Heart failure deaths are down – but readmissions show need for prevention

Mortality rates have improved for heart failure patients over the last 15 years despite patients being an average of 10 years older, a review by cardiologists in NSW has found.

But there has been no change in readmission rates for the condition, suggesting a need to address precipitating factors such as infections and atrial fibrillation, according to the clinicians behind the Management of Cardiac Function (MACARF) program in Sydney.

In their review of data for 5588 patients enrolled in the program between 2001 and 2015 they found that the average age of patients with heart failure increased from 74 to 84 years.

And despite an increase in co-morbidities such as hypertension, chronic kidney disease and atrial fibrillation, one-year mortality rates declined from 20.8% in 2001-2003 to 11.3% in 2013-2015.

However, there was no change in hospital readmission rates for heart failure patients, which remained at 8-10% at 30 days and 42-45% at one year.

The study authors, including  Dr Geoffrey Tofler of the Royal North Shore Hospital, said knowledge of precipitants of HF hospitalisation would offer opportunities for prevention of readmissions.

“The importance of infection [27% of admissions], predominantly respiratory, as a precipitant in our population reinforces the importance of vaccinations, early recognition and treatment of worsening symptoms, and coordination between respiratory and cardiology physicians,” they wrote.

And the fact that arrhythmia was the precipitant factor in 18% of admissions showed the need for optimising management of AF, they added.

Increasing exertional dyspnoea and peripheral oedema remained the most common symptoms of decompensation and represented another opportunity for prevention, whereas ischaemic symptoms had become less common in HF patients, (decreasing from 28% to 16% at hospitalisation), they wrote in Heart, Lung and Circulation.

The authors also expressed concern over an unexplained decline in use of recommended beta blockers and ACE inhibitors in recent years, after initially increasing from 2001. In contrast, use of diuretics increased for all patients, presumably due to evidence that spironolactone reduced hospitalisations in patients with heart failure with preserved ejection fraction.

They said their review showed that heart failure is now predominantly a disease of the elderly, and this created challenges for prevention approaches when many such patients were living alone or had cognitive decline.

“Heart failure remains a significant burden on morbidity and  mortality, with1-year readmission rates remaining over 40%.  Strategies to reduce readmission due to both HF and non-HF causes, will need to address the implications of the changing characteristics of these patients,” they concluded.

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