© 1999 European Society of Cardiology
Is the prognosis of heart failure improving?
a Academic Unit, Department of Cardiology, University of Hull, Castle Hill Hospital Cottingham, Kingston-upon-Hull, HU16 5JQ, UK
b Public Health Research Unit, University of Glasgow Glasgow, UK
c Clinical Research Initiative in Heart Failure, University of Glasgow Glasgow, UK
* Corresponding author. Tel.: +44-1482-624084; fax: +44-1482-624085
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Abstract |
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 Top Abstract 1. Introduction2. Methods3. Statistical methods4. Results5. DiscussionReferences |
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Background and Methods.: Heart failure is common and effective therapy exists but as yet there is little evidence that the overall prognosis is improving in clinical practice. We sought to determine if mortality, re-admission with heart failure and re-admission for any cause, had changed between cohorts of first-time admissions for heart failure identified in 1984, 1988 and 1992 using linked hospital discharge and mortality data from Scotland (population approximately 5 million).
Findings.: The number of first-time admissions for heart failure increased by 30% between 1984 and 1992, from 9716 to 12640. Their mean age was 74 years and 54% were women. Over the same period 3-year mortality declined in patients < 65 years from 53 to 41% (reduction in risk 12% (95% confidence interval 9–15%. Log-rank 70.0; P < 0.001) and for patients 
65 years from 71% to 66% (reduction in risk 5% (95% confidence interval 3–6%. Log-rank 74.5; P < 0.0001). Time to death or first re-admission with heart failure also improved but not time to death or first re-admission for any cause. The total number of re-admissions increased between 1984 and 1992 but bed-days occupancy for heart failure and for any cause, adjusted for days alive, declined due to a reduction in length of stay.
Interpretation.: These data suggest that the prognosis of patients with a first admission for heart failure is improving. The timing of improvement coincides with the gradual increase in the use of angiotensin converting enzyme inhibitors for heart failure although a causal link cannot be proved from these data.
Key Words: Heart failure • Epidemiology • Progress • Hospital discharge
Accepted June 23, 1999
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1. Introduction |
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TopAbstract1. Introduction2. Methods3. Statistical methods4. Results5. DiscussionReferences |
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Although clinical trials suggest that effective treatments can improve the prognosis of heart failure there is no evidence, as yet, that this has been translated into an improvement in the overall prognosis of heart failure in the community [1,2]. This may reflect the limited amount of prognostic data available on heart failure from community studies or that treatment is only effective in subgroups of patients carefully selected for clinical trials of heart failure.
The Framingham study reported that the community prognosis of heart failure had not improved between 1975 and 1988 [1]. A recent community study of heart failure from West London [2] reported a one year mortality of 34%, remarkably similar to that recently reported in the Framingham study.
We utilised data from the Scottish system of hospital discharge records to identify patients with a first time admission with heart failure to Scottish Hospitals in 1984, 1988 and 1992 [3,4]. These data include an internal linking of all episodes of hospital care and linkage to statutory death records; this meant that it was possible to explore whether the 3-year prognosis of heart failure had changed in patients with a first hospitalisation for heart failure.
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2. Methods |
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TopAbstract1. Introduction2. Methods3. Statistical methods4. Results5. DiscussionReferences |
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Form 1 of the system of Scottish Morbidity Records (SMR1) is completed for 100% of episodes of in-patient care provided in acute hospitals in Scotland. For the period 1981–1995, these episode based records have been linked to provide an account of the hospital care provided for individuals throughout this period and are also linked to statutory death records [5]. It is thus possible to follow events in individual patients over time and for the whole Scottish population regardless of the institution in which particular episodes of care are provided. The records provide information about age, gender, principal diagnosis and up to five other conditions coded to (four digit) ICD-9 diagnoses for each patient death or discharge. Data on the patient’s length of hospital stay are included. The system is maintained and controlled by the Information and Statistics Division (ISD) of the Scottish Health Service Common Services Agency [6].
We identified all hospital deaths and discharges for patients with ICD codes for heart failure (428.0, 428.1, 428.9 and 402.9) in any of the six diagnostic positions for the calendar years 1984, 1988 and 1992. Patients may generate more than one SMR1 record during a single hospital admission (for example, because of transfers between departments); we have based this report on ‘continuous in-patient stays’ regarding these as only one admission as this corresponds more closely to the clinical understanding of what constitutes an admission.
The CONSENSUS study published in late 1987 [7] and the SOLVD-treatment study published in late 1991 [8] are the two landmark studies on which recommendations for the widespread use of ACE inhibitors are founded. These publication dates were used to define the index and 3-year follow-up period for three cohorts of patients, 1984–1987, 1988–1991 and 1992–1995.
Treatments that reduce mortality may have the greatest impact on the highest risk patients. Therefore implementation of effective treatment may not reduce the number of deaths or mortality rate in a prevalent population once a new steady state has been reached. In order to study changes in prognosis at the community level it is necessary to study incident populations. The great majority of heart failure is first diagnosed in hospital, thus first-admission to hospital approximates an incident population [2,3].
Patients who had had an admission with any of the above codes in the 3 years prior to these index years were then excluded in order to identify patients in whom this was the first admission with heart failure. This exclusion was restricted to 3 years because the earliest date for linkage was 1981; longer periods for the later cohorts might have introduced bias between them. No patient qualified for more than one cohort. Using the linked data, it was then possible to identify deaths and re-admissions — either for heart failure of for all other causes — over the following 3 years. Previous reports have demonstrated that the record linkage system is accurate in identifying these subsequent events [9].
An improvement in the prognosis of patients with a discharge diagnosis of heart failure could reflect a change in the population under study rather than an effect of treatment. Accordingly, we explored the effect on prognosis of gender, age, concomitant diagnoses on the index admission, including myocardial infarction, and non-heart failure discharge diagnoses from admissions prior to the index admission. Age groups were arbitrarily divided into patients 25–54 years, 55–64 years, 65–74 years and 75 years old for the purposes of statistical analysis. For brevity in reporting, survival curves are displayed only for patients <65 and 65 years.
Co-morbidities on the index admission included in the analysis were acute myocardial infarction (ICD9 code 410), unstable angina or chest pain (ICD9 codes 413 or 786.5 excluding 410), acute stroke (ICD9 code 436), atrial fibrillation (ICD9 code 427.3) and chronic respiratory disease (ICD9 code 496). Non-heart failure diagnoses from previous discharges included in the model were acute myocardial infarction (ICD9 code 410), other coronary disease (ICD9 codes 411–414), any stroke (ICD9 codes 430–438), hypertension (ICD9 codes 401–405), diabetes (ICD9 code 250), atrial fibrillation (ICD9 code 427.3), renal failure (ICD9 codes 584–586) and respiratory disease (ICD9 code 496).
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3. Statistical methods |
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TopAbstract1. Introduction2. Methods3. Statistical methods4. Results5. DiscussionReferences |
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Kaplan–Meier survival curves [10] were produced for three outcomes, time to death, time to death or re-admission for any cause and time to death for re-admission with heart failure. Cases were censored after survival for more than 3 years. Curves were produced separately for males and females in the two age groups and differences in survival times between the three cohorts were assessed using the log-rank test [11]. Where a significant difference was detected the log-rank statistic was computed for each of the pair-wise comparisons. A Cox regression model [12] was used to determine the influence of age, gender and concomitant diagnoses on survival in the three cohorts. The variables were entered in blocks using forced-entry. The Cox regression model provided an estimate of the relative risk and associated P-value.
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4. Results |
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TopAbstract1. Introduction2. Methods3. Statistical methods4. Results5. DiscussionReferences |
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The total population of Scotland has remained relatively, numerically stable between 1984 and 1992 (Table 1). Although the proportion of the population <25 years declined by 11.1%, that >74 years increased by 9.6%.
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The total number of deaths and discharges with heart failure in each index year from which the ‘first discharge’ cohort was drawn is shown in Table 1. The number of hospitalisations increased by 57%, the number of patients admitted increased by 45% and the number of first-time admissions by 30% between 1984 and 1992.
There were 9716 first-time deaths or discharges coded for heart failure in 1984, 10 212 in 1988 and 12 640 in 1992. Heart failure was coded in the first diagnostic position in 4291 (44%) cases in 1984, 4899 (48%) in 1988 and 5657 (45%) in 1992 and in the second diagnostic position in a further 3567 (37%), 3541 (35%) and 4300 (34%), respectively. The mean age of the index cohort and the proportion that were male did not change over time.
Age and gender specific rates for first-admissions resulting in a death or discharge with heart failure are shown in Table 2, excluding patients admitted to long-stay geriatric facilities in whom heart failure is common but in whom this is seldom the over-riding reason for admission. An increase in the rate of first-admissions was observed between 1984 and 1992 and appeared proportionately similar in all age groups >55 years.
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Further analyses were conducted excluding not only admissions to long-stay geriatric facilities but also patients <25 years, in whom a diagnosis of heart failure is rare and may follow a different clinical course. For patients below 25 years of age there were only 33 records in 1984, 44 in 1988 and 59 in 1992 that constituted <0.5% of cases.
The concomitant diagnoses on the index admission and on previous discharges are shown in Table 3. The average number of death or discharge diagnoses coded for the index admission was 2.4 in 1984, 2.4 in 1988 and 2.7 in 1992 (P<0.001). This increase was due to an increase in the proportion of patients with concomitant discharge diagnoses such as non-infarction chest pain, atrial fibrillation and respiratory disease that are generally not coded in the first diagnostic position [3]. The proportion of discharges coded for stroke or myocardial infarction, which are commonly coded in position one or two, did not increase.
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The number of non-heart failure discharge diagnoses coded in the 3 years prior to index years 1984, 1988 and 1992 increased markedly in most diagnostic categories. This may also reflect an increase in the general number of coding positions used.
Figs. 1–3a–d show the Kaplan–Meier survival curves all-cause mortality and the combined outcomes of death or first re-admission with heart failure and death or first re-admission for any reason.
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Overall mortality fell between the cohorts identified in 1984, 1988 and 1992 (P<0.00001). The trend was apparent in both genders and for patients above or below age 65 years, although the magnitude of benefit was greater among patients <65 years old. The number of deaths during the index admission remained stable between the 1984, 1988 and 1992 cohorts but fell (P<0.001) as a proportion of admissions (Table 4). Out of hospital deaths, which are commonly classified as unwitnessed sudden death in clinical trials [13,14], constituted approximately 40% of deaths that occurred after discharge from the index admission.
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The combined outcome of time to death or first re-admission for heart failure also improved between the 1984, 1988 and 1992 cohorts although the magnitude of the effect was smaller than that for death alone. The improvement in this combined outcome was solely due to a delay in death and was partially offset by a higher rate of re-admission for heart failure in 1992 compared to 1984. The total number and proportion of patients discharged from the index admission who were re-admitted for heart failure increased between the 1984 and 1992 cohorts, both within 90 days and over the 3 years of follow-up. Length of stay with a discharge diagnosis of heart failure declined over the same period. Although the absolute number of bed-days occupancy with heart failure increased between 1984 and 1992, bed-days occupancy expressed as a percentage of days alive declined. Although re-admission for heart failure accounted for only approximately one third of re-admissions the length of stay after re-admission for heart failure was longer than that for other reasons and accounted for almost two-thirds of bed-days occupancy.
The combined outcome of time to death or first re-admission for any cause did not improve between the 1984, 1988 and 1992 cohorts reflecting an increase in re-admissions for all causes that off-set the effect on mortality. The increase in re-admissions for heart failure and for any reason was proportionately similar between 1984 and 1992, but non-heart failure reasons constituted the majority of events. About 70% of recurrent admissions in the above cohorts were not due to heart failure consistent with data from clinical trials [8], but non-heart failure related hospitalisation was briefer.
On multivariate analysis, in the whole data set, male gender and greater age conferred a worse prognosis in terms of death and death or admission with heart failure (Table 5). A concomitant admission diagnosis of acute myocardial infarction, stroke and respiratory disease was associated with a significantly higher mortality and risk of death or re-admission for heart failure, although these effects appeared modest apart from stroke. A concomitant admission diagnosis of angina or atrial fibrillation conferred a better outcome perhaps reflecting the reversible nature of their cardiac dysfunction. A previous discharge diagnosis of stroke, diabetes, atrial fibrillation, renal dysfunction and respiratory disease all conferred a significantly worse prognosis and a higher risk of death or re-admission with heart failure. Previous myocardial infarction did not confer an increased risk of death alone but did increase the risk of death or re-admission for heart failure. The effect of these factors on the risk of death and re-admission for all causes was broadly similar to that of death and re-admission for heart failure alone.
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The change in mortality between 1984, 1988 and 1992 persisted after correcting for age, gender and concomitant diagnoses, as did the improvement in the outcome of death and hospitalisation for heart failure. No improvement in the combined outcome of time to death or first hospitalisation for any reason was observed even after correction (Table 5).
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5. Discussion |
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TopAbstract1. Introduction2. Methods3. Statistical methods4. Results5. DiscussionReferences |
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As far as we are aware this is the first piece of evidence to suggest that the prognosis of heart failure might be improving not only in clinical trials but also in clinical practice. Although we have no medication data to link into this database the magnitude and timing of improvement is consistent with the increasing use of ACE inhibitors for the management of heart failure [15–17]. The only obvious alternative explanation is that the patients in later cohorts had an intrinsically better prognosis. While this possibility can never be entirely excluded it seems unlikely as differences persisted even after correction for age, gender and concomitant diagnoses that predicted outcome.
The magnitude of improvement in mortality appeared greatest amongst younger patients. Several studies have reported that older patients are less likely to receive an ACE inhibitor as part of their heart failure management and when they are the ACE inhibitor may be administered in lower doses than are proven to be effective [17–19]. These factors could account for the earlier and greater change in mortality in younger patients. However, it is also possible that ACE inhibitors exert less effect on mortality amongst very elderly patients with heart failure and left ventricular systolic dysfunction, although the available data tend to refute such a claim [20], or because of a higher prevalence of ‘diastolic’ heart failure.
Despite the improvement in prognosis the mortality of heart failure in clinical practice remains much higher than that generally reported in clinical trials, where it ranges from 10 to 20% per annum depending on the age and gender studied [21]. Others have also noted that investigators tend to select low risk patients, even among high-risk groups, to enter into randomised trials [22]. This perhaps reflecting a compassionate reluctance to include those patients, on whom, it can also be argued, there is the greatest need for evidence on the potential efficacy of new treatments. Although mortality has improved it remains high, even amongst younger patients, leaving no grounds for complacency. Out of hospital, and therefore presumably sudden death [13,14], constituted 40% of deaths after the index admission. Whether strategies to improve underlying cardiac dysfunction or measures aimed more directly at reducing sudden death by preventing arrhythmias or vascular events will ultimately have the greater impact on out of hospital deaths is an important issue yet to be resolved [23].
This analysis also suggests that the number of patients being hospitalised annually with heart failure is increasing in all age groups as has been noted in previous reports [3,4,22,24–27]. First-admissions with heart failure also appear to be increasing in all age groups even after correction for the changing demography of the population. This may reflect changes in the proportion of patients who survive large or multiple myocardial infarctions [28–30] but could also reflect changes in the pattern of reporting and in the survival of patients with heart failure itself. The progressive rise in admissions with heart failure has important implications for the costs of managing heart failure.
Re-admission rates after a first admission, whether for all-causes or just related to heart failure, appear similar in clinical practice to those observed in the SOLVD-treatment trial [8]. Heart failure re-admissions rose between 1984 and 1992 even after adjustment for the number of discharges in each cohort. Therefore, improved survival, exposing patients to a longer period at risk, failed to account for all the increase in re-admissions. Length of stay for admissions for heart failure shortened between 1984 and 1992, possibly reflecting increasing administrative pressure to discharge patients quickly. Premature discharges without adequate discharge planning could have been responsible for some recurrent admissions.
Although bed-days occupancy with heart failure increased, overall bed-days occupancy expressed as a percentage of days alive declined suggesting that beds may be being used more efficiently, given that mortality also declined. However, better discharge planning could have an impact especially on early re-admissions [31].
In conclusion these data suggest that the prognosis of heart failure in clinical practice is improving. A plausible explanation for this change is the increasingly widespread use of ACE inhibitors. Further efforts to ensure that ACE inhibitors are used at an appropriate dose and to ensure that appropriate patients now receive treatment with a beta-blocker might improve clinical outcomes further.
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Acknowledgements |
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We thank the staff of the Information and Statistics Division of the Scottish Health Service Common Services Agency for providing the data, and the British Heart Foundation for their support.
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S. Stewart, K. MacIntyre, D. J. Hole, S. Capewell, and J. J.V. McMurray More 'malignant' than cancer? Five-year survival following a first admission for heart failure Eur J Heart Fail, June 1, 2001; 3(3): 315 - 322. [Abstract] [Full Text] [PDF]
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J.G.F. Cleland, K. Swedberg, A. Cohen-Solal, J. Cosin-Aguilar, R. Dietz, F. Follath, A. Gavazzi, R. Hobbs, J. Korewicki, H.C. Madeira, et al. The Euro Heart Failure Survey of The EUROHEART Survey Programme: A survey on the quality of care among patients with heart failure in Europe Eur J Heart Fail, June 1, 2000; 2(2): 123 - 132. [Abstract] [Full Text] [PDF]
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