Temporal Trends in Treatment and Outcomes for Advanced Heart Failure With Reduced Ejection Fraction From 1993–2010

Abstract

Background Randomized trials have demonstrated the efficacy of several new therapies for heart failure (HF) with reduced ejection fraction over the preceding two decades. This study investigates whether these therapeutic advances have translated into improvement in outcomes for patients with advanced HF referred to a heart transplant center. Methods and Results Patients with HF (n=2507) referred to a single university center were analyzed in three 6-year eras during which medical and device therapies were evolving: 1993-1998 (era 1), 1999-2004 (era 2), and 2005-2010 (era 3). Impaired hemodynamics and comorbidities were more frequent at time of referral in later eras, whereas other HF severity parameters where similar or improved. Successive eras had greater utilization of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, aldosterone antagonists, implantable cardioverter defibrillators, and cardiac resynchronization therapy, consistent with evolving evidence and guideline-recommendations over the study period. All-cause mortality and sudden death were significantly lower in era 2 and 3 compared to era 1. After multivariable risk adjustment, era 3 had significantly decreased 2- and 3-year all-cause mortality risk and significantly decreased 1- and 3-year sudden death risk compared to era 1. However, progressive HF death and the combined outcome of mortality / urgent transplant / ventricular assist device were modestly increased in the latter eras. Conclusions Over the past two decades, patients with advanced HF referred to and managed at a tertiary university referral center have benefited from advances in HF medications and devices, as evidenced by improvements in overall survival and sudden death risk.

Most Heart Failure Patients Die from Pump Failure: Implications for Therapy

“…This implies that the improvements in HF therapy between 1993 and 2009 (e.g., beta-blockers and spironolactone) may not have had a positive impact on pump failure death. These findings were confirmed with data from a cohort of 2507 patients covering the last 2 decades [19]. Recent advances in medication and devices were shown to reduce all-cause death by 68 % at 1-year follow-up.…”

The Future of Heart Failure Diagnosis, Therapy, and Management

“…Improved survival has been documented in symptomatic HF from outpatient populations, [4][5][6] in patients discharged from hospitalization, 7,8 and for patients after referral for advanced therapies. 9, 10 The threat of sudden death in symptomatic HF has diminished markedly, associated with increasing penetrance of early β-blocker therapy and mineralocorticoid receptor antagonism, as shown by a 75% decrease from before 2000 to after 2005 in the prospective outpatient registries in the United Kingdom, even in patients without implantable cardioverter defibrillators. 6,8 As patients travel a longer journey with HF, each of the stages now provides more scope for intervention, as shown in Figure 2.…”

Fibroblast Growth Factor‐23 and Heart Failure With Reduced Versus Preserved Ejection Fraction: MESA

“…Half of these people have normal left ventricular ejection fraction (EF) >50% and are classified as having HF with preserved ejection fraction (HFpEF) 4. While the morbidity and mortality of HF with reduced ejection fraction (HFrEF) is improving,5 outcomes for HFpEF are unchanged 6, 7, 8…”