Prior Heart Failure Hospitalization and Outcomes in Patients with Heart Failure with Preserved and Reduced Ejection Fraction

Abstract

Background: A prior hospitalization resulting from heart failure is associated with poor outcomes in ambulatory patients with heart failure. Less is known about this association in hospitalized patients with heart failure and whether it varies by ejection fraction.

Methods: Of the 25,345 hospitalized patients in the Medicare-linked OPTIMIZE-HF registry, 22,491 had known heart failure, of whom 7648 and 9558 had heart failure with preserved (≥50%) and reduced (≤40%) ejection fraction (HFpEF and HFrEF), respectively. Overall, 927 and 1862 patients with HFpEF and HFrEF had hospitalizations for heart failure during the 6 months before the index hospitalization, respectively. Using propensity scores for prior heart failure hospitalization, we assembled two matched cohorts of 924 pairs and 1844 pairs of patients with HFpEF and HFrEF, respectively, each balanced for 58 baseline characteristics. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes during 6 years of follow-up.

Results: Among 1848 matched patients with HFpEF, HRs (95% CIs) for all-cause mortality, all-cause readmission, and heart failure readmission were 1.35 (1.21-1.50; P <0.001), 1.34 (1.21-1.47; P <0.001), and 1.90 (1.67-2.16; P <0.001), respectively. Respective HRs (95% CIs) in 3688 matched patients with HFrEF were 1.17 (1.09-1.26; P <0.001), 1.32 (1.23-1.41; P <0.001), and 1.48 (1.37-1.61; P <0.001).

Conclusions: Among hospitalized patients with heart failure, a previous hospitalization for heart failure is associated with higher risks of mortality and readmission in both HFpEF and HFrEF. The relative risks of death and heart failure readmission appear to be higher in HFpEF than in HFrEF.

Keywords: Heart failure; Mortality; Preserved ejection fraction; Prior hospitalization; Readmission.

Figure 1.

Flow chart displaying assembly of propensity score-matched cohorts of patients by a heart failure hospitalization (HFH) in the six months prior to the index HFH (HFH = Heart failure hospitalization; HFpEF = Heart failure with preserved ejection fraction; HFrEF = Heart failure with reduced ejection fraction; LVEF = Left ventricular ejection fraction; OPTIMIZE-HF = Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure)

Figure 2.

Love plot displaying absolute standardized differences comparing 58 baseline characteristics of 7648 pre-match and 1848 matched patients with heart failure with preserved ejection fraction, by prior versus no prior heart failure hospitalization in past six months, before and after propensity score matching. An absolute standardized difference of 0% indicates no residual bias and values <10% indicate inconsequential bias (ACE = Angiotensin-converting enzyme; ARB = Angiotensin receptor blockers; CCBs = Calcium channel blockers; COPD = Chronic obstructive pulmonary disease; ICD =Implantable cardioverter-defibrillator; JVP = Jugular venous pressure; LVEF = Left ventricular ejection fraction)

Figure 3.

Kaplan-Meier plots for all-cause mortality during six years of post-discharge follow up by heart failure hospitalization during six months prior to the index hospitalization in 924 and 1844 pairs of propensity score-matched patients with heart failure with preserved ejection fraction (HFpEF; top panel) and heart failure with reduced ejection fraction (HFrEF; bottom panel), respectively (CI = Confidence interval; HR = Hazard ratio).

Figure 4.

Forest plots displaying associations of heart failure hospitalization in the six months prior to index hospitalization and all-cause mortality during six years of follow-up in clinically relevant subgroups of propensity score-matched patients with heart failure with preserved ejection fraction (≥50%) (ACE = Angiotensin-converting enzyme; ARB = Angiotensin receptor blocker; CI = Confidence interval)