Outcomes after HF hospitalization suboptimal, perhaps due to failure to follow guidelines


The study was funded by AstraZeneca. Bozkurt reports receiving consulting, advisory or research support from Abbott Vascular, Amgen, AstraZeneca, Baxter Healthcare Corp., Boehringer Ingelheim, Bristol Myers Squibb, Cardurion, LivaNova, Relypsa, Renovacor, Roche, Sanofi, scPharmaceuticals and Vifor. Please see the study for all other authors’ relevant financial disclosures.

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Key takeaways:

  • More than one-quarter of patients hospitalized for heart failure for the first time died within 1 year after their hospitalization.
  • Guideline-directed medical therapy is underused in this population.

Among more than 250,000 patients hospitalized for HF for the first time in four countries, more than one-quarter died within 1 year of their hospitalization, according to the EVOLUTION HF cohort study.

During the study period of 2018 to 2022, prescriptions of guideline-directed medications mostly did not change, except for an increase in prescription of SGLT2 inhibitors, the researchers wrote.

Graphical depiction of data presented in article

More than one-quarter of patients hospitalized for heart failure for the first time died within 1 year after their hospitalization.
Data were derived from Bozkurt B, et al. JACC Heart Fail. 2023;doi:10.1016/j.jchf.2023.04.017.

“These are heart failure patients who were sicker than ambulatory heart failure patients and required a hospital stay,” Biykem Bozkurt, MD, PhD, senior dean of faculty, professor of medicine – cardiology and researcher with the Cardiovascular Research Institute at Baylor College of Medicine, and past president of the Heart Failure Society of America, said in a press release. “Despite that, most patients were not optimally treated with lifesaving therapies following hospitalization. It is a huge lost opportunity for saving lives and changing the trajectory of heart failure.”

Guideline-directed medical therapy

U.S. and European guidelines recommend promptly initiating four classes of medications after discharge for HF hospitalizations: renin-angiotensin system inhibitors (preferably an angiotensin receptor/neprilysin inhibitor), beta-blockers, mineralocorticoid receptor antagonists and SGLT2 inhibitors.

Biykem Bozkurt

Bozkurt and colleagues conducted an observational longitudinal cohort study to analyze 263,525 patients from the U.S., the U.K., Japan and Sweden who were hospitalized for HF for the first time from 2018 to 2022. They calculated 1-year rates of death and rehospitalization for HF, chronic kidney disease (CKD), MI, stroke or peripheral artery disease, cumulatively summarized hospital health care costs and assessed cumulative guideline-directed medical therapy use.

The mean age was 68 years in the U.S. and ranged from 78 to 81 years in the other countries, whereas the percentage of women ranged from 44% in Japan to 50% in the U.K.

Among the cohort, 28% died within the first year of HF hospitalization (event rate per 100 patient-years = 28.4; 95% CI, 27-29.9), the researchers wrote.

The highest rehospitalization rates were for HF (event rate per 100 patient-years = 13.6; 95% CI, 9.8-17.4) and CKD (event rate per 100 patient-years = 4.5; 95% CI, 3.6-5.3), according to the researchers. The event rates per 100 patient-years for MI, stroke and PAD were 2, 3 and 0.9, respectively.

Rehospitalization costs for HF and CKD were higher than those for MI, stroke or PAD, the researchers wrote.

Initiation of renin-angiotensin system inhibitors and beta-blockers ranged from 60% to 80% and did not change over time, the researchers wrote. Initiation of the only angiotensin receptor/neprilysin inhibitor, sacubitril/valsartan (Entresto, Novartis), was less than 10% and changed slightly over time. Initiation of mineralocorticoid receptor antagonists ranged from 20% to 40% and mostly did not change over time, with the exception of toward the end of the study period in Sweden, they wrote.

Three months after discharge, the use of SGLT2 inhibitors ranged from 2% to 11% at the beginning of the study period and rose to 8% to 35% at the end of the study period, according to the researchers.

Use of two guideline-recommended medication classes ranged from 40% to 80% and rose slightly over time, whereas use of three classes ranged from 10% to 30%, rising over time, and the use of four classes ranged from 2% to 21%, Bozkurt and colleagues wrote.

‘Not receiving the standard of treatment’

“Patients are supposed to receive specific medications in a certain period of time for effectiveness; however, we found patients were not receiving the standard of treatment in accordance with the guidelines,” Bozkurt, who was vice chair of the writing committee for the 2022 American College of Cardiology/American Heart Association/HFSA guideline on the management of HF, said in the release. “Adherence to medications and proper implementation not only lessen hospitalizations, but they actually slow the decline of kidney disfunction in heart failure patients. So not only would lives be saved, but rehospitalization could be reduced, lowering health care costs.”

She said in the release that treatments should be initiated before hospital discharge, specialists and primary care physicians should collaborate on care of this population, and electronic health record alerts should be employed to support the correct timing and dosages of medications.

“It may seem like a lot of medication to some, but they are proven to be an effective and safe way to improve survivorship and reduce hospitalizations,” Bozkurt said. “They should not view this as a pill burden; if anything, it should be viewed as the ammunition needed to improve symptoms, quality of life, well-being and reduce the risk of cardiovascular death and hospitalizations.”



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