Non-cardiology vs. cardiology care of patients with heart failure and reduced ejection fraction is associated with lower use of guideline-based care and higher mortality: Observations from The Swedish Heart Failure Registry

Abstract

Background: Patients with heart failure (HF) are often cared for by non-cardiologists. The implications are unknown. Methods: In a nationwide HF cohort with reduced ejection fraction (HFrEF), we compared demographics, clinical characteristics, guideline-based therapy use and outcomes in non-cardiology vs. cardiology in-patient and outpatient care. Results: Between 2000 and 2016, 36,076 patients with HFrEF were enrolled in the Swedish HF registry (19,337 [54%] in-patients overall), with 44% of in-patients and 45% of out-patients managed in non-cardiology settings. Predictors of treatment in non-cardiology were age > 75 years (adjusted odds ratio for non-cardiology 1.20; 95% confidence interval 1.14-1.27), lower education level (0.71; 0.66-0.76 for university vs. compulsory), valve disease (1.24; 1.18-1.31) and systolic blood pressure (SBP) >120 mmHg (1.05; 1.00-1.10). Non-cardiology care was significantly associated with lower use of beta-blockers (0.80; 0.74-0.86) and devices (intracardiac defibrillator [ICD] and/or cardiac resynchronization therapy [CRT]: 0.63; 0.56-0.71), and less frequent specialist follow-up (0.61; 0.57-0.65). Over 1-year follow-up the risk of all-cause mortality (adjusted hazard ratio 1.09; 1.03-1.15) was higher but the risk of first HF (re-) hospitalization was lower (0.93; 0.89-0.97) in non-cardiology vs. cardiology care. Conclusions: In HFrEF, non-cardiology care was independently associated with older ageand lower education. After covariate adjustment, non-cardiology care was associated with lower use of beta-blockers and devices, higher mortality, and lower risk of HF hospitalization. Access to cardiology care may not be equitable and this may have implications for use of guideline-based care and outcomes.

Temporal Trends of Heart Failure Hospitalizations in Cardiology Versus Noncardiology Wards According to Ejection Fraction: 16-Year Data From the SwedeHF Registry

“…It is important to note that starting 2012 25 HFpEF has been primarily discussed through guidelines promoted by cardiologists, 13 and thus a bias towards a greater detection of HFpEF and [E], white bars) further strengthens our belief that these findings reflect true increases in HFpEF prevalence/incidence. Cardiology wards seem to be intertemporally reserved for patients with HFrEF presenting with shock, coronary syndromes and arrhythmic events, 4,6,9,11 and this was confirmed by our analysis spanning 16 years showing a relatively stable prevalence of HFrEF admitted to cardiology from years 2000 to 2004 to years 2013 to 2016 (from 62% to 55%, ie, −7%), as compared with a quite marked drop of HFrEF patients admitted to noncardiology wards in the same years (from 58% to 41%, ie, −17%). Notably, the prevalence of HFmrEF, which was introduced in the HF guidelines since 2016, 13 remained substantially stable around 20% both in cardiology and noncardiology wards over the 16 years explored in our analysis.…”

“…The SwedeHF registry (www.swedeHF.se) has been previously described. 4,16 Patients enrolled in the registry as in-patients between May 11, 2000 (start date of the registry) and December 31, 2016 were included in the current analysis if they had no missing data for type of care at index date (cardiology versus noncardiology) and for left ventricular EF. Patients in SwedeHF were classified as HFrEF when EF <40%, HFmrEF when EF 40% to 49%, and HFpEF when EF ≥50%.…”

“…he prevalence of heart failure (HF) is growing worldwide, and observational studies suggest that patients with acute HF (AHF) are increasingly triaged to and managed in noncardiology wards with an associated increased risk of subsequent rehospitalization and mortality. [1][2][3][4][5][6][7][8] The increasing age, comorbidity burden, and proportion of AHF patients with HF and preserved ejection fraction (HFpEF) may in part explain this increasing triage to noncardiology wards. [9][10][11][12] The availability of a greater number of disease-modifying treatments for patients with reduced ejection fraction (HFrEF) 13 may contribute to their preferential triage to cardiology wards.…”

Evidence-based Therapy in Older Patients with Heart Failure with Reduced Ejection Fraction

“…cardiovascular and non-cardiovascular comorbidities, frailty issues, polypharmacy). [ 19 , 20 , 38 ] Whatever the cause, the widening discrepancy between RCTs and the real world opens up the debate of the generalisability of trial results in the routine management of HF, particularly in older patients.…”

Comparative benchmark analysis of coverage by specialists involved in healthcare provision to patients with cardiovascular diseases in the regions of the Northwestern Federal District

“…Увеличение числа фельдшеров СМП может представлять эффективную меру компенсации дефицита врачей СМП с точки зрения планирования и организации помощи и маршрутизации пациентов с острым коронарным синдромом (ОКС). Действительно, длительность подготовки фельдшеров СМП значительно меньше, чем врачей, однако различия в выживаемости в группах системного тромболизиса у пациентов с ОКС с подъемом сегмента ST, выполненного фельдшером или врачом СМП, отсутствуют [24]. В другом исследовании также получены данные о высокой эффективности догоспитального тромболизиса у пациентов с ОКС c подъемом сегмента ST, проводимого специалистами со средним медицинским образованием [25].…”