Heart-Failure Incidence Falls, but New Cases Hit Disconcerting Milestone

Patrice Wendling

November 29, 2017

OXFORD, UK —The number of new heart-failure (HF) cases in the UK is rising with a growing and graying population and is now on par with the four most common cancers combined, researchers have found[1].

New diagnoses of HF increased 12% from 170,727 in 2002 to 190,798 in 2014, while the number of new cases of lung, breast, bowel, and prostate cancer totaled 189,136 in 2014.

There was a 7% decline in the incidence of HF, standardized by age and sex, from 2002 to 2014. Nonetheless, the absolute number of people living with HF in the UK increased 23% during this time.

Senior author Dr Kazem Rahimi (University of Oxford, UK) suggested the decline in HF incidence is likely because of better survival after MI but said it's unclear why it failed to mirror the drop by about a third in the incidence of MI over the same period.

"If you're optimistic, you might just say that the preventive strategies have a longer lag period to take effect for heart-failure disease, which tends on average to affect an elderly population; so we might see it still to come," he said. "If you're less optimistic, you would just argue that probably those preventive strategies—in particular, those that have a greater weight on heart failure than MI and stroke—might not have been effectively controlled."

Notably, 87% of patients had three or more comorbidities in 2014, up from 68% in 2002. While hypertension was present in 67% and atrial fibrillation in 40%, many had noncardiovascular conditions such as chronic kidney disease and diabetes, seen in 24% and 22%, respectively.

"There are a lot of data coming out now that there's an increase in the prevalence of heart failure, but the thing that's the most fascinating about this study is how the risk factors are going up, up, up," Dr Stuart D Russell (regional director of heart failure, Duke University School of Medicine, Raleigh, NC), who was not involved in the study, said in an interview.

"Heart failure is a booming business, and I think that the focus and the emphasis has really been on treating it once it happens instead of prevention," he added.

The population-based study involving 4 million UK residents also found that the age at which HF was diagnosed differed by socioeconomic status and that this gap widened over time, even in a healthcare system where access is free.

Patients with the lowest socioeconomic status were more likely to develop HF than the most affluent patients (incidence rate ratio 1.61; 95% CI 1.58–1.64) and did so about 3.5 years earlier and more often with three or more comorbidities (81% vs 77%).

"If incidence from the most affluent group could be achieved for all socioeconomic groups, we would expect 31,810 fewer heart-failure cases annually in the UK, or an approximately 18% lower crude incidence," the investigators, led by Nathalie Conrad (University of Oxford) write in the study, published November 21, 2017 in the Lancet.

In an accompanying editorial[2], Dr Faiez Zannad (Université de Lorraine, Nancy, France) writes, "Although prevention is often touted as a means to combat heart failure, effective prevention strategies have clearly not been widely embraced, suggesting that the approach to prevention also needs to evolve."

He suggests that prevention strategies targeting hypertension and diabetes, which are also more common in lower socioeconomic groups, could help reverse the observed trends and that matching preventive strategies to mechanistic biotargets in patients with HF could also hold promise.

"Despite their similar epidemiology, and worse survival for patients with heart failure compared with many forms of cancer, there is a continued disparity between the diseases in terms of research investment, focused prevention, and societal awareness. Perhaps these data will stimulate change and encourage heart failure to be addressed as an equal priority with cancer," Zannad writes.

For years the American College of Cardiology/American Heart Association has classified patients at risk of developing HF, yet there are virtually zero stage A HF trials published each year, Duke's Russell observed.

"So you could make an argument that we have no preventive strategy truly focused on preventing heart failure except for a more grand, global idea of treating hypertension to reduce the incidence of stroke, MI, and heart failure," he said.

Russell also highlighted a worrying trend in the study, in which the standardized incidence of HF appears to be increasing in the very elderly (>85 years), despite decreasing for MI in this age group, which is rarely included in clinical trials.

"It could be that they're just surviving longer and so we're seeing more of it, but we clearly don't know how to treat them," he said. "I've got a 97-year-old on service right now and I have no idea if we should put him on spironolactone. His kidney function isn't perfect; is he at more risk for the side effects of spironolactone than a 70-year-old? We don't know."

The National Institutes of Health Heart Failure Clinical Research Network is set up to conduct clinical trials unlikely to be sponsored by industry, but part of the solution may also lie in increasing national awareness of HF, suggests Russell. For instance, the National Football League has made October synonymous with breast cancer over the past decade and expanded its campaign this fall to include multiple types of cancers and a risk-prediction tool.

"We have a softer diagnosis than cancer: 'So you're short of breath, but we got an echo[cardiogram], and it shows that your heart is a little bit stiff.' Nobody is saying, 'You've got heart failure, we need to jump on this because you're going to be dead from it in 10 years.' So it's on us," Russell said. "I think we do a very poor job of advocating at a national level like the cancer people do."

The study was funded by the British Heart Foundation and National Institute for Health Research. The authors report no relevant financial relationships. Zannad reports receiving steering committee fees from Janssen, Bayer, Pfizer, Novartis, Boston Scientific, Resmed, Takeda, General Electric, Boehringer Ingelheim, CVRx, and AstraZeneca; and consulting fees from Amgen, Quantum Genomics, Relypsa, ZS Pharma, AstraZeneca, Roche Diagnostics, and Vifor Fresenius. He is also a cofounder owing equity in Cardiorenal and founder owning equity in CVCT. Russell reports no relevant financial relationships.

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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