Angiotensin converting enzyme inhibition and hospitalisation rates for heart failure in the Netherlands, 1980 to 1999: the end of an epidemic?

Trends for Readmission and Mortality After Heart Failure Hospitalisation in Malaysia, 2007 to 2016

Background and objectives:

Data on population-level outcomes after heart failure (HF) hospitalisation in Asia is sparse. This study aimed to estimate readmission and mortality after hospitalisation among HF patients and examine temporal variation by sex and ethnicity.

Methods:

Data for 105,399 patients who had incident HF hospitalisations from 2007 to 2016 were identified from a national discharge database and linked to death registration records. The outcomes assessed here were 30-day readmission, in-hospital, 30-day and one-year all-cause mortality.

Results:

Eighteen percent of patients (n = 16786) were readmitted within 30 days. Mortality rates were 5.3% (95% confidence interval (CI) 5.1–5.4%), 11.2% (11.0–11.4%) and 33.1% (32.9–33.4%) for in-hospital, 30-day and 1-year mortality after the index admission. Age, sex and ethnicity-adjusted 30-day readmissions increased by 2% per calendar year while in-hospital and 30-day mortality declined by 7% and 4% per year respectively. One-year mortality rates remained constant during the study period. Men were at higher risk of 30-day readmission (adjusted rate ratio (RR) 1.16, 1.13–1.20) and one-year mortality (RR 1.17, 1.15–1.19) than women. Ethnic differences in outcomes were evident. Readmission rates were equally high in Chinese and Indians relative to Malays whereas Others, which mainly comprised Indigenous groups, fared worst for in-hospital and 30-day mortality with RR 1.84 (1.64–2.07) and 1.3 (1.21–1.41) relative to Malays.

Conclusions:

Short-term survival was improving across sex and ethnic groups but prognosis at one year after incident HF hospitalisation remained poor. The steady increase in 30-day readmission rates deserves further investigation.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Snapshot evaluation of acute and chronic heart failure in real-life in Turkey: A follow-up data for mortality

Objective:

Heart failure (HF) is a progressive clinical syndrome. SELFIE-TR is a registry illustrating the overall HF patient profile of Turkey. Herein, all-cause mortality (ACM) data during follow-up were provided.

Methods:

This is a prospective outcome analysis of SELFIE-TR. Patients were classified as acute HF (AHF) versus chronic HF (CHF) and HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction, and HF with preserved ejection fraction and were followed up for ACM.

Results:

There were 1054 patients with a mean age of 63.3±13.3 years and with a median follow-up period of 16 (7–17) months. Survival data within 1 year were available in 1022 patients. Crude ACM was 19.9% for 1 year in the whole group. ACM within 1 year was 13.7% versus 32.6% in patients with CHF and AHF, respectively (p<0.001). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta blocker, and mineralocorticoid receptor antagonist were present in 70.6%, 88.2%, and 50.7%, respectively. In the whole cohort, survival curves were graded according to guideline-directed medical therapy (GDMT) scores ≤1 versus 2 versus 3 as 28% versus 20.2% versus 12.2%, respectively (p<0.001). Multivariate analysis of the whole cohort yielded age (p=0.009) and AHF (p=0.028) as independent predictors of mortality in 1 year.

Conclusion:

One-year mortality is high in Turkish patients with HF compared with contemporary cohorts with AHF and CHF. Of note, GDMT score is influential on 1-year mortality being the most striking one on chronic HFrEF. On the other hand, in the whole cohort, age and AHF were the only independent predictors of death in 1 year. (Anatol J Cardiol 2020; 23: 160-8)

Epidemiology of heart failure

The heart failure syndrome has first been described as an emerging epidemic about 25 years ago. Today, because of a growing and ageing population, the total number of heart failure patients still continues to rise. However, the case mix of heart failure seems to be evolving. Incidence has stabilized and may even be decreasing in some populations, but alarming opposite trends have been observed in the relatively young, possibly related to an increase in obesity. In addition, a clear transition towards heart failure with a preserved ejection fraction has occurred. Although this transition is partially artificial, due to improved recognition of heart failure as a disorder affecting the entire left ventricular ejection fraction spectrum, links can be made with the growing burden of obesity‐related diseases and with the ageing of the population. Similarly, evidence suggests that the number of patients with heart failure may be on the rise in low‐income countries struggling under the double burden of communicable diseases and conditions associated with a Western‐type lifestyle. These findings, together with the observation that the mortality rate of heart failure is declining less rapidly than previously, indicate we have not reached the end of the epidemic yet. In this review, the evolving epidemiology of heart failure is put into perspective, to discern major trends and project future directions.

Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age

This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.

Heart Failure Clinics in the Netherlands in 2003

PURPOSE

Heart failure (HF) care in the Netherlands is going through a lot of changes. Nurses have increasingly important roles in providing optimal care for these chronically ill patients. In this study, we describe the current number of HF management programs and the role of the nurses in these programs.

METHOD

Data were collected by a national survey as part of a European HF clinic survey of the UNITE study group of the Working Group on Cardiovascular Nursing between February and March 2003 to 142 hospitals in the Netherlands.

RESULTS

In 60% of the hospital locations, there is a HF management program. Most of the programs are organized as HF outpatient clinics. In all HF programs, cardiologists and nurses are involved. Other health care providers involved are, amongst others, general practitioners (29%), dieticians (59%), physical therapists (47%), social workers (30%) and psychologists (17%). All programs offer follow-up after discharge from the hospitals and in most of the programs patients have increased access to a health care provider. Behavioural interventions (68%), psychosocial counselling (64%), patient education (88%) and support of the informal caregivers (59%) are important components. In 90% of the programs (restricted), physical examination is the responsibility of the HF nurse and in 65% of the programs nurses are involved in optimizing medical treatment. Financial support and education of HF nurses is still unstructured and diverse.

CONCLUSION

There is a rise in the number of HF programs in the Netherlands. There is diversity in content and intensity of these programs and the role of the nurse is not clearly defined yet. Research and discussion on the subject of optimal effective HF care and the role of the HF nurse is still needed.

Understanding the epidemic of heart failure: past, present, and future

Heart failure (HF) is a major public health problem affecting more than five million Americans and more than 23 million patients worldwide. The epidemiology of HF is evolving. Data suggests that the incidence of HF peaked in the mid-1990s and has since declined. Survival after HF diagnosis has improved, leading to an increase in prevalence. The case mix is also changing, as a rising proportion of patients with HF have preserved ejection fraction and multimorbidity is increasingly common. After diagnosis, HF can have a profound associated morbidity. Hospitalizations in HF remain both frequent and costly, though they may be declining as a result of preventive efforts. The need for skilled nursing facility care in HF has risen. The role of palliative medicine in the care of patients with advanced HF is evolving as we learn how to best care for this population with a large symptom burden.

Treatment of acute heart failure in the emergency department

Millions of patients are hospitalized for acute heart failure (AHF) every year throughout the world. Despite tremendous advances in cardiovascular care, morbidity and mortality for AHF remain high, consuming billions of health care dollars. With the aging of the population, the incidence and prevalence of HF is projected to increase. Yet, initial treatment of AHF today is similar to 40 years ago. Multiple studies have yielded new insights regarding initial management, with regards to both treatment and strategies of care. These advances will be reviewed in the context of initial or early AHF management. There remains, however, an unmet need to improve outcomes for AHF patients.

The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries

Heart failure is a global pandemic affecting an estimated 26 million people worldwide and resulting in more than 1 million hospitalizations annually in both the United States and Europe. Although the outcomes for ambulatory HF patients with a reduced ejection fraction (EF) have improved with the discovery of multiple evidence-based drug and device therapies, hospitalized heart failure (HHF) patients continue to experience unacceptably high post-discharge mortality and readmission rates that have not changed in the last 2 decades. In addition, the proportion of HHF patients classified as having a preserved EF continues to grow and may overtake HF with a reduced EF in the near future. However, the prognosis for HF with a preserved EF is similar and there are currently no available disease-modifying therapies. HHF registries have significantly improved our understanding of this clinical entity and remain an important source of data shaping both public policy and research efforts. The authors review global HHF registries to describe the patient characteristics, management, outcomes and their predictors, quality improvement initiatives, regional differences, and limitations of the available data. Moreover, based on the lessons learned, they also propose a roadmap for the design and conduct of future HHF registries.

National trends in heart failure hospital stay rates, 2001 to 2009

OBJECTIVES

This study sought to analyze recent trends over time in heart failure (HF) hospital stay rates, length of stay (LOS), and in-hospital mortality by age groups with a large national dataset of U.S. hospital discharges.

BACKGROUND

Heart failure hospital stay rates, LOS, and mortality have fallen over the past decade for older Medicare beneficiaries, but whether this holds true for younger adults is unknown.

METHODS

From the National Inpatient Sample, we calculated HF hospital stay rates, LOS, and in-hospital mortality from 2001 to 2009 with survey data analysis techniques.

RESULTS

Hospital stays (n = 1,686,089) with a primary discharge diagnosis of HF were identified from National Inpatient Sample data between 2001 and 2009. The overall national hospital stay rate decreased from 633 to 463 hospital stays/100,000 persons, (-26.9%, p-for-trend <0.001). However, statistically significant declines (p < 0.001) were only observed for patients 55 to 64 years of age (-36.5%) 65 to 74 years (-37.4%), and ≥ 75 years (-28.3%) but not for patients 18 to 44 years of age (-12.8%, p = 0.57) or 45 to 55 years (-16.2%, p = 0.04). Statistically significant declines in LOS were only observed for patients 65 years of age and older. Overall in-hospital mortality fell from 4.5% to 3.3%, a relative decline of -27.4%, (p-for-trend <0.001), but patients 18 to 44 years of age did not exhibit a significant decline (-8.1%, p-for-trend = 0.18). In secondary analyses significant declines in HF hospital stay rate over time were observed for white men, white women, and black women but not for black men (-9.5%, p-for-trend = 0.43).

CONCLUSIONS

Younger patients have not experienced comparable declines in HF hospital stay, LOS, and in-hospital mortality as older patients. Black men remain a vulnerable population for HF hospital stay.

The Ecology of Medical Care in Norway: Wide Use of General Practitioners may not Necessarily Keep Patients out of Hospitals

BACKGROUND

Our aim was to investigate the pattern of self reported symptoms and utilisation of health care services in Norway.

DESIGN AND METHODS

With data from the cross-sectional Tromsø Study (2007-8), we estimated population proportions reporting symptoms and use of seven different health services. By logistic regression we estimated differences according to age and gender.

RESULTS

In this study 12,982 persons aged 30-87 years participated, constituting 65.7% of those invited. More than 900/1000 reported symptoms or health problems in a year as well as in a month, and 214/1000 and 816/1000 visited a general practitioner once or more in a month and a year, respectively. The corresponding figures were 91/1000 and 421/1000 for specialist outpatient visits, and 14/1000 and 116/1000 for hospitalisations. Physiotherapists were visited by 210/1000, chiropractors by 76/1000, complementary and alternative medical providers by 127/1000, and dentists by 692/1000 in a year. Women used most health care services more than men, but genders used hospitalisations and chiropractors equally. Utilisation of all services increased with age, except chiropractors, dentists and complementary and alternative medical providers.

CONCLUSIONS

Almost the entire population reported health related problems during the previous year, and most residents visited a general practitioner. Yet there were high rates of inpatient and outpatient specialist utilisation. We suggest that wide use of general practitioners may not necessarily keep patients out of specialist care and hospitals.

ACKNOWLEDGMENTS

the authors would like to thank Tor Anvik for a significant contribution in developing the idea for the study, Tom Wilsgård for useful discussions about the statistical analyses and Jarl-Stian Olsen for graphic design of the figures. They would also thank the people of Tromsø and The Tromsø Study for giving data to this study. Northern Norway Regional Health Authority and The University of Tromsø funded this research.

Tailored telemonitoring in patients with heart failure: results of a multicentre randomized controlled trial

AIMS

Recent increases in heart failure tend to overload the healthcare system. Consequently, there is a need for innovative strategies to reduce heart failure hospitalizations.

METHODS AND RESULTS

A multicentre randomized controlled trial was carried out to test the hypothesis that telemonitoring reduces heart failure hospitalizations during 1 year follow-up. The mean age of the 382 participating patients was 71.5 (32-93) years; the mean left ventricular ejection fraction was 0.38, and in 61% it was ≤0.45%. Mean time to first heart failure-related hospitalization was 161 days for the intervention group and 139 days for the usual-care group; hospitalizations occurred in 18 (9.1%) compared with 25 (13.5%) patients, with a total number of 24 and 43 hospitalizations, respectively [Kaplan-Meier P = 0.151, hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.35-1.17]. Subgroup analysis of the primary endpoint showed benefits for three subgroups: duration of heart failure, having a pacemaker, and co-habiting. The combined endpoint of heart failure admission and all-cause mortality was similar for both groups (Kaplan-Meier P = 0.641, HR 0.89, 95% CI 0.69-1.83). No differences were found regarding secondary endpoints, except for the reduced number of face to face contacts with the heart failure nurse (Mann-Whitney P < 0.001). Mortality was 18 (9.1%) in the intervention group and 12 (6.5%) in the usual-care group (Mann-Whitney P = 0.34, Cox regression analysis P = 0.82).

CONCLUSION

No significant differences were found regarding the primary endpoint, possibly caused by a relative underpowering of the population combined with well-treated study groups. However, telemonitoring tends to reduce heart failure (re)admissions and significantly decreases contacts with specialized nurses. Further research with pre-specified groups, as found in the subgroup analysis, is needed.

TRIAL REGISTRATION

NCT00502255.

Nuclear cardiology and heart failure

The prevalence of heart failure in the adult population is increasing. It varies between 1% and 2%, although it mainly affects elderly people (6-10% of people over the age of 65 years will develop heart failure). The syndrome of heart failure arises as a consequence of an abnormality in cardiac structure, function, rhythm, or conduction. Coronary artery disease is the leading cause of heart failure and it accounts for this disorder in 60-70% of all patients affected. Nuclear techniques provide unique information on left ventricular function and perfusion by gated-single photon emission tomography (SPECT). Myocardial viability can be assessed by both SPECT and PET imaging. Finally, autonomic dysfunction has been shown to increase the risk of death in patients with heart disease and this may be applicable to all patients with cardiac disease regardless of aetiology. MIBG scanning has a very promising prognostic value in patients with heart failure.

The causes, consequences, and treatment of left or right heart failure

Chronic heart failure (HF) is a cardiovascular disease of cardinal importance because of several factors: a) an increasing occurrence due to the aging of the population, primary and secondary prevention of cardiovascular events, and modern advances in therapy, b) a bad prognosis: around 65% of patients are dead within 5 years of diagnosis, c) a high economic cost: HF accounts for 1% to 2% of total health care expenditure. This review focuses on the main causes, consequences in terms of morbidity, mortality and costs and treatment of HF.

Population Impact of Heart Failure and the Most Common Forms of Cancer

Background—

The contemporary impact of heart failure (HF) versus the most common forms of cancer as reflected by related first-ever hospitalizations and subsequent case-fatality rates is unknown.

Methods and Results—

Using a national registry in Sweden, we compared the rate of first-ever hospitalization and associated short- and long-term survival for HF, acute myocardial infarction (AMI), and the most common forms of cancer on an age and sex-specific basis during 1988 to 2004 in 949 733 Swedish patients (1 162 309 hospital admissions in total). Annual incidence of first-ever hospitalization for HF, AMI, and cancer in Sweden were 484, 424, and 373 (lung, colorectal, prostate, and bladder cancer combined) per 100 000 men and 470, 280, and 350 (lung, colorectal, bladder, breast, and ovarian cancer combined) per 100 000 women age >20 years. The ratio of individual cases of HF to cancer was 1.37:1 (465 998 versus 340 738). Despite improvements in 30-day and 5-year survival (adjusted 7% and 6% increase per calendar year for men and women, respectively), HF was associated with unadjusted case-fatality rate of 59% within 5 years and 196 400 deaths versus 58% and 131 000 deaths in patients with cancer. During 10-year follow-up, HF was associated with 66 318 versus 55 364 premature life-years lost than all common forms of cancer in men. In women, the equivalent figures were 59 535 versus 64 533 premature life-years lost.

Conclusions—

These data confirm that, like most common forms of cancer combined, HF exerts a major health burden in respect to age-adjusted rates of first hospitalization, poor overall survival, and premature life-years lost.

Heart failure burden and therapy

Heart failure (HF) is a syndrome with a broad spectrum of heterogeneous symptoms and signs resulting in a wide range of clinical expressions. The prevalence of HF is estimated to be 1-2% in developed countries, increasing with age. Heart failure is the leading cause of hospitalization for patients older than 65 years, raising concerns about the economic burden of this syndrome. This article provides a critical review of epidemiological and clinical aspects for HF; causes, comorbidities, and types of HF are also described. The systolic vs. diastolic, the acute vs. chronic approaches, and the connections between HF and left bundle branch block or atrial fibrillation are further detailed. In addition, a synthesis of the latest results and recommendations concerning the indication and the prescription of pharmacological (such as diuretics or rennin-angiotensin-aldosterone system inhibitors) and non-pharmacological treatments (particularly device therapy) is proposed.

Long-term trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: a population study of 5.1 million people

BACKGROUND

We examined whether population-level hospitalization rates for heart failure (HF) and subsequent survival have continued to improve since the turn of the century. We also examined trends in the prescribing of evidence-based pharmacological treatment for HF.

METHODS AND RESULTS

All patients in Scotland hospitalized with a first episode of HF between 1986 and 2003 were followed up until death or the end of 2004. Prescriptions of evidence-based treatments issued from 1997 to 2003 by a sample of primary care practices were also examined. A total of 116 556 individuals (52.6% women) had a first hospital discharge for HF. Age-adjusted first hospitalization rates for HF (per 100 000; 95% CI in parentheses) rose from 124 (119 to 129) in 1986 to 162 (157 to 168) in 1994 and then fell to 105 (101 to 109) in 2003 in men; in women, they rose from 128 (123 to 132) in 1986 to 160 (155 to 165) in 1993, falling to 101 (97 to 105) in 2003. Case-fatality rates fell steadily over the period. Adjusted 30-day case-fatality rates fell after discharge (adjusted odds [2003 versus 1986] 0.59 [95% CI 0.45 to 0.63] in men and 0.77 [95% CI 0.67 to 0.88] in women). Adjusted 1- and 5-year survival improved similarly. Median survival increased from 1.33 to 2.34 years in men and from 1.32 to 1.79 years in women. Age-adjusted prescribing rates for angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone increased from 1997 to 2003 (all P<0.0001 for trend).

CONCLUSIONS

After rising between 1986 and 1994, rates of first hospitalization for HF declined. Case-fatality rates also fell. Prescribing rates for HF therapies increased from 1997 to 2003. These findings suggest that improvements in the prevention and treatment of HF may have had progressive, sustained effects on outcomes at the population level; however, prognosis remains poor in HF.

The Emergency Department presenting complaint as predictor of in-hospital fatality

BACKGROUND

The relationship between major discharge diagnoses and prediction of in-hospital death has been intensively studied. The relation between the presenting complaint at the Emergency Department (ED) and in-hospital fatality, however, is less well known.

OBJECTIVE

To investigate if presenting complaints add information regarding in-hospital fatality risk for nonsurgical ED patients.

METHODS

Investigating the relationship of in-hospital fatality rate and presenting complaint by comparing the presenting complaints, discharge diagnoses and in-hospital fatality for all nonsurgical patients visiting the ED during 1 year.

RESULTS

Of 12,995 nonsurgical admissions, 40% were treated as in-hospital patients. Among these, 328 in-hospital deaths occurred. Age was the most powerful predictor of death in hospitalized patients (P<0.0001). After adjustment for age, the female sex was found to be protective [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.58-0.92, P=0.007)]. Compared with the largest complaint group, chest pain with an in-hospital fatality rate of 2.5%, there was a significantly increased risk of dying among those with stroke-like symptoms (OR 2.04, 95% CI 1.35-3.08, P=0.0007), dyspnoea (OR 1.95, 95% CI 1.27-3.00, P=0.002) or general disability (OR 1.81, 95% CI 1.17-2.79, P=0.008).

CONCLUSIONS

The presenting complaint at the ED carries valuable information of the risk for in-hospital fatality in nonsurgical patients. This knowledge can be valuable in the prioritization between different patient groups in the process of initiating diagnostics and treatment procedures at the ED.

Trends in heart failure mortality in England and Wales since 1950

BACKGROUND

This study aims to analyse trends in heart failure mortality for England and Wales from 1950 to 2003.

METHODS

A retrospective observational study was conducted using death certificate and population data from the Office for National Statistics.

RESULTS

Unadjusted heart failure deaths rose by a factor of more than four between 1950 and 1974 and then fell by a quarter by 2003. When standardised for changes in the age, sex and size of the population, there was a tripling in mortality rate from 1950 to the mid-1970s and since then, a sustained decline in mortality rate of 50% by 2003. The unadjusted female heart failure death rate has been between 1.5-2 times that of males since the early 1970s, but this is much less marked when the differences in the age distribution and sizes of the male and female populations are taken into account. Heart failure mortality trends are similar to those of coronary heart disease (CHD), but the peak is about 10 years earlier, and the male/female ratios are reversed. There is a continuing rise in deaths from both heart failure and CHD in the very elderly (>85 years).

CONCLUSION

Unlike hospital trends, deaths from heart failure in the community in England and Wales show a decline since the early 1970s, in spite of an ageing population. This may reflect genuine changes in heart failure incidence, or parallel changes in CHD.

Inequitable provision of optimal services for patients with chronic heart failure: a national geo-mapping study

OBJECTIVE

To compare the location and accessibility of current Australian chronic heart failure (CHF) management programs and general practice services with the probable distribution of the population with CHF.

DESIGN AND SETTING

Data on the prevalence and distribution of the CHF population throughout Australia, and the locations of CHF management programs and general practice services from 1 January 2004 to 31 December 2005 were analysed using geographic information systems (GIS) technology.

OUTCOME MEASURES

Distance of populations with CHF to CHF management programs and general practice services.

RESULTS

The highest prevalence of CHF (20.3-79.8 per 1000 population) occurred in areas with high concentrations of people over 65 years of age and in areas with higher proportions of Indigenous people. Five thousand CHF patients (8%) discharged from hospital in 2004-2005 were managed in one of the 62 identified CHF management programs. There were no CHF management programs in the Northern Territory or Tasmania. Only four CHF management programs were located outside major cities, with a total case load of 80 patients (0.7%). The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median, 163 km; range, 0.15-3246 km). In rural areas, where the burden of CHF management falls upon general practitioners, the mean distance to general practice services was 37 km (median, 20 km; range, 0-656 km).

CONCLUSION

There is an inequity in the provision of CHF management programs to rural Australians.

Uncovering a hidden epidemic: a study of the current burden of heart failure in Australia

BACKGROUND

Australia, like other countries, is experiencing an epidemic of heart failure (HF). However, given the lack of national and population-based datasets collating detailed cardiovascular-specific morbidity and mortality outcomes, quantifying the specific burden imposed by HF has been difficult.

METHODS

Australian Bureau of Statistics (ABS data) for the year 2000 were used in combination with contemporary, well-validated population-based epidemiologic data to estimate the number of individuals with symptomatic and asymptomatic HF related to both preserved (diastolic dysfunction) and impaired left ventricular systolic (dys)function (LVSD) and rates of HF-related hospitalisation.

RESULTS

In 2000, we estimate that around 325,000 Australians (58% male) had symptomatic HF associated with both LVSD and diastolic dysfunction and an additional 214,000 with asymptomatic LVSD. 140,000 (26%) live in rural and remote regions, distal to specialist health care services. There was an estimated 22,000 incidents of admissions for congestive heart failure and approximately 100,000 admissions associated with this syndrome overall.

CONCLUSION

Australia is in the midst of a HF epidemic that continues to grow. Overall, it probably contributes to over 1.4 million days of hospitalization at a cost of more than 1 billion dollars. A national response to further quantify and address this enormous health problem is required.

Antithrombotic therapy for congestive heart failure

Patients with congestive heart failure (CHF) are at increased risk of thromboembolic events. However, there is much debate and uncertainty over the use of antithrombotic therapy in these patients. The evidence for oral anticoagulation is limited, although large randomised trial data are forthcoming. Aspirin may be detrimental for heart failure due to a possible interaction with angiotensin-converting enzyme inhibitors, leading to increased hospitalisations from decompensated heart failure. The objective of this review article is to summarise the available evidence regarding the risk of stroke and thromboembolic events in CHF patients, as well as the effectiveness and risks of antithrombotic therapy in these patients.

Temporal trends in survival and hospitalizations in outpatients with chronic systolic heart failure in 1995 and 1999

Abstract Background Community and hospital studies have suggested that survival of patients with heart failure (HF) has increased; however, the causes of the improvement and the hospital readmission rates remain undetermined. Methods and Results We compared survival and hospital admission rates in 2 cohorts enrolled in a national registry of outpatients with HF secondary to left ventricular (LV) systolic dysfunction referred to cardiology centers in 1995 (n = 712) and 1999 (n = 603). One year after enrollment, 163 of 1315 patients (12%) were dead. Survival rates were 85% in the 1995 versus 91% in the 1999 cohort. Older age, New York Heart Association (NYHA) class III-IV, anemia, hyponatremia, hypotension, and a lower LV ejection fraction (LVEF) were associated to an increased risk of all-cause mortality by multivariate analysis. Furthermore a significant independent cohort effect was observed: the adjusted risk of death was 1.30 (95% CI 1.16-1.45) for the 1995 versus 1999 cohort (survival difference adjusted P = .0067). The proportion of patients admitted to hospital declined significantly in 1999 versus 1995, for all causes (20% versus 27%, P = .006), for cardiac causes (16% versus 22%, P = .002), and for worsening congestive heart failure (8% versus 15%, P = .0005). Survival free from HF admission was 69% in 1995 versus 84% in 1999 (adjusted P = .0001); NYHA class III-IV, hypotension, diuretics and a lower LVEF were associated to an increased risk of this combined end point by multivariate analysis, as well as the enrollment year (relative risk 1.38, 95% CI 1.22-1.56, P = .0039). Conclusion In a national cardiologic registry of outpatients with systolic HF, survival improved and hospital admissions decreased over a 4-year period. These results underscore the importance of networking and the careful implementation of practice guidelines to elevate standards of care.

Heart failure programmes in countries with a primary care-based health care system. Are additional trials necessary? Design of the DEAL-HF study

BACKGROUND

Several randomised studies of heart failure (HF) management programmes in the United States, Australia and Europe have shown a considerable reduction in hospitalisation rates for HF. In this article, a comprehensive review of these studies will be provided and their applicability to countries, with a primary care-based healthcare system, will be discussed. In addition, the design of the Deventer-Alkmaar HF Project (DEAL-HF), a randomised study of the effect of a nurse and physician-directed intervention over 1 year in The Netherlands, will also be presented.

AIM

To discuss the applicability of the results of available studies on heart failure management programmes to countries with well-structured primary care facilities and to determine whether additional trials should be conducted in these countries.

METHODS

We performed a literature search in PubMed. In a review of the available studies, essential methodological aspects, in particular, the population involved, the sample size, follow-up period, setting, type of intervention, and the outcome parameters, are discussed critically. Also, the applicability of these studies to countries with a primary care-based healthcare system and easy access to medical care is evaluated.

CONCLUSION

Applicability of the results of the available studies on the efficacy of heart failure management programmes to countries with a primary care-based health care system is doubtful. An efficacy trial in a country with a well-established primary care-based healthcare system, such as The Netherlands, is due to report soon (DEAL-HF).

Carvedilol reduces the costs of medical care in severe heart failure: An economic analysis of the COPERNICUS study applied to the United Kingdom

BACKGROUND

The aim of this study was to determine the effects of carvedilol on the costs related to the treatment of severe chronic heart failure (CHF).

METHODS

Costs for the treatment for heart failure within the National Health Service (NHS) in the United Kingdom (UK) were applied to resource utilisation data prospectively collected in all patients randomized into the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study. Unit-specific, per diem (hospital bed day) costs were used to calculate expenditures due to hospitalizations. We also included costs of carvedilol treatment, general practitioner surgery/office visits, hospital out-patient clinic visits and nursing home care based on estimates derived from validated patterns of clinical practice in the UK.

RESULTS

The estimated cost of carvedilol therapy and related ambulatory care for the 1156 patients assigned to active treatment was pound530,771 ( pound44.89 per patient/month of follow-up). However, patients assigned to carvedilol were hospitalised less often and accumulated fewer and less expensive days of admission. Consequently, the total estimated cost of hospital care was pound3.49 million in the carvedilol group compared with pound4.24 million for the 1133 patients in the placebo arm. The cost of post-discharge care was also less in the carvedilol than in the placebo group ( pound479,200 vs. pound548,300). Overall, the cost per patient treated in the carvedilol group was pound3948 compared to pound4279 in the placebo group. This equated to a cost of pound385.98 vs. pound434.18, respectively, per patient/month of follow-up: an 11.1% reduction in health care costs in favour of carvedilol.

CONCLUSIONS

These findings suggest that not only can carvedilol treatment increase survival and reduce hospital admissions in patients with severe CHF but that it can also cut costs in the process.

Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure

BACKGROUND

Few studies have examined the potential benefits of specialist nurse-led programs of care involving home and clinic-based follow-up to optimise the post-discharge management of chronic heart failure (CHF).

OBJECTIVE

To determine the effectiveness of a hybrid program of clinic plus home-based intervention (C+HBI) in reducing recurrent hospitalisation in CHF patients.

METHODS

CHF patients with evidence of left ventricular systolic dysfunction admitted to two hospitals in Northern England were assigned to a C+HBI lasting 6 months post-discharge (n=58) or to usual, post-discharge care (UC: n=48) via a cluster randomization protocol. The co-primary endpoints were death or unplanned readmission (event-free survival) and rate of recurrent, all-cause readmission within 6 months of hospital discharge.

RESULTS

During study follow-up, more UC patients had an unplanned readmission for any cause (44% vs. 22%: P=0.019, OR 1.95 95% CI 1.10-3.48) whilst 7 (15%) versus 5 (9%) UC and C+HBI patients, respectively, died (P=NS). Overall, 15 (26%) C+HBI versus 21 (44%) UC patients experienced a primary endpoint. C+HBI was associated with a non-significant, 45% reduction in the risk of death or readmission when adjusting for potential confounders (RR 0.55, 95% CI 0.28-1.08: P=0.08). Overall, C+HBI patients accumulated significantly fewer unplanned readmissions (15 vs. 45: P<0.01) and days of recurrent hospital stay (108 vs. 459 days: P<0.01). C+HBI was also associated with greater uptake of beta-blocker therapy (56% vs. 18%: P<0.001) and adherence to Na restrictions (P<0.05) during 6-month follow-up.

CONCLUSION

This is the first randomised study to specifically examine the impact of a hybrid, C+HBI program of care on hospital utilisation in patients with CHF. Its beneficial effects on recurrent readmission and event-free survival are consistent with those applying either a home or clinic-based approach.

Management of heart failure in The Netherlands

In The Netherlands, the incidence and prevalence of heart failure are rising as is the case in most other European countries. Overall, there are 200,000 patients with heart failure in The Netherlands and around 25,000 hospitalisations annually with a discharge diagnosis of heart failure. Most of these patients are managed in primary care, often together with a cardiologist. There is an active guideline program in different professional organisations (e.g. general practitioners, cardiologists) and in 2002 a collaborative multidisciplinary guideline for management of chronic heart failure was developed. However, there is clearly room for improvement in the adherence to these guidelines both with regard to the diagnosis and the treatment of HF patients. For example, ACE-I and beta-blockers are still under-prescribed. In particular, the more severely ill patients seem to be under treated. At present, general practitioners and cardiologists differ in their views on heart failure, resulting in differences in diagnosis and management. In addition to the multidisciplinary guidelines, several other initiatives have been developed to improve outcomes in these patients, such as rapid access clinics and outpatient heart failure clinics.

Financial aspects of heart failure programs of care

As suggested by studies that have examined the economic burden imposed by heart failure and, more specifically where the greatest expenditure occurs, the key to cost-effectively minimising the impact of a sustained heart failure epidemic is to minimise recurrent hospital use--even at the expense of increasing levels of community-based care and prescribed pharmacotherapy. This paper examines the potential cost-benefits of applying specialist heart failure programs of care and the range of financial issues that need to be considered when establishing a formal heart failure service.

Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE)

BACKGROUND

The ADHERE is designed to study characteristics, management, and outcomes in a broad sample of patients hospitalized with acute decompensated heart failure. Heart failure is a leading cause of hospitalization for adults older than 65 years in the United States. Most available data on these patients are limited by patient selection criteria and study design of clinical trials and single-center studies.

METHODS

Participating hospitals identify patients with a primary or secondary discharge diagnosis of heart failure. Medical history, management, treatments, and health outcomes data are collected through review of medical records and entered into a database via secure web browser technology.

RESULTS

As of January 2004, data on 107 362 patients have been received from 282 participating hospitals. Of enrollees with available analyzable data (N = 105 388 from 274 hospitals), the mean age was 72.4 (+/-14.0), and 52% were women. The most common comorbid conditions were hypertension (73%), coronary artery disease (57%), and diabetes (44%). Evidence of mild or no impairment of systolic function was found in 46% of patients. Inhospital mortality was 4.0% and the median hospital length of stay was 4.3 days.

CONCLUSIONS

The ADHERE demonstrates both the feasibility and significant implications of gathering representative data on large numbers of patients hospitalized with heart failure. Initial data provided important insights into the clinical characteristics and patterns of care of these patients. Ongoing registry work will provide the framework for improved treatment strategies for patients hospitalized with decompensated heart failure.