Advanced Heart Failure Epidemiology and Outcomes: A Population-Based Study

Abstract

Objectives: The goal of this study was to evaluate the prevalence, characteristics, and outcomes of patients with advanced heart failure (HF) in a geographically defined population.

Background: Some patients with HF progress to advanced HF, characterized by debilitating HF symptoms refractory to therapy. Limited data are available on the epidemiology and outcomes of patients with advanced HF.

Methods: This was a population-based cohort study of all Olmsted County, Minnesota, adults with and without HF from 2007 to 2017. The 2018 European Society of Cardiology advanced HF diagnostic criteria were operationalized and applied to all patients with HF. Hospitalization and mortality in advanced HF, overall and according to ejection fraction (EF) type (reduced EF <40% [HFrEF], mid-range EF 40%-49% [HFmrEF], and preserved EF ≥50% [HFpEF]) were examined using Andersen-Gill and Cox models.

Results: Of 6,836 adults with HF, 936 (13.7%) met criteria for advanced HF. The prevalence of advanced HF increased with age and was higher in men. At advanced HF diagnosis, 396 (42.3%) patients had HFrEF, 134 (14.3%) had HFmrEF, and 406 (43.4%) had HFpEF. The median (interquartile range) time from advanced HF diagnosis to death was 12.2 months (3.7-29.9 months). The mean rate of hospitalization was 2.91 (95% CI: 2.78-3.06) per person-year in the first year after advanced HF diagnosis. There were no differences in risks of all-cause mortality or hospitalization by EF. Patients with advanced HFpEF were at lower risk for cardiovascular mortality compared with advanced HFrEF (HR: 0.79; 95% CI: 0.65-0.97).

Conclusions: In this population-based study, more than one-half of patients with advanced HF had mid-range or preserved EF, and survival was poor regardless of EF.

Keywords: advanced heart failure; epidemiology; hospitalization; mortality; outcomes; population health.

Figure 1.. Study Flow Diagram

The number of patients meeting each of the European Society of Cardiology criteria for advanced heart failure is shown. ED=emergency department; EF= ejection fraction, HF= heart failure, NYHA= New York Heart Association, RV= right ventricular, VT/VF= ventricular tachycardia/ ventricular fibrillation

Figure 2.. Prevalence of Advanced Heart Failure in Patients with Heart Failure

The annual proportion of patients whose HF is advanced is shown in men and women (Figure 2A) and by age group (<65, 65–79, 80+ years old, Figure 2B)

Figure 2.. Prevalence of Advanced Heart Failure in Patients with Heart Failure

The annual proportion of patients whose HF is advanced is shown in men and women (Figure 2A) and by age group (<65, 65–79, 80+ years old, Figure 2B)

Figure 3.. Prevalence Rates of Advanced Heart Failure Among Adults in the Community

The annual rate of advanced HF among Olmsted County adults in the study period is shown. Figure 3A shows the age-adjusted prevalence rate of advanced HF in men and women, while Figure 3B shows the prevalence rate of advanced HF by age group (<65, 65–79, 80+ years old).

Figure 3.. Prevalence Rates of Advanced Heart Failure Among Adults in the Community

The annual rate of advanced HF among Olmsted County adults in the study period is shown. Figure 3A shows the age-adjusted prevalence rate of advanced HF in men and women, while Figure 3B shows the prevalence rate of advanced HF by age group (<65, 65–79, 80+ years old).

Central Illustration.. Survival and Hospitalizations Following Advanced Heart Failure

The Kaplan Meier survival curves by EF are shown in Central Illustration A. Mean cumulative hospitalizations after advanced HF by EF are shown in Central Illustration B.

Central Illustration.. Survival and Hospitalizations Following Advanced Heart Failure

The Kaplan Meier survival curves by EF are shown in Central Illustration A. Mean cumulative hospitalizations after advanced HF by EF are shown in Central Illustration B.