Predictors of in-hospital mortality due to heart failure hospitalisation and trends of guideline-directed medical therapy usage
Authors: Koh H B , Quah W J , Raja Shariff R E F , Beh T Y , Ong S H , Tey Y S , Sulong M A , Sabian I S , Teo J Y L , Md Shahrom H , Shaparudin A A , Low M Y , Abdul Rahim A A , Teoh C K , Mohd Ghazi A 
Published: October 2022

Abstract

Background
The burden of heart failure (HF) is immense, from reducing quality of life (QoL) to increasing mortality risks and additional financial implications. The risk of adverse outcomes get higher with each HF hospitalisation (HFH).

Purpose
To look at predictors of in-hospital mortality outcomes during HFH and the prescription trends in conventional guideline-directed medical therapy (GDMT) for HF.

Methods
Retrospective analyses were performed for 7405 HFH cases admitted to our cardiology institution from 2009 to 2018, diagnosed based on the signs and symptoms of heart failure with NTProBNP≥300 at presentation.

Results
Most patients that required HFH were aged &lt;65 years (53.5%), were males (72.8%) and had more diabetes mellitus (66%) and hypertension (75.1%). There were fewer other co-morbidities such as coronary artery disease (CAD) (26.9%), renal insufficiency (33.8%), atrial fibrillation (Afib) (23.9%), dyslipidaemia (40.3%), prior stroke/transient ischaemic attack (TIA) (5.6%), chronic obstructive pulmonary disease (11.6%), current/ex-smokers (45.5%). Most had presenting systolic blood pressure (SBP) &gt;100 mmHg (88.8%), presenting heart rate ≥70 bpm (78.6%) and were in heart failure with reduced ejection fraction (HFrEF) &lt;40% (74.8%). At presentation for HFH, 31.2% had 3 GDMTs (GDMT III) (angiotensin converting enzyme inhibitor / angiotensin receptor blocker / angiotensin receptor neprilysin inhibitor + beta blocker + mineralocorticoid receptor antagonist), 37% had either 2 GDMTs (GDMT II), 25% had only 1 GDMT (GDMT I), while 6.8% had none. The average in-hospital mortality rate was 5.2%. Independent predictors associated with increased in-hospital mortality were males, renal insufficiency, Afib, prior stroke/TIA, SBP ≤100 mmHg, serum sodium &lt;135 mmol/L, uric acid ≥529 μmol/L, NTProBNP ≥6590, inpatient procedures i.e. dialysis, mechanical ventilation and cardiopulmonary resuscitation (CPR). Independent predictors associated with reduced inpatient mortality were hypertension, inpatient cardiac diagnostic procedures and presence of GDMT I, GDMT II and GDMT III at presentation (Figure 1). Throughout the 10 years, the proportion of GDMT prescription were similar; GDMT I (19.1–28.7%), GDMT II (35.1–41.6%), GDMT III (25.2–37.3%). The proportion of GDMT III across the CKD group stages were never more than 50% (Figure 2).

Conclusion
There remains significant in-hospital mortality risk for HFH. While some of these predictors are not modifiable, others are, especially when it comes to GDMT prescriptions. GDMTs provide better prognosis in patients living with HF. There are growing evidence that simultaneous / rapid sequence initiation of GDMTs are more beneficial than the conventional step wise approach. The analysis findings of GDMT proportions at presentation of HFH and also in the CKD group stages meant that many patients are still receiving suboptimal care for their HF and this clinician inertia mentality has got to change.

Funding Acknowledgement
Type of funding sources: None.