Clinical burden and health service challenges of chronic heart failure

Missed opportunities in heart failure diagnosis and management: study of an urban UK population

AIMS

This study aimed to examine the diagnostic pathways and outcomes of patients with heart failure (HF), stratified by left ventricular ejection fraction (EF), and to highlight deficiencies in real-world HF diagnosis and management.

METHODS AND RESULTS

We conducted a retrospective cohort study in Salford, United Kingdom, utilizing linked primary and secondary care data for HF patients diagnosed between January 2010 and November 2019. We evaluated characteristics, diagnostic patterns, healthcare resource utilization, and outcomes. Patients were categorized according to baseline (the latest measure prior to or within 90 days post-diagnosis) as having HF with reduced EF (HFrEF), mildly reduced EF (HFmrEF), or preserved EF (HFpEF). The data encompassed a 2 year period before diagnosis and up to 5 years post-diagnosis. A total of 3227 patients were diagnosed with HF between January 2010 and November 2019. The mean follow-up time was 2.6 [±1.9 standard deviation (SD)] years. The mean age at diagnosis was 74.8 (±12.7 SD) years, and 1469 (45.5%) were female. HFpEF was the largest cohort (46.6%, npEF = 1505), HFmrEF constituted 16.1% (nmrEF = 520), and HFrEF 18.5% (nrEF = 596) of the population, while 18.8% (nu = 606) of patients remained unassigned due to insufficient evidence to support categorization. At baseline, measurement of natriuretic peptide (NP; brain NP and N-terminal pro-B-type NP) and echocardiographic report data were available for 592 (18.3%) and 2621 (81.2%) patients, respectively. A total of 2099 (65.0%) of the HF cohort had access to a cardiology-led outpatient clinic prior to the HF diagnosis, and 602 (18.7%) attended cardiac rehabilitation post-diagnosis. The 5 year crude survival rate was 37.8% [95% confidence interval (CI) (35.2-40.7%)], 42.3% [95% CI (38.0-47.2%)], and 45.5% [95% CI (41.0-50.4%)] for HFpEF, HFrEF, and HFmrEF, respectively.

CONCLUSIONS

Low survival rates were observed across all HF groups, along with suboptimal rates of NP testing and specialist assessments. These findings suggest missed opportunities for timely and accurate HF diagnosis, a pivotal first step in improving outcomes for HF patients. Addressing these gaps in diagnosis and management is urgently needed.

Resource utilisation and outcomes of people with heart failure in England: a descriptive analysis of linked primary and secondary care data - the PULSE study

BACKGROUND

Heart failure (HF) is associated with high levels of resource use and mortality, but prior UK studies have not compared outcomes by HF subtype (HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)) in large patient populations. This study investigated healthcare resource utilisation and mortality in patients with HF in England, overall and by HF subtype.

METHODS

This non-interventional cohort study linked data from the Clinical Practice Research Datalink database to Hospital Episode Statistics inpatient and UK Office for National Statistics mortality data. Patients with a recorded HF diagnosis (new (incident) or existing (prevalent)) based on clinical codes or measures of ejection fraction between 2015 and 2019 were included.

RESULTS

Of 383 896 patients identified with HF, 100 224 patients (26%) had a recorded subtype: 68 780 patients with HFrEF (69%) and 31 444 patients (31%) with HFpEF. In total, 918 553 person-years (PY) were included (median follow-up: 2.1 years): 625 619 PY (68%) for unknown HF subtype, 204 862 PY (22%) for HFrEF and 88 017 PY (10%) for HFpEF. Overall, 11% of patients experienced ≥1 HF hospitalisation. After age and sex adjustment, hospitalisations for HF (HHF; including recurrent hospitalisations) and HF-related general practitioner consultations occurred at rates of approximately 80/1000 and 124/1000 PY, respectively, and were highest for patients with HFrEF and unknown subtype. Overall, all-cause and cardiovascular mortality rates were 132/1000 and 49/1000 PY, respectively. Patients with unknown subtype had the highest 1-year and 5-year mortality (20% and 48%), followed by HFrEF (8% and 35%) and HFpEF (6% and 25%).

CONCLUSIONS

HF is associated with high levels of healthcare resource use, mortality, HHF and comorbidities. Ensuring that patients receive early and appropriate guideline-directed therapies to manage HF and associated comorbidities is likely to improve patient care and reduce the burden of HF on the English healthcare system.

Incidence and prevalence of heart failure in England: a descriptive analysis of linked primary and secondary care data - the PULSE study

BACKGROUND

Heart failure (HF) is associated with high morbidity and mortality, yet data on HF subtype (HF with reduced ejection fraction [HFrEF] and preserved ejection fraction [HFpEF]) in broad populations are lacking. Additionally, it is unknown whether current HF incidence and prevalence rates are consistent with historical data. Here, we estimate the incidence and prevalence of HF in England and describe the characteristics of patients with HF, both overall and by subtype.

METHODS

This was a non-interventional cohort study based on data from the UK Clinical Practice Research Datalink (CPRD), linked to Hospital Episode Statistics data and Office for National Statistics mortality data. Patients aged ≥ 18 years who were registered in the CPRD Aurum database between 1^st January 2015 and 31^st December 2019 formed the base cohort, from which patients with a recorded chronic HF diagnosis (historical or incident) from 2015-2019 contributed to the incidence and prevalence calculations.

RESULTS

The eligible denominator over the study period comprised 11,414,490 patients, from which 383,896 patients with HF were included as prevalent or incident HF cases. From 2015 to 2019, the incidence rate of newly diagnosed HF increased from 4.1/1,000 person-years to 4.9/1,000 person-years, and HF prevalence increased from 2.1% to 2.4%. Phenotype data were available for 100,224 (26.1%) patients, of which 68,780 patients had HFrEF and 31,444 had HFpEF (HFrEF/HFpEF ratio: 70.1%/29.9%). Comorbidity levels were high and broadly similar across HF subgroups.

CONCLUSIONS

Primary care recording of HF subtype is suboptimal, with more than 7/10 patients with HF lacking subtype data. In patients with a recorded subtype (n = 100,224), a HFrEF/HFpEF ratio of 70%/30% was observed. Comorbidity levels were high regardless of subtype. Between 2015 and 2019, we observed modest but consistent increases in the incidence and prevalence of chronic HF in adults, in line with historical data.

The Application of Porous Scaffolds for Cardiovascular Tissues

As the number of arteriosclerotic diseases continues to increase, much improvement is still needed with treatments for cardiovascular diseases. This is mainly due to the limitations of currently existing treatment options, including the limited number of donor organs available or the long-term durability of the artificial organs. Therefore, tissue engineering has attracted significant attention as a tissue regeneration therapy in this area. Porous scaffolds are one of the effective methods for tissue engineering. However, it could be better, and its effectiveness varies depending on the tissue application. This paper will address the challenges presented by various materials and their combinations. We will also describe some of the latest methods for tissue engineering.

Factors Influencing Potentially Futile Treatments at the End of Life in a Multiethnic Asian Cardiology Setting: A Qualitative Study

BACKGROUND

Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood.

AIM

This study aimed to explore clinicians' perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting.

DESIGN

We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed.

RESULTS

A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment.

CONCLUSION

Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment.

Economic Burden of Heart Failure in Asian Countries with Different Healthcare Systems

Heart failure poses significant burden in the form of hospitalizations and mortality alongside direct and indirect costs incurred for the treatment of the disease. Health expenditure for heart failure is fast rising, for example the costs incurred increased by 50% over last 5 years in Korea. Identification of cost drivers will enable optimization of treatment strategies for the population and improve the outcomes and standard of care. This study concurrently assessed the economic burden in four Asian countries (South Korea, Taiwan, Thailand, and Malaysia) where estimation of disease burden is challenging owing to limited disease surveillance.

Background and Objectives

Heart failure (HF) poses substantial economic burden, primarily driven by high hospitalization and mortality rates. This study aimed to understand the economic burden of HF in 4 Asian countries under varying healthcare systems.

Methods

This was a non-interventional, retrospective study conducted in South Korea, Taiwan, Thailand and Malaysia through medical chart review. Eligible patients included those who had either ≥1 hospitalization or ≥2 outpatient visits from January 1st to December 31st, 2014, and at least one year of follow-up. Resource use and direct healthcare costs (adjusted to 2015 USD) of HF were assessed. HF costs for subgroups stratified by age and sex were assessed.

Results

A total of 568 patients were recruited from South Korea (n=200), Taiwan (n=200), Thailand (n=100) and Malaysia (n=68). The proportion of patients hospitalized ranged from 20.0% to 93.5% (South Korea 20.0%, Thailand 49.0%, Malaysia 70.6%, and Taiwan 93.5%). The overall annual HF cost per patient was $2,357, $4,513, $3,513 and $1,443 in South Korea, Taiwan, Thailand, and Malaysia, respectively; hospitalized HF care costs were $10,714, $4,790, $7,181 and $1,776, respectively. The length of stay was more than 12.2 days except in Malaysia. No specific trend was observed in subgroup analysis.

Conclusions

In Asia, HF poses significant economic burden and hospitalization has emerged as the major cost driver among healthcare costs. A streamlined treatment strategy reducing hospitalization rate can minimize the economic burden.

Healthcare professionals' perception of quality of care of patients with cardiac disease in Nigeria: Implication for clinical guideline, inter-professional education and team work

Background

Heart disease is one of the leading chronic conditions posing a major and growing threat to the public. Studies on quality of care given to patients with heart diseases in Nigeria are not available. The purpose of this study was to explore healthcare professionals' perception of quality of care of patients with heart disease at a tertiary hospital in Nigeria.

Methods

A mixed method design was utilized in this study. Twenty eight healthcare professionals consisting of cardiologists, nurses, physiotherapists and dieticians were recruited into the study through purposive sampling technique. A questionnaire developed and validated from existing questionnaire was used to survey the health care professionals' perception of care and qualitative design was further used to explore their perceptions of care. The data were analyzed using descriptive statistics of percentages and graphs. The qualitative data were analyzed using thematic analysis. Quality of care was assessed through structure, process and outcome of care indices.

Results

The mean age of the healthcare professionals was 38.46±8.988 years. 19 (66.7%) reported that there were treatment guidelines for cardiac disease management but there was no system for internal quality assurance. 18 (95%) out of these 19 healthcare professionals reported that the treatment guidelines were either never applied or not applied regularly during treatment. Other areas that were perceived as poor were poor teamwork, poor staff strength, inadequate equipment, and inadequate consultation with staff during procurement of medical supplies.

Conclusion

Quality of care for cardiac patients in a Nigerian tertiary hospital was perceived as sub-optimal. There is a need for the improvement of the structure and process of quality of care to enhance quality of care for cardiac patients in Nigeria.

Injectable Hydrogels for Cardiac Tissue Engineering

In light of the limited efficacy of current treatments for cardiac regeneration, tissue engineering approaches have been explored for their potential to provide mechanical support to injured cardiac tissues, deliver cardio-protective molecules, and improve cell-based therapeutic techniques. Injectable hydrogels are a particularly appealing system as they hold promise as a minimally invasive therapeutic approach. Moreover, injectable acellular alginate-based hydrogels have been tested clinically in patients with myocardial infarction (MI) and show preservation of the left ventricular (LV) indices and left ventricular ejection fraction (LVEF). This review provides an overview of recent developments that have occurred in the design and engineering of various injectable hydrogel systems for cardiac tissue engineering efforts, including a comparison of natural versus synthetic systems with emphasis on the ideal characteristics for biomimetic cardiac materials.

N-Terminal Pro-B-Type Natriuretic Peptide-Guided Therapy in Chronic Heart Failure Reduces Repeated Hospitalizations-Results From TIME-CHF

BACKGROUND

Although heart failure (HF) patients are known to experience repeated hospitalizations, most studies evaluated only time to first event. N-Terminal B-type natriuretic peptide (NT-proBNP)-guided therapy has not convincingly been shown to improve HF-specific outcomes, and effects on recurrent all-cause hospitalization are uncertain. Therefore, we investigated the effect of NT-proBNP-guided therapy on recurrent events in HF with the use of a time-between-events approach in a hypothesis-generating analysis.

METHODS AND RESULTS

The Trial of Intensified Versus Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) randomized 499 HF patients, aged ≥60 years, left ventricular ejection fraction ≤45%, New York Heart Association functional class ≥I,I to NT-proBNP-guided versus symptom-guided therapy for 18 months, with further follow-up for 5.5 years. The effect of NT-proBNP-guided therapy on recurrent HF-related and all-cause hospitalizations and/or all-cause death was explored. One hundred four patients (49 NT-proBNP-guided, 55 symptom-guided) experienced 1 and 275 patients (133 NT-proBNP-guided, 142 symptom-guided) experienced ≥2 all-cause hospitalization events. Regarding HF hospitalization, 132 patients (57 NT-proBNP-guided, 75 symptom-guided) experienced 1 and 122 patients (57 NT-proBNP-guided, 65 symptom-guided) experienced ≥2 events. NT-proBNP-guided therapy was significant in preventing 2nd all-cause hospitalizations (hazard ratio [HR] 0.83; P = .01), in contrast to nonsignificant results in preventing 1st all-cause hospitalization events (HR 0.91; P = .35). This was not the case regarding HF hospitalization events (HR 0.85 [P = .14] vs HR 0.73 [P = .01]) The beneficial effect of NT-proBNP-guided therapy was seen only in patients aged <75 years, and not in those aged ≥75 years (interaction terms with P = .01 and P = .03 for all-cause hospitalization and HF hospitalization events, respectively).

CONCLUSION

NT-proBNP-guided therapy reduces the risk of recurrent events in patients <75 years of age. This included all-cause hospitalization by mainly reducing later events, adding knowledge to the neutral effect on this end point when shown using time-to-first-event analysis only.

CLINICAL TRIAL REGISTRATION

isrctn.org, identifier: ISRCTN43596477.