Temporal Trends and Patterns in Mortality After Incident Heart Failure: A Longitudinal Analysis of 86000 Individuals

Key PointsQuestionWhy has there been no improvement in the prognosis for patients with heart failure over the past 15 years when considerable advances in heart failure care have been introduced during the same period? FindingsIn this cohort study of patients who received a new diagnosis of heart failure between 2002 and 2013 in the United Kingdom, cardiovascular mortality declined by 27% and premature deaths from any cause declined by 21%. Improvements to overall mortality were hindered by noncardiovascular diseases, which represented most deaths and increased by 22% over time. MeaningManagement strategies that solely target cardiovascular outcomes appear insufficient to improve the survival of patients with heart failure; the management of associated comorbidities, particularly infection prevention, appears as a major priority and opportunity. ImportanceDespite considerable improvements in heart failure care, mortality rates among patients in high-income countries have changed little since the early 2000s. Understanding the reasons underlying these trends may provide valuable clues for developing more targeted therapies and public health strategies. ObjectiveTo investigate mortality rates following a new diagnosis of heart failure and examine changes over time and by cause of death and important patient features. Design, Setting, and ParticipantsThis population-based retrospective cohort study analyzed anonymized electronic health records of individuals who received a new diagnosis of heart failure between January 2002 and December 2013 who were followed up until December 2014 from the Clinical Practice Research Datalink, which links information from primary care, secondary care, and the national death registry from a subset of the UK population. The data were analyzed from January 2018 to February 2019. Main Outcomes and MeasuresAll-cause and cause-specific mortality rates at 1 year following diagnosis. Poisson regression models were used to calculate rate ratios (RRs) and 95% confidence intervals comparing 2013 with 2002, adjusting for age, sex, region, socioeconomic status, and 17 major comorbidities. ResultsOf 86833 participants, 42581 (49%) were women, 51215 (88%) were white, and the mean (SD) age was 76.6 (12.6) years. While all-cause mortality rates declined only modestly over time (RR comparing 2013 with 2002, 0.94; 95% CI, 0.88-1.00), underlying patterns presented explicit trends. A decline in cardiovascular mortality (RR, 0.73; 95% CI, 0.67-0.80) was offset by an increase in noncardiovascular deaths (RR, 1.22; 95% CI, 1.11-1.33). Subgroup analyses further showed that overall mortality rates declined among patients younger than 80 years (RR, 0.79; 95% CI, 0.71-0.88) but not among those older than 80 years (RR, 0.97; 95% CI, 0.90-1.06). After cardiovascular causes (898 [43%]), the major causes of death in 2013 were neoplasms (311 [15%]), respiratory conditions (243 [12%]), and infections (13%), the latter 2 explaining most of the observed increase in noncardiovascular mortality. Conclusions and RelevanceAmong patients with a new heart failure diagnosis, considerable progress has been achieved in reducing mortality in young and middle-aged patients and cardiovascular mortality across all age groups. Improvements to overall mortality are hindered by high and increasing rates of noncardiovascular events. These findings challenge current research priorities and management strategies and call for a greater emphasis on associated comorbidities. Specifically, infection prevention presents as a major opportunity to improve prognosis. This cohort study examines trends in outcomes and mortality rates for UK patients with a new heart failure diagnosis.