Trends in long-term cardiovascular mortality and morbidity in men and women with heart failure of ischemic versus non-ischemic aetiology in Western Australia between 1990 and 2005
Introduction
Heart failure (HF) is a major public health problem [1]. Although population-based studies have suggested an improved prognosis for HF since the late 1980s [2], [3], [4] survival in HF remains poor, with a 5-year all-cause mortality of 60% or more after HF hospitalization [5], [6], [7]. The advent of proven HF treatments in the 1990s, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and aldosterone antagonists, has been shown to improve survival in patients with HF related to left ventricular systolic dysfunction [8], [9], [10]. Similarly, advances in evidence-based treatments including revascularization procedures in ischemic heart disease (IHD) have the potential to prolong survival in patients with IHD at high risk of developing HF [11], [12], [13]. Conversely, there is a paucity of evidence-based treatments for HF with preserved systolic function (PSF) [14].
In contrast to the usual patients included in clinical trials, population-based studies have shown that HF is predominantly a condition of older age and as much as half of the patients hospitalized with HF have PSF, which comprises women as a predominant group [14], [15], [16]. Additionally, gender differences in the genesis and treatment of HF have been reported, with men being more affected by IHD and less by hypertension than women, and with less aggressive procedure-based treatments reported in women [15], [16], [17]. Population-based studies are important as they reflect the full spectrum of patients hospitalized with HF, and can assess the impact of changing HF management on long-term survival in the total population.
We have previously reported improved mortality at 30-days and 1-year in patients after index hospitalization for HF in Western Australia (WA) over the period 1990 to 2005, coincident with a growing uptake of evidence-based HF treatments [17], [18]. The present study extends our investigation, first, to examine trends in long-term (5-year) cardiovascular (CV) cause-specific mortality of patients after index hospitalization for HF; second, to compare trends in long-term CV mortality and hospitalization of patients with ischemic and non-ischemic forms of HF and third, to examine differences in gender and age-specific trends in these patients.
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Study population
The WA Hospital Morbidity Database (HMD) records principal and secondary discharge diagnoses in 21 fields for all public and private hospitalized patients in WA since the 1970s, and is routinely linked to other health data such as the death register [19]. The WA HMD was used to identify patients with an index non-elective hospitalization for HF between 1990 and 2005, defined as no prior HF admissions in WA in the previous 10 years [18]. Patients were followed until death attributed to
Population characteristics
Over the study period, 21,507 index HF cases (mean age 73.9 years, 49.1% women) were identified. Prior or coexistent IHD was present in 42.5% of cases (Table 1). Women were more likely to have non-ischemic HF and were on average 5 years older than men at first hospitalization irrespective of aetiology (Table 1). Both HF subgroups showed a significant increase in mean age over the study period, primarily in men with ischemic HF (from 71.5 years to 72.9 years, p = 0.001) and in women with non-ischemic
Discussion
The present study investigated long-term CV mortality and morbidity trends in men and women after first hospitalization with ischemic or non-ischemic HF between 1990 and 2005 in WA. We found the age-standardized incidence of index hospitalization for ischemic and non-ischemic HF had both declined substantially, although the decline was relatively modest for women with non-ischemic HF. Importantly, the adjusted 5-year CV mortality after index HF hospitalization had fallen by around 35% in both
Limitations
In the present study the diagnosis of HF was obtained from an administrative database without further internal validation. However, we have previously shown that a principal diagnosis of HF in the WA HMD has a high positive predictive accuracy [20]. Temporal changes in coding practices and in diagnostic accuracy may have affected the information on comorbidities and their trends, although there is a high accuracy for coding of interventional procedures [29]. We had no information about left
Conclusions
Long-term survival for HF has significantly improved for patients with ischemic and non-ischemic HF, and in both women and men across age groups, during the contemporary era of HF management in Western Australia. Although incident hospitalization rates for HF have fallen overall, the declines are not uniform across heterogeneous subgroups and the burden of hospitalizations for non-ischemic HF has increased substantially over the recent period. These trends and the persistent poor prognosis of
Acknowledgements
This study has been supported by an award (NHF G08P 3675) from the National Heart Foundation of Australia. Simon Stewart is supported by the National Health and Medical Research Council of Australia. The authors thank the Data Linkage Branch, Department of Health WA, for the providing the linked data.
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [30].
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