of the HFrEF phenotype. In conclusion, emerging new therapies in HFrEF could reduce the reliance on diuretics in the management of this phenotype of HF. These developments further highlight the clinical importance to continually assess an individual's diuretic requirements through careful volume assessment.

Risk of myocardial infarction associated with non‐steroidal anti‐inflammatory drugs: Impact of additional confounding control for variables collected from self‐reported data

What is known and objective

Important risk factors and over‐the‐counter (OTC) dispensing of non‐steroidal anti‐inflammatory drugs (NSAIDs) are often not routinely recorded in electronic health records. This study aimed to assess the impact of patient's reports on these factors on the risk of acute myocardial infarction (AMI) for NSAID use.

Methods

A nested case‐control study was conducted among adults in the Utrecht Cardiovascular Pharmacogenetics study. Cases were patients with a first diagnosis of AMI as a hospital discharge diagnosis and controls were those without AMI. NSAID exposure was either current use of selective COX‐2 inhibitors or conventional NSAIDs. Information was collected from The Dutch PHARMO Database Network (pharmacy records of drug dispensing linked to hospitalization records) and the patient's questionnaire (lifestyle factors, body mass index and history of cardiovascular diseases). Unconditional logistic regression analysis was used to calculate odds ratios (ORs) and to control for confounding factors.

Results

We identified 970 AMI cases and 2974 controls. Among cases, 11 (1.1%) and 185 (19.1%) were exposed to selective COX‐2 inhibitors and conventional NSAIDs, respectively. Compared to non‐use, none of these drug classes were associated with an increased risk of AMI (adjusted OR 1.07, 95% CI: 0.52‐2.18 and 0.93, 95% CI: 0.77‐1.12, respectively). Additional adjustment for potential confounders from patient's reports did not change the risk estimates (adjusted OR 1.08, 95% CI: 0.53‐2.22 and 0.89, 95% CI: 0.73‐1.09, respectively).

What is new and conclusion

Additional confounding control for variables from self‐reported data or considering self‐reported OTC NSAID use did not change the risk estimates for the association between NSAIDs and AMI.

Association of diuretic treatment at hospital discharge in patients with heart failure with all-cause short- and long-term mortality: A propensity score-matched analysis from SwedeHF

AIMS

Diuretics are recommended for treating congestive symptoms in heart failure (HF). The short- and long-term prognostic effects of diuretic treatment at hospital discharge have not been studied in randomized clinical trials or in a Western world population. We aimed to determine the association of diuretic treatment at discharge with the risk of short-and long-term all-cause mortality in real-life patients in Sweden with HF irrespective of EF.

METHODS AND RESULTS

From a Swedish nationwide HF register 26,218 patients discharged from hospital were included in the present study. A total of 87% of patients were treated with and 13% were not treated with diuretics at hospital discharge. In a 1:1 propensity score-matched cohort of 6564 patients, the association of diuretic treatment at hospital discharge with the risk of 90-day all-cause mortality was neutral (HR 0.89, 95% CI 0.74-1.07, p=0.21) whereas the risk of long-term all-cause mortality (median follow-up: 2.85years) was increased (HR 1.15, 95% CI 1.06-1.24, p<0.001).

CONCLUSION

Diuretic treatment at hospital discharge was not associated with short-term mortality whereas it was associated with increased long-term mortality. Although we accounted for a wide range of clinical features, measured or unmeasured factors could still explain this increase in risk. However, our results suggest that diuretic treatment at hospital discharge may be regarded as a marker of increased long-term mortality.

Decrease in loop diuretic treatment from 2005 to 2014 in Swedish real-life patients with chronic heart failure

Purpose

Loop diuretics are recommended to treat congestive symptoms in patients with heart failure. However, observational studies have indicated that loop diuretic treatment in heart failure is associated with increased mortality. Therefore, loop diuretic discontinuation or dose reduction, when clinically possible, is recommended. Our aim was to study nationwide temporal trends in loop diuretic treatment from 2005 to 2014 in real-life patients with chronic heart failure.

Methods

Data from the nationwide Swedish National Patient, Prescribed Drug and Cause of Death Registers were linked. The annual proportions of patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated. In addition, the annual median loop diuretic doses (DDD) in patients with chronic heart failure treated with loop diuretics from 2005 to 2014 were calculated.

Results

The proportion of real-life patients with chronic heart failure treated with loop diuretics decreased from 73.2% in 2005 to 65.7% in 2014 (p for trend < 0.001). The median loop diuretic DDD in real-life patients with chronic heart failure decreased from 2.13 (IQR 1.09–2.77) in 2005 to 1.63 (IQR 1.09–2.25) in 2014 (p = 0.001 for trend).

Conclusions

Loop diuretic treatment decreased from 2005 to 2014 in real-life patients with chronic heart failure. The prognostic impact of changes in loop diuretic treatment in patients with heart failure remains unclear.

Electronic supplementary material

The online version of this article (10.1007/s00228-018-2574-6) contains supplementary material, which is available to authorized users.

Gastrointestinal toxicity among patients taking selective COX-2 inhibitors or conventional NSAIDs, alone or combined with proton pump inhibitors: a case-control study

PURPOSE

To assess the risk of gastrointestinal perforation, ulcers, or bleeding (PUB) associated with the use of conventional nonsteroidal anti-inflammatory drugs (NSAIDs) with proton pump inhibitors (PPIs) and selective COX-2 inhibitors, with or without PPIs compared with conventional NSAIDs.

METHODS

A case-control study was performed within conventional NSAIDs and/or selective COX-2 inhibitors users identified from the Dutch PHARMO Record Linkage System in the period 1998-2012. Cases were patients aged ≥18 years with a first hospital admission for PUB. For each case, up to four controls were matched for age and sex at the date a case was hospitalized (index date). Logistic regression analysis was used to calculate odds ratios (ORs).

RESULTS

At the index date, 2634 cases and 5074 controls were current users of conventional NSAIDs or selective COX-2 inhibitors. Compared with conventional NSAIDs, selective COX-2 inhibitors with PPIs had the lowest risk of PUB (adjusted OR 0.51, 95% confidence interval [CI]: 0.35-0.73) followed by selective COX-2 inhibitors (adjusted OR 0.66, 95%CI: 0.48-0.89) and conventional NSAIDs with PPIs (adjusted OR 0.79, 95%CI: 0.68-0.92). Compared with conventional NSAIDs, the risk of PUB was lower for those aged ≥75 years taking conventional NSAIDs with PPIs compared with younger patients (adjusted interaction OR 0.79, 95%CI: 0.64-0.99). However, those aged ≥75 years taking selective COX-2 inhibitors, the risk was higher compared with younger patients (adjusted interaction OR 1.22, 95%CI: 1.01-1.47).

CONCLUSIONS

Selective COX-2 inhibitors with PPIs, selective COX-2 inhibitors, and conventional NSAIDs with PPIs were associated with lower risks of PUB compared with conventional NSAIDs. These effects were modified by age. © 2017 The Authors. Pharmacoepidemiology & Drug Safety Published by John Wiley & Sons Ltd.

Inequity of access to ACE inhibitors in Swedish heart failure patients: a register-based study

Background

Several international studies suggest inequity in access to evidence-based heart failure (HF) care. Specifically, studies of ACE inhibitors (ACEIs) point to reduced ACEI access related to female sex, old age and socioeconomic position. Thus far, most studies have either been rather small, lacking diagnostic data, or lacking the possibility to account for several individual-based sociodemographic factors. Our aim was to investigate differences, which could reflect inequity in access to ACEIs based on sex, age, socioeconomic status or immigration status in Swedish patients with HF.

Methods

Individually linked register data for all Swedish adults hospitalised for HF in 2005–2010 (n=93 258) were analysed by multivariate regression models to assess the independent risk of female sex, high age, low employment status, low income level, low educational level or foreign country of birth, associated with lack of an ACEI dispensation within 1 year of hospitalisation. Adjustment for possible confounding was made for age, comorbidity, Angiotensin receptor blocker therapy, period and follow-up time.

Results

Analysis revealed an adjusted OR for no ACEI dispensation for women of 1.31 (95% CI 1.27 to 1.35); for the oldest patients of 2.71 (95% CI 2.53 to 2.91); and for unemployed patients of 1.59 (95% CI 1.46 to 1.73).

Conclusions

Access to ACEI treatment was reduced in women, older patients and unemployed patients. We conclude that access to ACEIs is inequitable among Swedish patients with HF. Future studies should include clinical data, as well as mortality outcomes in different groups.

Mortality by heart failure and ischemic heart disease in Brazil from 1996 to 2011

BACKGROUND

Circulatory system diseases are the first cause of death in Brazil.

OBJECTIVE

To analyze the evolution of mortality caused by heart failure, by ischemic heart diseases and by ill-defined causes, as well as their possible relations, in Brazil and in the geoeconomic regions of the country (North, Northeast, Center-West, South and Southeast), from 1996 to 2011.

METHODS

Data were obtained from DATASUS and death declaration records with codes I20 and I24 for acute ischemic diseases, I25 for chronic ischemic diseases, and I50 for heart failure, and codes in chapter XIII for ill-defined causes, according to geoeconomic regions of Brazil, from 1996 to 2011.

RESULTS

Mortality rates due to heart failure declined in Brazil and its regions, except for the North and the Northeast. Mortality rates due to acute ischemic heart diseases increased in the North and Northeast regions, especially from 2005 on; they remained stable in the Center-West region; and decreased in the South and in the Southeast. Mortality due to chronic ischemic heart diseases decreased in Brazil and in the Center-West, South and Southeast regions, and had little variation in the North and in the Northeast. The highest mortality rates due to ill-defined causes occurred in the Northeast until 2005.

CONCLUSIONS

Mortality due to heart failure is decreasing in Brazil and in all of its geoeconomic regions. The temporal evolution of mortality caused by ischemic heart diseases was similar to that of heart failure. The decreasing number of deaths due to ill-defined causes may represent the improvement in the quality of information about mortality in Brazil. The evolution of acute ischemic heart diseases ranged according to regions, being possibly confused with the differential evolution of ill-defined causes.

Trends in prevalence from 1990 to 2007 of patients hospitalized with heart failure in Sweden

AIMS

To investigate trends in absolute numbers and prevalence from 1990 to 2007 of patients hospitalized with heart failure (HF) in Sweden.

METHODS AND RESULTS

National inpatient and cause-specific death registers were used to calculate age- and sex-specific trends in absolute numbers and prevalence from 1990 to 2007 of patients hospitalized with HF in Sweden. Absolute numbers increased from 105 449 in 1990 to 144 925 in 2007, with a 77% increase in patients aged 85-99 years. The overall age-adjusted prevalence in 1990 was 1.73%, and this increased with an estimated annual percentage change (EAPC) of 4.3% [95% confidence interval (CI) 3.6-4.9%] from 1990 to 1995, with no further significant change until 2002. The single year with the highest prevalence was 1998, when it peaked at 2.13%. The prevalence then declined slowly from 2002 (EAPC -1.1, 95% CI -1.5% to -0.6%) to 1.99% in 2007. The decrease in prevalence was not found in persons <65 years, where, instead, an increase was found throughout the period.

CONCLUSION

Fears of an impending HF 'epidemic' could not be confirmed in this analysis of trends in prevalence for the period 1990-2007 of patients hospitalized with HF in Sweden. An overall slight decrease in age-adjusted prevalence was observed from 2002. The prevalence in patients <65 years increased markedly. In absolute numbers, there was a substantial increase among the very old, consistent with demographic changes.

Community care in England: reducing socioeconomic inequalities in heart failure

BACKGROUND

Socioeconomic deprivation is associated with increased heart failure (HF) incidence, hospitalization rates, and mortality. However, whether the delivery of survival-enhancing medical therapy is equitable remains uncertain. We examined secular trends in the uptake of key medical therapies (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, spironolactone) stratified by socioeconomic circumstances in patients with HF. Secondary analyses examined trends in HF incidence, prevalence, and survival.

METHODS AND RESULTS

This study was a cross-sectional observational analysis of nationally representative primary care data from England. Treatments for patients with HF in 1999 and 2007 (n=13 330) were extracted from the General Practice Research Database. Socioeconomic circumstances were defined with the Index of Multiple Deprivation 2007, a weighted composite of 7 area-level deprivation domains. Treatment uptake estimates were age standardized. The incidence and prevalence of HF decreased year to year. Although clear socioeconomic gradients in both the incidence and prevalence of HF were apparent, the absolute difference between most and least deprived reduced over time. Uptake of therapies improved over time in both men and women. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker uptake increased from 46% to 64%, β-blocker uptake from 12% to 41%, and spironolactone uptake from 3% to 20%. Modest age and sex inequalities were apparent. However, no consistent socioeconomic gradients were observed in either treatment or case fatality.

CONCLUSIONS

Socioeconomic gradients in the incidence and prevalence of HF are reducing. Treatment is generally equitable and independent of socioeconomic circumstances. Most important, no significant inequality in outcomes was apparent. Future strategies should continue to address inequalities in the underlying causes of HF and to increase overall treatment levels further.

Stroke aetiology and predictors of outcome in patients with heart failure and acute stroke: a 10-year follow-up study

AIMS

The aim of this study was to investigate stroke aetiology and assess the predictors of early and late outcome in patients with heart failure (HF) and acute stroke.

METHODS AND RESULTS

A total of 2904 patients, admitted between 1993 and 2010, were regularly followed up at months 1, 3, and 6, and yearly thereafter up to 10 years. There were 283 (9.7%) stroke patients with HF; atrial fibrillation (AF) was present in 144 (50.9%) of them. Stroke aetiology in patients with HF and AF was mainly cardioembolism (82%) regardless of HF aetiology. In contrast, in the 139 non-AF patients with HF, the stroke mechanism was associated with the aetiology of HF: valvular heart disease and dilated cardiomyopathy were related to cardioembolism in 60% and 66.7% of patients, respectively, whereas HF due to coronary artery disease or hypertension was associated with atherosclerotic and lacunar stroke in 40.8% and 61.5%, respectively. In the overall population, HF was an independent predictor of 10-year mortality [hazard ratio = 1.54, 95% confidence interval (CI) 1.29-1.83; P < 0.001]. Probability of 10-year survival was 19.4% (95% CI 14.5-23.5) for HF patients and 44.1% (95% CI 41.4-46.8) for non-HF patients (P < 0.0001). Ten-year mortality in HF patients was associated with functional class of HF, age, diabetes, stroke severity, and in-hospital aspirin use. The presence of AF in HF stroke patients did not influence 10-year survival and composite cardiovascular events (P = 0.429 and P = 0.406, respectively).

CONCLUSIONS

In patients with HF, stroke aetiology is influenced by the presence of AF and the underlying cause of HF. Early and late stroke outcome is associated with HF severity but not with the presence of AF.

Heart failure services in the United Kingdom: rethinking the machine bureaucracy

Poor outcomes and poor uptake of evidence based therapies persist for patients with heart failure in the United Kingdom. We offer a strategic analysis of services, defining the context, organization and objectives of the service, before focusing on implementation and performance. Critical flaws in past service development and performance are apparent, a consequence of failed performance management, policy and political initiative. The barriers to change and potential solutions are common to many health care systems. Integration, information, financing, incentives, innovation and values: all must be challenged and improved if heart failure services are to succeed. Modern healthcare requires open adaptive systems, continually learning and improving. The system also needs controls. Performance indicators should be simple, clinically relevant, and outcome focused. Heart failure presents one of the greatest opportunities to improve symptoms and survival with existing technology. To do so, heart failure services require radical reorganization.

CONSENSUS to EMPHASIS: the overwhelming evidence which makes blockade of the renin-angiotensin-aldosterone system the cornerstone of therapy for systolic heart failure

We will shortly celebrate the 25th anniversary of the publication of the Co-operative North Scandinavian Enalapril Survival Study (CONSENSUS), a clinical trial which revolutionized the treatment of heart failure and highlighted the importance of the renin-angiotensin-aldosterone system (RAAS) in the pathophysiology of heart failure (Figure 1). In this article I will give a brief, historical overview of this exciting quarter-century of discovery related to the RAAS. My focus is on the treatment of heart failure in patients with a low left ventricular ejection fraction.