IMPORTANCE Syncope may have serious consequences for traffic safety. Current clinical guideline recommendations on driving following syncope are primarily based on expert consensus. OBJECTIVE To identify whether there is excess risk of motor vehicle crashes among patients with syncope compared with the general population.
Despite landmark heart failure (HF) with reduced ejection fraction (HFrEF) trials showing effect of mineralocorticoid receptor antagonists (MRA) on the risk of death and HF hospitalization, it has been suggested that MRAs are underutilized or frequently withdrawn. This study sought to identify temporal trends in the initiation of MRAs and the subsequent risk of withdrawal and adherence of MRAs in HF patients treated with a renin-angiotensin system inhibitor and a beta-blocker in Denmark from 2003-2017.
Familial AF was associated with an increased RR of AF in first-degree relatives compared with the general Danish population. This suggests that familial AF is a major risk factor for developing AF in relatives.
Aim
To investigate temporal trends in in-patient versus out-patient diagnosis of new-onset heart failure (HF) and the subsequent risk of death and hospitalization.
Methods and results
Using nationwide registers, 192,581 patients with a first diagnosis of HF (1997–2017) were included. We computed incidences of HF, age-standardized mortality rates, and absolute risks (AR) of death and hospitalization (accounting for competing risk of death) to understand the importance of the diagnosis setting in relation to subsequent mortality and hospitalization. The overall incidence of HF was approximately the same (170/100,000 persons) every year during 1997–2017. However, in 1997, 77% of all first diagnoses of HF were made during a hospitalization, whereas the proportion was 39% in 2017. As in-patient diagnoses decreased, out-patient diagnoses increased from 23% to 61%. Out-patients had lower mortality and hospitalization rates than in-patients throughout the study period, although the 1-year age-standardized mortality rate decreased for each of in-patients (24 to 14/100-person) and out-patients (11 to 7/100-person). 1-year and 5-year AR of death decreased by 11.1% and 17.0%, respectively, for all HF patients, while the risk of hospitalization for HF did not decrease significantly (1.13% and 0.96%, respectively).
Conclusions
Between 1997 and 2017, HF changed from being primarily diagnosed during hospitalization to being mostly diagnosed in the outpatient setting. Out-patients had much lower mortality rates than in-patients throughout the study period. Despite a significant decrease in mortality risk for all HF patients, neither in-patients nor out-patients experienced a reduction in the risk of a HF hospitalization.
BACKGROUND:
As heart failure therapeutic care becomes increasingly complex, a composite medical therapy score could be useful to conveniently summarize background medical therapy. We applied the composite medical therapy score developed by the Heart Failure Collaboratory (HFC) to the Danish heart failure with reduced ejection fraction population to evaluate its external validation including assessing the distribution of the score and its association with survival.
METHODS:
In a retrospective nationwide cohort study, we identified all Danish heart failure with reduced ejection fraction patients alive on July 1, 2018, and assessed their treatment doses. Patients were excluded if they did not have at least 365 days for up-titration of medical therapy prior to identification. The HFC score (range 0–8) accounts for use and dosing of multiple therapies prescribed to each patient. Risk-adjusted association between the composite score and all-cause mortality was examined.
RESULTS:
In total, 26 779 patients (mean age 71.9 years; 32% women) were identified. At baseline, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker was used in 77%, β-blocker in 81%, mineralocorticoid receptor antagonist in 30%, angiotensin receptor-neprilysin inhibitor in 2%, and ivabradine in 2%. The median HFC score was 4. After multivariable adjustment, higher HFC scores were independently associated with lower mortality (≥median versus <median: hazard ratio, 0.72 [0.67–0.78];
P
<0.001). In restricted cubic spline analysis based on a fully adjusted Poisson regression model, a graded inverse association between the HFC score and death was observed,
P
<0.001.
CONCLUSIONS:
Nationwide assessment of therapeutic optimization in heart failure with reduced ejection fraction using the HFC score was feasible and the score was strongly and independently associated with survival.
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