Temporal trends in treatment and outcomes for advanced heart failure with reduced ejection fraction from 1993-2010: findings from a university referral center

Abstract

Background: Randomized trials have demonstrated the efficacy of several new therapies for heart failure (HF) with reduced ejection fraction over the preceding 2 decades. This study investigates whether these therapeutic advances have translated into improvement in outcomes for patients with advanced HF referred to a heart transplant center.

Methods and results: Patients with HF (n=2507) referred to a single university center were analyzed in three 6-year eras during which medical and device therapies were evolving: 1993 to 1998 (era 1), 1999 to 2004 (era 2), and 2005 to 2010 (era 3). Impaired hemodynamics and comorbidities were more frequent at time of referral in later eras, whereas other HF severity parameters where similar or improved. Successive eras had greater usage of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, aldosterone antagonists, implantable cardioverter defibrillators, and cardiac resynchronization therapy, consistent with evolving evidence and guideline recommendations over the study period. All-cause mortality and sudden death were significantly lower in era 2 and 3 compared with era 1. After multivariable risk adjustment, era 3 had significantly decreased 2- and 3-year all-cause mortality risk and significantly decreased 1- and 3-year sudden death risk compared with era 1. However, progressive HF death and the combined outcome of mortality/urgent transplant/ventricular assist device were modestly increased in the latter eras.

Conclusions: Over the past 2 decades, patients with advanced HF referred to and managed at a tertiary university referral center have benefited from advances in HF medications and devices, as evidenced by improvements in overall survival and sudden death risk.

Keywords: heart failure; mortality; therapy.

Figure 1

Unadjusted and risk-adjusted survival curves for the outcome of all-cause mortality (panels a and b) and all-cause mortality, urgent transplant and VAD (panels c and d). Risk adjusted survival curves are adjusted for patients' age, gender, LVEF, NYHA class, body mass index, history of CAD, history of diabetes, history of hypertension, total cholesterol, serum sodium, serum BUN and pulmonary capillary wedge pressure after optimization of therapy. P values for unadjusted curves (panels a and c) are derived from log-rank statistic. P values for adjusted curves (panels b and d) are derived from Cochran-Armitage trend test.

Figure 1

Unadjusted and risk-adjusted survival curves for the outcome of all-cause mortality (panels a and b) and all-cause mortality, urgent transplant and VAD (panels c and d). Risk adjusted survival curves are adjusted for patients' age, gender, LVEF, NYHA class, body mass index, history of CAD, history of diabetes, history of hypertension, total cholesterol, serum sodium, serum BUN and pulmonary capillary wedge pressure after optimization of therapy. P values for unadjusted curves (panels a and c) are derived from log-rank statistic. P values for adjusted curves (panels b and d) are derived from Cochran-Armitage trend test.

Figure 1

Unadjusted and risk-adjusted survival curves for the outcome of all-cause mortality (panels a and b) and all-cause mortality, urgent transplant and VAD (panels c and d). Risk adjusted survival curves are adjusted for patients' age, gender, LVEF, NYHA class, body mass index, history of CAD, history of diabetes, history of hypertension, total cholesterol, serum sodium, serum BUN and pulmonary capillary wedge pressure after optimization of therapy. P values for unadjusted curves (panels a and c) are derived from log-rank statistic. P values for adjusted curves (panels b and d) are derived from Cochran-Armitage trend test.

Figure 1

Unadjusted and risk-adjusted survival curves for the outcome of all-cause mortality (panels a and b) and all-cause mortality, urgent transplant and VAD (panels c and d). Risk adjusted survival curves are adjusted for patients' age, gender, LVEF, NYHA class, body mass index, history of CAD, history of diabetes, history of hypertension, total cholesterol, serum sodium, serum BUN and pulmonary capillary wedge pressure after optimization of therapy. P values for unadjusted curves (panels a and c) are derived from log-rank statistic. P values for adjusted curves (panels b and d) are derived from Cochran-Armitage trend test.

Figure 2

Sudden death, non sudden death, and total mortality at one year in the three eras, (a) unadjusted and (b) adjusted rates. See figure 1 legend for adjustment variables.

Figure 2

Sudden death, non sudden death, and total mortality at one year in the three eras, (a) unadjusted and (b) adjusted rates. See figure 1 legend for adjustment variables.