Suspected de novo heart failure in outpatient care: the REVOLUTION HF study

Abstract

Background and aims: Ambulatory patients presenting with signs or symptoms of heart failure (HF) should undergo natriuretic peptide testing. Rates of death, HF hospitalization, and healthcare costs were examined in patients thus identified with suspected de novo HF.

Methods: This population-based study (REVOLUTION HF) encompassing two large healthcare regions in Sweden examined patients who presented to outpatient care for the first time between 1 January 2015 and 31 December 2020, who had a recorded sign (peripheral oedema) or symptom (dyspnoea) of HF, and whose N-terminal pro-B-type natriuretic peptide (NT-proBNP) measured >300 ng/L within ±30 days of that sign or symptom. Characteristics, outcomes, healthcare patterns, and healthcare costs for these patients were followed for 1 year. Comparisons were made with matched controls without history of HF, its signs, its symptoms, or elevated NT-proBNP.

Results: Overall, 5942 patients (median age 78.7 years; 54% women) presented with suspected de novo HF. Within 1 year, 29% had received a HF diagnosis. Patients with suspected de novo HF had higher rates of all-cause death (11.7 vs. 6.5 events/100 person-years) and HF hospitalizations (12.5 vs. 2.2 events/100 person-years) than matched controls (n = 2048), with the highest event rates in the weeks after presentation. Rates were higher with higher NT-proBNP levels. Although some patients already used HF guideline-directed medical therapies for other indications, initiation of new medications was variable. Healthcare costs were higher in patients with suspected de novo HF than in matched controls, driven mostly by HF and chronic kidney disease.

Conclusions: Patients with suspected HF and elevated NT-proBNP had high mortality and morbidity in the weeks after presentation, and accrued substantial healthcare costs, highlighting an urgent need for prompt identification, evaluation, and treatment of HF.

Keywords: De novo heart failure; Dyspnoea; Echocardiography; NT-proBNP testing; Peripheral oedema; SGLT2i.

Structured Graphical Abstract

Baseline characteristics, risks, healthcare costs, medication use, and healthcare patterns among patients with suspected de novo HF (REVOLUTION HF). HF, heart failure; HHF, hospitalization for heart failure; NT-proBNP, N-terminal pro-B-type natriuretic peptide; PY, person-years.

Figure 1

The cumulative incidence of (A) hospitalization for heart failure, (B) death related to cardiovascular disease, (C) all-cause death, and (D) the composite endpoint of hospitalization for heart failure and/or all-cause death in patients with suspected de novo heart failure, stratified by N-terminal pro-B-type natriuretic peptide thresholds, during the year following the identification of signs and symptoms of heart failure. Numbers at risk for each timepoint are detailed. CVD, cardiovascular disease; HF, heart failure; HHF, hospitalization for heart failure; NT-proBNP, N-terminal pro-B-type natriuretic peptide

Figure 2

The time to (A) a first diagnosis of heart failure and (B) the first echocardiogram in patients with suspected de novo heart failure following the identification of the condition’s signs and symptoms. Patients are stratified by N-terminal pro-B-type natriuretic peptide thresholds. Numbers at risk for each timepoint are detailed. Time to first echo data only available in Stockholm County. HF, heart failure; NT-proBNP, N-terminal pro-B-type natriuretic peptide

Figure 3

Use of guideline-directed medical therapies for heart failure before and after index date in (A) patients with suspected de novo heart failure and (B) the matched controls. MRA, mineralocorticoid receptor antagonist; RASi, renin-angiotensin system inhibitor; SGLT2i, sodium-glucose cotransporter 2 inhibitor

Figure 4

The average cumulative cost of specialized outpatient care and inpatient care each month during the 12-month period following the index date for (A) patients with suspected de novo heart failure and (B) the matched controls. Each month is a standardized 30-day month and costs are expressed in euros and Unites States dollars. CKD, chronic kidney disease; HF, heart failure; MI, myocardial infarction; PAD, peripheral artery disease