Recently Diagnosed vs. Worsening Chronic Heart Failure
What is the influence of heart failure (HF) chronicity on acute HF patient profile and outcomes?
The present analysis is from the ASCEND-HF trial cohort of 7,141 hospitalized acute HF patients with reduced or preserved ejection fraction (EF) randomized to nesiritide or placebo in addition to standard care. This analysis compares patients by duration of HF diagnosis prior to index hospitalization using prespecified cutoffs (0-1 month [i.e., ‘recently diagnosed’], >1-12 months, >12-60 months, >60 months). These cutoffs were chosen a priori based on the distribution of HF duration within the study population (i.e., roughly even distribution of patients in each group) and for ease of communication (i.e., cutoffs at 1 month, 1 year, and 5 years). They assessed duration as a continuous variable. The study investigators constructed unadjusted and adjusted logistic regression models to evaluate associations between HF duration and 30-day endpoints and persistent dyspnea. They also used unadjusted and adjusted Cox models to evaluate associations with 180-day all-cause death.
The investigators found that 80.4% (n = 5,741) of patients had documentation of duration of HF diagnosis (recently diagnosed, n = 1,536; >1-12 months, n = 1,020; >12-60 months, n = 1,653; >60 months, n = 1,532). The mean age of this study cohort ranged from 64-66 years, and mean EF ranged from 29-32%. Recently diagnosed patients were more likely female with nonischemic HF etiology, higher baseline blood pressure, better baseline renal function, and fewer comorbidities when compared to patients with longer HF duration. When compared to recently diagnosed patients, after adjusting for confounders, the study investigators found that longer HF duration was associated with more persistent dyspnea at 24 hours (>1-12 months, odds ratio [OR], 1.20; 95% confidence interval [CI], 0.97-1.48; >12-60 months, OR, 1.34; 95% CI, 1.11-1.62; >60 months, OR, 1.31; 95% CI, 1.08-1.60) and increased 180-day mortality (>1-12 months, hazard ratio [HR], 1.89; 95% CI, 1.35-2.65; >12-60 months, HR, 1.82; 95% CI, 1.33-2.48; >60 months, HR, 2.02; 95% CI, 1.47-2.77). Compared to recently diagnosed patients, all other HF duration groups carried a >2-fold greater risk of 180-day all-cause death. These associations remained statistically significant after accounting for patient characteristics (all p < 0.001). The influence of HF duration on mortality was potentially more pronounced among females (interaction p = 0.05), but did not differ by age, race, prior ischemic heart disease, or EF (all interaction p ≥ 0.23).
The study investigators concluded that patient profile differs by duration of the HF diagnosis. They also concluded that a diagnosis of HF for ≤1 month prior to hospitalization was independently associated with greater early dyspnea relief and improved post-discharge survival compared to patients with chronic HF diagnoses.
The findings of this study are important because it suggests that while designing future randomized trials of acute HF, it is important to target stratify patients particularly between de novo or recently diagnosed HF and worsening chronic HF. This may be due to different natural histories of these two ‘types’ of HF and possibly due to varying degrees of accompanying comorbidities such as renal dysfunction.
Keywords: Blood Pressure, Dyspnea, Geriatrics, Heart Failure, Hospitalization, Myocardial Ischemia, Natriuretic Peptide, Brain, Renal Insufficiency, Stroke Volume
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