Burden of Illness beyond Mortality and Heart Failure Hospitalizations in Patients Newly Diagnosed with Heart Failure in Spain According to Ejection Fraction

Abstract

Objective: The objective of this study was to describe the rates of adverse clinical outcomes, including all-cause mortality, heart failure (HF) hospitalization, myocardial infarction, and stroke, in patients newly diagnosed with HF to provide a comprehensive picture of HF burden.

Methods: This was a retrospective and observational study, using the BIG-PAC database in Spain. Adults, newly diagnosed with HF between January 2013 and September 2019 with ≥1 HF-free year of enrolment prior to HF diagnosis, were included.

Results: A total of 19,961 patients were newly diagnosed with HF (43.5% with reduced ejection fraction (EF), 26.3% with preserved EF, 5.1% with mildly reduced EF, and 25.1% with unknown EF). The mean age was 69.7 ± 19.0 years; 53.8% were men; and 41.0% and 41.5% of patients were in the New York Heart Association functional classes II and III, respectively. The baseline HF treatments included beta-blockers (70.1%), renin-angiotensin system inhibitors (56.3%), mineralocorticoid receptor antagonists (11.8%), and SGLT2 inhibitors (8.9%). The post-index incidence rates of all-cause mortality, HF hospitalization, and both combined were 102.2 (95% CI 99.9-104.5), 123.1 (95% CI 120.5-125.7), and 182 (95% CI 178.9-185.1) per 1000 person-years, respectively. The rates of myocardial infarction and stroke were lower (26.2 [95% CI 25.1-27.4] and 19.8 [95% CI 18.8-20.8] per 1000 person-years, respectively).

Conclusions: In Spain, patients newly diagnosed with HF have a high risk of clinical outcomes. Specifically, the rates of all-cause mortality and HF hospitalization are high and substantially greater than the rates of myocardial infarction and stroke. Given the burden of adverse outcomes, these should be considered targets in the comprehensive management of HF. There is much room for improving the proportion of patients receiving disease-modifying therapies.

Keywords: MACE; SGLT2 inhibitors; dapagliflozin; heart failure; myocardial infarction; stroke.

Figure 1

Survival free of adverse clinical outcomes. (a) Survival free of the composite MACE outcome: overall and by EF subgroup. (b) Survival free of stroke: overall and by EF subgroup. (c) Survival free of all-cause mortality: overall and by EF subgroup. (d) Survival free of myocardial infarction: overall and by EF subgroup. (e) Survival free of HF hospitalization: overall and by EF subgroup. (f) Survival free of HF hospitalization and all-cause mortality: overall and by EF subgroup. Abbreviations: EF = ejection fraction; HF = heart failure; HFmrEF = heart failure with a mildly reduced ejection fraction; HFpEF = heart Failure with a preserved ejection fraction; HFrEF = heart failure with a reduced ejection fraction; HFuEF = heart failure with an unknown ejection fraction; MACE = major adverse cardiovascular event.

Figure 1

Survival free of adverse clinical outcomes. (a) Survival free of the composite MACE outcome: overall and by EF subgroup. (b) Survival free of stroke: overall and by EF subgroup. (c) Survival free of all-cause mortality: overall and by EF subgroup. (d) Survival free of myocardial infarction: overall and by EF subgroup. (e) Survival free of HF hospitalization: overall and by EF subgroup. (f) Survival free of HF hospitalization and all-cause mortality: overall and by EF subgroup. Abbreviations: EF = ejection fraction; HF = heart failure; HFmrEF = heart failure with a mildly reduced ejection fraction; HFpEF = heart Failure with a preserved ejection fraction; HFrEF = heart failure with a reduced ejection fraction; HFuEF = heart failure with an unknown ejection fraction; MACE = major adverse cardiovascular event.

Figure 1

Survival free of adverse clinical outcomes. (a) Survival free of the composite MACE outcome: overall and by EF subgroup. (b) Survival free of stroke: overall and by EF subgroup. (c) Survival free of all-cause mortality: overall and by EF subgroup. (d) Survival free of myocardial infarction: overall and by EF subgroup. (e) Survival free of HF hospitalization: overall and by EF subgroup. (f) Survival free of HF hospitalization and all-cause mortality: overall and by EF subgroup. Abbreviations: EF = ejection fraction; HF = heart failure; HFmrEF = heart failure with a mildly reduced ejection fraction; HFpEF = heart Failure with a preserved ejection fraction; HFrEF = heart failure with a reduced ejection fraction; HFuEF = heart failure with an unknown ejection fraction; MACE = major adverse cardiovascular event.

Figure 2

Cox regression analysis for associations between specific patient characteristics and the risk of the composite outcome of HF hospitalization and all-cause mortality (time to first event, either HF hospitalization or all-cause death) in the overall HF cohort. Abbreviations: CABG = coronary artery bypass graft; COPD = chronic obstructive pulmonary disease; HF = heart failure; HFmrEF = heart failure with a mildly reduced ejection fraction; HFpEF = heart failure with a preserved ejection fraction; HFrEF = heart failure with a reduced ejection fraction; HFuEF = heart failure with an unknown ejection fraction; M. Infarction = myocardial infarction; PCI = percutaneous intervention; Unstable A.P. = unstable angina pectoris.