Persistent High Burden of Heart Failure Across the Ejection Fraction Spectrum in a Nationwide Setting

Abstract

Background Heart failure (HF) has a dramatic impact on worldwide health care systems that is determined by the growing prevalence of and the high exposure to cardiovascular and noncardiovascular events. Prognosis remains poor. We sought to compare a large population with HF across the ejection fraction (EF) spectrum with a population without HF for patient characteristics, and HF, cardiovascular, and noncardiovascular outcomes. Methods and Results Patients with HF registered in the Swedish HF registry in 2005 to 2018 were compared 1:3 with a sex-, age-, and county-matched population without HF. Outcomes were cardiovascular and noncardiovascular mortality and hospitalizations. Of 76 453 patients with HF, 53% had reduced EF, 23% mildly reduced EF, and 24% preserved EF. Compared with those without HF, patients with HF had more cardiovascular and noncardiovascular comorbidities and worse socioeconomic status. Incidence of cardiovascular and noncardiovascular events was higher in people with HF versus non-HF, with increased risk of all-cause (hazard ratio [HR], 2.53 [95% CI, 2.50-2.56]), cardiovascular (HR, 4.67 [95% CI, 4.59-4.76]), and noncardiovascular (HR, 1.49 [95% CI, 1.46-1.52]) mortality, 2- to 5-fold higher risk of first/repeated cardiovascular and noncardiovascular hospitalizations, and ~4 times longer in-hospital length of stay for any cause. Patients with HF with reduced EF had higher risk of HF hospitalizations, whereas those with HF with preserved EF had higher risk of all-cause and noncardiovascular hospitalization and mortality. Conclusions Patients with HF exert a high health care burden, with a much higher risk of cardiovascular, all-cause, and noncardiovascular events, and nearly 4 times as many days spent in hospital compared with those without HF. These epidemiological data may enable strategies for optimal resource allocation and HF trial design.

Keywords: comorbidity; ejection fraction; epidemiology; heart failure.

Figure 1. Differences in comorbidities and treatments between patients with HF and control individuals without HF.

COPD indicates chronic obstructive pulmonary disease; HF, heart failure; IHD, ischemic heart disease; MRA, mineralocorticoid receptor antagonists; PAD, peripheral artery disease; and RASI/ARNI, renin‐angiotensin system inhibitor/angiotensin receptor neprilysin inhibitor.

Figure 2. Distribution of the main cardiovascular and noncardiovascular comorbidities and of HF and non‐HF treatments across the EF spectrum.

BMI indicates body mass index; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; HF, heart failure; HFmrEF, mildly reduced ejection fraction heart failure; HFpEF, preserved ejection fraction heart failure; HFrEF, reduced ejection fraction heart failure; IHD, ischemic heart disease; MRA, mineralocorticoid receptor antagonists; PAD, peripheral artery disease; and RASI/ARNI, renin‐angiotensin system inhibitors/angiotensin receptor neprilysin inhibitors.

Figure 3. Temporal trends in the use of HF medications across the EF spectrum.

EF indicates ejection fraction; HFmrEF, mildly reduced ejection fraction heart failure; HFpEF, preserved ejection fraction heart failure; HFrEF, reduced ejection fraction heart failure; RASI/ARNI, renin‐angiotensin system inhibitors/angiotensin receptor neprilysin inhibitors; and RR, relative risk.

Figure 4. Differences in outcomes between patients with HF and control individuals without HF.

HF indicates heart failure; and HHF, hospitalization for heart failure. * ×10.

Figure 5. Incidence of the study outcomes in the population with HF across the EF categories.

EF indicates ejection fraction; HF, heart failure; HFmrEF, mildly reduced ejection fraction heart failure; HFpEF, preserved ejection fraction heart failure; HFrEF, reduced ejection fraction heart failure; and HHF, hospitalization for heart failure. * ×10.