Heart failure : studies of prognosis and advanced therapy

Background

Heart failure (HF) is a major health problem affecting 2-3% of the Western population. The clinical
syndrome of HF is associated with reduced (HFrEF) or preserved (HFpEF) ejection fraction.
Around 50% of the patients have HFrEF and despite advances in treatment, prognosis remains
poor and treatments are underutilized. In HFpEF the prognosis is comparable to in HFrEF, but there
is no evidence-based therapy.



Aims -to investigate

1 The use of evidence-based therapy and survival over time in patients with HFrEF

2 The use of the inotropic drug levosimendan in HF in Sweden

3 a) Contemporary prognosis in patients with severe HFrEF

3 b) If simple predictors of prognosis can be identifid and used as criteria for referral to a HF center

4 Predictors of mortality in patients hospitalized with acute decompensated HFpEF



Evidence-based therapy and survival

We studied 5,908 HFrEF patients with New York Heart Association (NYHA) class II-IV registered
in the Swedish Heart Failure registry (SwedeHF) between 2003 and 2012. The use of beta-blockers
and renin angiotensin system (RAS) blockers was >85% and stable over time. There was a decrease
in the use of mineralocorticoid receptor antagonists (MRA) from 53 to 42%. The use of cardiac
resynchronization therapy (CRT) and implantable cardioverter defirillators (ICD) increased over
time, but absolute numbers were low, less than 11% for both. In 2003 vs. 2012, the 30-day, oneyear, and 3-year survival was 92 vs. 94%, 81 vs. 77% and 58 vs. 54% respectively. The changes in
survival were not statistically signifiant. Reported numbers are risk-adjusted.



The use of levosimendan in Sweden

In SwedeHF, 655 registrations were confimed with use of inotropes. Levosimendan alone was the
inotropic drug of choice in 91% of the registrations. Of all levosimendan registrations, 38% were
planned repetitive treatment. The proportion of planned repetitive to all levosimendan registrations
ranged from 0 to 65% between hospitals.



Who should be referred to a heart failure center?

We studied 10,062 HFrEF patients with NYHA class III-IV from SwedeHF. One-year survival in
the age groups ≤65 years, 66-80 years, and >80 years was 90, 79, and 61% respectively. Five prespecifid risk factors were assessed as potential triggers for referral to a HF center: systolic blood
pressure ≤90 mmHg; creatinine ≤160 mmol/L; hemoglobin ≤120 g/L; no use of RAS antagonist;
and no use of beta-blocker. In patients <80 years of age, the presence of 1, 2, or 3-5 of these risk
factors were associated with a one-year survival of 79, 60, and 39% respectively.



Risk prediction in HFpEF

HF Surveillance data from four different communities in the United States were used to study
2,304 hospitalizations of HFpEF. Mortality at 28 days and one year was 11 and 34% respectively.
The most powerful predictors of mortality were higher age, hypoxia, higher blood urea nitrogen
and lower hemoglobin.



Conclusions

Patients with HF face a high risk of death. In HFpEF novel interventions are urgently called for,
whereas improving implementation of existing evidence-based treatments should be emphasized
in HFrEF. Specifially, the poor use of ICD and CRT needs to be recognized. Levosimendan
was the dominant choice of inotrope in Sweden. Effects of the frequent use of planned repetitive
levosimendan treatment in a non-acute setting need to be further evaluated. Few and simple risk
factors used as referral criteria to a HF center, may increase the number of patients who can benefi
from further therapy. In HFpEF, risk predictors may be used for discrimination of high risk patients
and contribute to further characterization of this population