More Americans Hospitalized, Readmitted for Heart Failure

Patrice Wendling

February 11, 2021

Heart failure (HF) hospitalizations and readmissions are on the rise in the United States, reversing a multiyear downward trend, a new national cohort study shows.

Overall primary HF hospitalization rates per 1000 adults declined from 4.4 in 2010 to 4.1 in 2013, and then increased from 4.2 in 2014 to 4.9 in 2017.

Rates of unique patient visits for HF were also on the way down — falling from 3.4 in 2010 to 3.2 in 2013 and 2014 — before climbing to 3.8 in 2017.

Similar trends were observed for rates of postdischarge HF readmissions (1.0 in 2010 to 0.9 in 2014 to 1.1 in 2017) and all-cause 30-day readmissions (0.8 in 2010 to 0.7 in 2014 to 0.9 in 2017).

"We should be emphasizing the things we know work to reduce heart failure hospitalization, which is, number one, prevention," senior author Boback Ziaeian, MD, PhD, told theheart.org | Medscape Cardiology.

Comorbidities that can lead to heart failure crept up over the study period, such that by 2017, hypertension was present in 91.4% of patients, diabetes in 48.9%, and lipid disorders in 53.1%, up from 76.5%, 44.9%, and 40.4%, respectively, in 2010. Half of all patients had coronary artery disease at both time points. Renal disease shot up from 45.9% to 60.6% by 2017.

"If we did a better job of controlling our known risk factors, we would really cut down on the incidence of heart failure being developed and then, among those estimated 6.6 million heart failure patients, we need to get them on our cornerstone therapies," said Ziaeian, VA Greater Los Angeles Healthcare System, California, and David Geffen School of Medicine, University of California, Los Angeles.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which have shown clear efficacy and safety in trials like DAPA-HF and EMPEROR-Reduced, provide a "huge opportunity" to add on to standard therapies, he noted. Competition for VA contracts has brought the price down to about $50 a month for veterans, compared with a cash price of about $500 to $600 a month.

Yet in routine practice, only 8% of veterans with HF at his center are on an SGLT2 inhibitor, compared with 80% on angiotensin-converting-enzyme (ACE) inhibitors or beta blockers, observed Ziaeian. "This medication has been indicated for the last year and a half and we're only at 8% in a system where we have pretty easy access to medications."

As reported online February 10 in JAMA Cardiology, notable sex differences were found in hospitalization, with higher rates per 1000 persons among men.

Heart Failure Hospitalizations, Patient Visits (per 1000 Persons)
Endpoint 2010 2013 2014 2017
Men  
Primary HF hospitalizations 4.6 4.3 4.4 5.3
Unique patient visits 3.4 3.3 3.4 4.0
Women  
Primary HF hospitalizations 4.3 3.8 3.9 4.5
Unique patient visits 3.2 3.0 3.1 3.7

In contrast, a 2020 report on HF trends in the VA system showed a 2% decrease in unadjusted 30-day readmissions from 2007 to 2017 and a decline in the adjusted 30-day readmission risk.

The present study did not risk-adjust readmission risk and included a population that was 51% male, compared with about 98% male in the VA, the investigators, led by Manyoo Agarwal, MD, also from UCLA, note.

"The increasing hospitalization rate in our study may represent an actual increase in HF hospitalizations or shifts in administrative coding practices, increased use of HF biomarkers, or lower thresholds for diagnosis of HF with preserved ejection fraction," they write.

The analysis was based on data from the Nationwide Readmission Database, which included 35,197,725 hospitalizations with a primary or secondary diagnosis of HF and 8,273,270 primary HF hospitalizations from January 2010 to December 2017.

A single primary HF admission occurred in 5,092,626 unique patients and 1,269,109 had two or more HF hospitalizations. The mean age was 72.1 years.

The administrative database did not include clinical data, so it wasn't possible to differentiate between HF with preserved or reduced ejection fraction, the authors note. Patient race and ethnicity data also were not available.

"Future studies are needed to verify our findings to better develop and improve individualized strategies for HF prevention, management, and surveillance for men and women," the investigators conclude.

Coauthor Gregg Fonarow, MD, reports having received personal fees from Abbott, Amgen, AstraZeneca, Bayer, CHF Solutions, Edwards Lifesciences, Janssen Pharmaceuticals, Medtronic, Merck, and Novartis. No other disclosures were reported.

JAMA Cardiol. Published February 10, 2021. Full text

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