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Outcomes and Use of Medicines After First Heart Failure Hospitalization
Quick Takes
- In a large multinational cohort of patients with first HF hospitalization, 1-year rates of mortality were high at 28 per 100 patient-years and HF rehospitalization at 13.6 events per 100 patient-years.
- HF and chronic kidney disease were predominant drivers of associated costs within 1 year of first HF hospitalization.
- Within 3 months of discharge, use of RASi and BB were high but SGLT-2i and ARNI uptake was low.
Study Questions:
What are the contemporary rates of rehospitalization, hospital health care costs, use of key therapies, and mortality after first heart failure (HF) hospitalization in Japan, Sweden, United Kingdom (UK), and the United States?
Methods:
This study used data from a multinational, observational, longitudinal cohort extracting data from electronic health records and included all adults with new-onset HF hospitalization from 2018-2022. Two cohorts were created for each country—one assessing outcomes and health care costs (n = 263,525 patients) and the second to describe medication use after HF hospitalization. Outcomes assessed included HF rehospitalization, chronic kidney disease (CKD), myocardial infarction (MI), stroke, and peripheral arterial disease and cardiovascular and all-cause mortality within 12 months of index HF hospitalization. All costs associated with inpatient and outpatient care aggregated for 12 months after index HF hospitalization were calculated.
Results:
Overall, hospitalized HF patients in the United States were younger compared with patients from Japan, Sweden, and the UK (ages 68, 78, 81, and 81 years, respectively). Event rates were high but similar across countries including death (28.4 per 100 patient-years), HF rehospitalization (13.6 events per 100 patient-years), and CKD (4.5 events per 100 patient-years). HF was the most common cause for rehospitalizations. In-hospital all-cause mortality was similar across all four countries. All events were more common in older patients aged ≥70 years. Health care costs within 1 year of index HF varied between countries and were largely driven by HF and CKD. At 3 months after index HF hospitalization, use of renin-angiotensin system inhibitors (RASi) and beta-blockers (BB) was noted in 60-80% patients, mineralocorticoid receptor antagonists (MRA) in 20-40% of patients, and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) in 2-11%. Sacubitril/valsartan was used infrequently (<10% at 3 months). There were few changes in medication use from 2020-2022, except for SGLT-2i.
Conclusions:
In a large multinational cohort of patients with first HF hospitalization, 1-year rates of mortality and HF rehospitalization were high. HF and CKD were predominant drivers of associated costs within 1 year. Use of RASi and BB were high but SGLT-2i and angiotensin receptor/neprilysin inhibitor (ARNI) uptake was low.
Perspective:
Using a large multinational, observational cohort, the authors provide contemporary rates of adverse events occurring in a cohort of patients hospitalized for the first time with HF. While the rates of mortality did not vary across countries, observed rates were quite high at 28 deaths per 100 patient-years. HF was the most common cause for rehospitalization and noted at a rate of 13.6 events per 100 patient-years. While costs varied widely across countries, they were largely driven by HF and CKD. Despite all the adverse events after an index HF hospitalization, a small minority were on appropriate guideline-directed medical therapy (GDMT) with low rates of ARNI uptake. Low rates of SGLT-2i uptake can likely be explained by their recent inclusion in the guidelines. These data highlight both the importance of GDMT given high adverse events in hospitalized HF patients and the delay in real-world adoption of medications despite overwhelming evidence favoring it. Limitations of this study include lack of data on ejection fraction and lack of data on contraindications for various HF medications.
Clinical Topics: Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Novel Agents, Acute Heart Failure, Heart Failure and Cardiac Biomarkers
Keywords: Angiotensins, Costs and Cost Analysis, Diabetes Mellitus, Type 2, Drug Therapy, Geriatrics, Heart Failure, Inpatients, Mineralocorticoid Receptor Antagonists, Myocardial Infarction, Neprilysin, Outpatients, Patient Readmission, Peripheral Arterial Disease, Receptors, Angiotensin, Renal Insufficiency, Chronic, Renin, Secondary Prevention, Sodium-Glucose Transporter 2 Inhibitors, Valsartan, Vascular Diseases
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