In-hospital and 1-year outcomes of acute heart failure patients according to presentation (de novo vs. worsening) and ejection fraction. Results from IN-HF Outcome Registry

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Abstract

Background

To investigate the outcomes of hospitalized patients with both de-novo and worsening heart failure (HF) with preserved left ventricular ejection fraction (LVEF) (HFpEF) (LVEF  50%), compared to those with reduced LVEF (HFrEF).

Methods and results

We studied 1669 patients (22.6% HFpEF) hospitalized for acute HF in the prospective multi-center nationwide Italian Network on Heart Failure (IN-HF) Outcome Registry. In all patients LVEF was assessed during hospitalization. De-novo HF presentations constituted 49.6% of HFpEF and 43.1% of HFrEF hospitalizations. All-cause mortality during hospitalization was lower in HFpEF than HFrEF (2.9% vs 6.5%, p = 0.01), but this mortality difference was not significant at 1 year (19.6% vs 24.4%, p = 0.06), even after adjusting for clinical covariates. Similarly, there were no differences in 1-year mortality between HFpEF and HFrEF when compared by cause of death (cardiovascular vs non-cardiovascular) or mode of presentation (worsening HF vs de novo). Rehospitalization rates (all-cause, non-cardiovascular, cardiovascular, HF-related) at 90 days and 1 year were also similar. Mode of presentation influenced rehospitalizations in HFpEF, where those presenting with worsening HFpEF had higher all-cause (36.8% vs 21.6%, p = 0.001), cardiovascular (28.1% vs 14.9%, p = 0.002), and HF-related (21.1% vs 7.7%, p = 0.0003) rehospitalization rates at 1 year compared to those with de novo presentations.

Conclusions

Outcomes at 1 year following hospitalization for HFpEF are as poor as that of HFrEF. A prior history of HF decompensation or hospitalization identifies patients with HFpEF at particularly high risk of recurrent events. These findings may have implications for clinical practice, quality and process improvements and trial design.

Introduction

Heart failure (HF) with preserved ejection fraction (HFpEF) is increasingly recognized as a major public health problem associated with high hospitalization and death rates [1], [2], [3], [4], [5], [6], [7], [8]. However, prior studies have produced conflicting results regarding the prognosis of HFpEF compared with HF with reduced ejection fraction (HFrEF). Some showed a better survival in patients with HFpEF, whereas others found similar survival rates [9]. The majority of these studies were retrospective and the most recent meta-analysis [7], [8] did not include patients enrolled in the landmark community studies [2], [3]. Furthermore, most studies included patients with chronic ambulatory HFpEF. Hospitalizations for HFpEF are increasing relative to HFrEF [10], yet data are scarce regarding the prognosis in hospitalized HFpEF. In most of the studies the LVEF measurement was not performed during the hospitalization, or the timing was not clearly reported. The few available studies included follow-up periods limited to the in-hospital period or extended up to 90 days after discharge [11], [12], whereas studies including follow-up of 1-year or longer were limited to single centers or selected regions [3], [13]. Large knowledge gaps remain concerning the causes of rehospitalization (cardiovascular versus non-cardiovascular) [14], and the impact of the mode of clinical presentation (patients hospitalized for the first episode of decompensation i.e. de-novo HF versus those hospitalized for a worsening chronic HF i.e. worsening HF) on outcomes in HFpEF.

Accordingly, we aimed to assess outcomes of patients hospitalized for both de-novo and worsening HFpEF, compared to that of patients with HFrEF, in the large, prospective, multi-center Italian Network on Heart Failure (IN-HF) Outcome Registry [15], [16].

Section snippets

Methods

The IN-HF Outcome Registry is a prospective, observational, nationwide study that involved 61 cardiology centers in Italy. These centers were a mix of academic and community hospitals, well distributed across the country. Both hospitalized patients with acute HF and out-patients with chronic HF were enrolled by the same centers in the IN-HF Outcome Registry. The present report deals with the acute HF cohort.

The enrollment of patients was planned at the time of admission at the Cardiology Unit

Results

Of 5610 patients enrolled in IN-HF from November 2007 to December 2009, 1855 patients were admitted for acute HF. LVEF measurements were available in 1669 (90.0%) acute HF patients, among whom 377 (22.6%) were classified as HFpEF and 1292 (77.4%) as HFrEF. The mode of clinical presentation was de-novo HFpEF in 187, de novo HFrEF in 557, worsening HFpEF in 190 and worsening HFrEF in 735 patients.

Discussion

In this prospective, observational, nationwide study, we found that patients admitted for HFpEF had a lower in-hospital mortality but a similar total, cardiovascular and non-cardiovascular mortality at 1 year compared to those with HFrEF. Rehospitalization rates (all-cause, non-cardiovascular, cardiovascular, HF-related) at 90 days and 1 year were also similar. Mode of presentation influenced rehospitalizations in HFpEF, where those presenting with worsening HFpEF had higher event rates compared

Conclusions

Although patients with HFpEF represent an important group recognized as a major public health problem and despite significant advances in the knowledge of HFpEF epidemiology, substantial gaps still exist in our understanding. This study shows similar mortality and rehospitalization rate in HFpEF and HFrEF cohorts at mid-term after an acute decompensation, as well as in the de-novo and worsening groups, underscoring the urgent need to improve the outcome of these patients. This registry provides

Funding sources

The sponsor of the study was the Heart Care Foundation (Fondazione Italiana per la Lotta alle Malattie Cardiovascolari), a non-profit independent institution which is also the owner of the database. Database management, quality control of the data and data analyses were the responsibility of the Research Centre of the Italian Association of Hospital Cardiologists (ANMCO). The study was partially supported by an unrestricted grant by Novartis, Abbott and Medtronic, Italy. No fees were provided

Disclosures

M.S., A.G., F.O., A.M., R.U. and M.P. have no conflict of interest to disclose. M.M. has participated in speaker bureaus for Servier, advisory boards for Novartis and Bayer and has received honoraria from Abbott Vascular, Bayer, Corthera, Novartis and Servier. D.L. and L.G. are employees of Heart Care Foundation which conducted the study with an unrestricted grant of research from Novartis, Abbott and Medtronic. V.C., L.M. and A.D.L. have no conflict of interest to disclose. A.P.M. is an

Acknowledgments

The authors warmly thank Carolyn Lam for her precious critical review of the manuscript.

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    See Appendix for a complete list of participating Centers and Investigators.

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