Health literacy and prognosis of heart failure: a prospective propensity-matched study in the community.

AIMS: Health literacy (HL), the ability to obtain and understand health information, is critical to self-care in chronic disorders. A low HL is common among these patients and has been associated with a worse prognosis. Nevertheless, the relationship between HL and the prognosis of heart failure (HF) with reduced (HFrEF) vs. preserved (HFpEF) ejection fraction remains unsettled. To analyse the relationship between HL and the prognosis of patients with incident HFrEF and HFpEF. METHODS AND RESULTS: Prospective study over 10 years (2010-19) on 6444 patients diagnosed with incident HF. The main outcomes were mortality, hospitalizations, and visits to emergency services. The independent relationship between HL and the prognosis, stratifying patients for cardiovascular comorbidity after propensity score-matching was analysed.After matching 5355 HF patients, 1785 with low HL (874 with HFrEF and 911 with HFpEF) vs. 3570 with adequate HL (1748 with HFrEF and 1822 with HFpEF), during a median follow-up of 5.41 years, 3874 patients died (72.3%) and 3699 patients were hospitalized (69.1%). After adjustment for potential confounders, an adequate HL was associated with a lower all-cause and cardiovascular mortality, less hospitalizations, and less 30-day readmissions [relative risk (RR) for HF <0.72 (0.66-0.86), RR for HFrEF <0.69 (0.63-0.95), and RR for HFpEF <0.62 (0.55-0.88), P < 0.001 in all cases], both for patients with HFrEF and HFpEF. Analyses of recurrent hospitalizations gave larger HL effects than time-to-first-event analyses. CONCLUSIONS: In this propensity-matched study, a low HL is associated with a worse prognosis of patients with incident HFrEF and HFpEF.

Treatment with renin-angiotensin system inhibitors and prognosis of heart failure with preserved ejection fraction: A propensity-matched study in the community.

AIMS: There is currently no consensus on the effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), on the prognosis of patients with heart failure and preserved ejection fraction (HFpEF). Therefore, we have analysed the relationship of commencing treatment with ACEIs or ARBs and the prognosis of patients with incident HFpEF. METHODS: Retrospective study over 15 years on 3864 patients with HFpEF (GAMIC cohort). Main outcomes were mortality (all-cause and cardiovascular) and hospitalisations for HF. The independent relationship between CT-RASIs and the prognosis, stratifying patients for cardiovascular comorbidity after propensity score-matching was analysed. RESULTS: During a median follow-up of 7.94 years, 2960 died (76.6%) and 3138 were hospitalised (81.2%). Therapy with RASIs was associated with a lower mortality, all-cause (RR [95% CI] for ACEIs: 0.76 [0.66-0.86], and RR for ARBs: 0.88 [0.80-0.96]; P < 0.001 in both cases), and cardiovascular (RR for ACEIs: 0.72 [0.66-0.78], and RR for ARBs: 0.87 [0.80-0.94]; P < 0.001), a lower hospitalisation rate (RR for ACEIs: 0.82 [0.74-0.90], and RR for ARBs: 0.90 [0.82-0.98]; P < 0.001), and a lower 30-day readmission rate (RR for ACEIs: 0.66 [0.60-0.73], and RR for ARBs: 0.86 [0.75-0.97]; P < 0.001), after adjustment for the propensity to take RASIs or other medications, comorbidities and other potential confounders. Results on the effect of ARBs are compromised by the small number of patients. Analyses of recurrent hospitalisations gave larger treatment benefits than time-to-first-event analyses. CONCLUSION: In this propensity-matched study, commencing treatment with ACEIs is associated with an improved prognosis of patients newly diagnosed with incident HFpEF.

Prognosis of heart failure treated with digoxin or with ivabradine: A cohort study in the community.

BACKGROUND: Resting heart rate (HR) reduction with ivabradine (IVA) improves outcomes of patients with heart failure and reduced ejection fraction (HFrEF). Nevertheless, the best option to slow HR in patients with HFrEF treated with beta-blockers and a HR >70 bpm is unsettled. AIMS: To evaluate whether, in patients with HFrEF, commencing therapy with digoxin (CT-DIG) is associated to a worse prognosis than commencing treatment with ivabradine (CT-IVA). METHODS: Observational study over 10 years on 2364 patients with HFrEF in sinus rhythm and a HR >70 bpm. Main outcomes were mortality, hospitalisations and visits. We analyse the independent relationship of CT-DIG or CT-IVA with the prognosis, stratifying patients for cardiovascular comorbidity, and for other potential confounders (378 patients who CT-DIG vs another 355 patients who CT-IVA vs another 1631 patients non-exposed to IVA or DIG). RESULTS: During a median follow-up of 57.5 months, 1751 patients (74.1%) died, and 2151 (91.0%) were hospitalised for HF. CT-DIG or CT-IVA was associated with a lower all-cause mortality (DIG: HR = 0.86 [95% CI, 0.82-0.90], and IVA: HR = 0.88 [0.83-0.93]), cardiovascular mortality (DIG: HR = 0.84 [0.80-0.89] and IVA: HR = 0.83 [0.78-0.89]), hospitalisation (DIG: HR = 0.86 [0.83-0.89] and IVA: HR = 0.87 [0.83-0.91]) and 30-day readmission (DIG: HR = 0.84 [0.79-0.90] and IVA: HR = 0.88 [0.79-0.95]), after adjustment for cardiovascular comorbidity, and other potential confounders. These associations with the prognosis of HFrEF did not differ between patients who CT-DIG and those who CT-IVA. CONCLUSION: Commencing therapy with digoxin or with ivabradine is associated with an improved prognosis of patients with HFrEF.

Prognosis of heart failure with preserved ejection fraction treated with ß-blockers: A propensity matched study in the community.

BACKGROUND: The effect of treatment with ß-blockers on the prognosis of patients newly diagnosed with heart failure with preserved ejection fraction (HFpEF) is unknown. OBJECTIVE: To analyze the relationship of commencing treatment with the ß-blockers bisoprolol or carvedilol (CT-ßB) with the prognosis of newly diagnosed HFpEF. METHODS: Prospective study over 10years on 2704 patients with HFpEF. Main outcomes were mortality (all-cause and cardiovascular), hospitalizations for HF worsening, and visits. The independent relationship between CT-ßB and the prognosis, stratifying patients for cardiovascular co-morbidity after propensity score-matching (985 patients CT-ßB vs. another 985 patients non-CT-ßB), was analyzed. RESULTS: During a median follow-up of 1877.4days (interquartile range, 1-3651.2) 1600 died (81.2%), and 1702 were hospitalized (86.4%). CT-ßB was associated with a lower risk of mortality (all-cause: HR [CI 95%] 0.78 [0.71 to 0.85], and cardiovascular: 0.75 [0.69 to 0.82]), a lower hospitalization rate (per 100 persons-year), 15.8 vs. 19.2, and a lower 30-day readmission rate (per 100 persons-year), 4.0 vs. 5.8, (P<0.001 in all cases), even after adjustment for the propensity to take ß-blockers or other medications, comorbidities, and other potential confounders. These effects of CT-ßB were independent of gender, and were observed in both patients taking high dose ßB (over the median dose) and lower dose ßB (under or equal to the median dose). CONCLUSIONS: In this propensity matched study, commencing treatment with bisoprolol or carvedilol, both at high and at lower doses, is associated with an improved prognosis of patients newly diagnosed with HFpEF.

Impact of new-onset diabetes mellitus and glycemic control on the prognosis of heart failure patients: a propensity-matched study in the community.

OBJECTIVES: To assess the incidence of type 2 diabetes mellitus (DM) in patients with heart failure (HF), and to evaluate the effect of new-onset DM and glycemic control on the prognosis of HF patients treated with a contemporary medical regimen. METHODS: Prospective study of 5314 HF patients and previously unknown DM during 9 years. Their mean age was 71.8 ± 7.9 years, 53.0% were women, and 50.2% had non-systolic HF. During a median follow-up of 56.9 ± 18.2 months, 68.9% of the patients died, 88.6% were hospitalized for HF, and 1519 (27.3%) developed new-onset DM. We propensity-matched those 1519 HF patients with DM, with 1519 HF patients non-diagnosed with DM. RESULTS: The age- and sex-adjusted incidence (per 100 HF patients/years) of DM in HF patients was 3.20, higher in women and in patients with non-systolic HF (p<0.01). Patients with HF and DM and those with a mean HbA1c>7.0% presented an increased mortality (HR of death [CI 95%]: 2.44 [1.68-3.19] and, HR: 2.56 [1.77-3.35], respectively), mainly due to an increased cardiovascular mortality (HR ≥ 2.40 [1.46-3.34]) (P<0.001). The rate of hospitalization, of 30-day readmissions, and the number of visits were higher among HF patients with DM or with HbA1c>7.0% (p<0.001). These relationships of DM and its poor metabolic control with prognosis were maintained, independently of the gender, the type of HF (systolic or, non-systolic), the comorbidities, and the medication used (P<0.01). CONCLUSION: New-onset diabetes mellitus and its poor metabolic control (HbA1c>7.0%) are associated with a increased mortality and morbidity of patients with heart failure.

Metformin therapy and prognosis of patients with heart failure and new-onset diabetes mellitus. A propensity-matched study in the community.

OBJECTIVE: To assess the effect of the commencement of metformin therapy (CMet) on the prognosis of patients with newly diagnosed heart failure (HF) and new-onset diabetes mellitus (DM) treated with a contemporary medical regimen. METHODS: Prospective study of 1519 HF patients with DM during 9 years. Mean age was 71.7+/-7.8 years, 817 (53.8%) were women, and 780 (51.3%) had preserved systolic function. During a median follow-up of 56.9+/-18.2 months, 1045 patients (68.8%) died, 1344 (88.5%) were hospitalized for worsening HF, 593 (39.0%) did not CMet, and 391 of the patients CMet (42.2%) had a mean HbA1c=<7.0%. No case of lactic acidosis due to metformin was observed. We propensity-score matched 592 patients who CMet with another 592 patients non-CMet. RESULTS: CMet was associated with a decreased mortality (HR [CI 95%]: .85 [.82-.88]), mainly due to a reduced cardiovascular mortality (HR: .78 [.74-.82]), and with a lower hospitalization rate (HR: .81 [.79-.84]). Nevertheless, CMet was not associated with an improved prognosis of HF patients with a mean HbA1c=<7.0%. These relationships of CMet with prognosis were maintained, independently of the gender, the type of HF (systolic or, non-systolic), the comorbidities, and the medication used (P<.01). CONCLUSION: Metformin therapy is associated with a reduced mortality of heart failure patients with new-onset diabetes mellitus, mainly due to a decreased cardiovascular mortality, and with a lower hospitalization rate. Nevertheless, CMet was not associated with an improved prognosis of HF patients with a mean HbA1c=<7.0%.

Incidence and mortality of heart failure: a community-based study.

BACKGROUND: Data on the incidence and mortality of heart failure (HF) in community-based populations of developed countries are limited. We estimated the trends of the incidence and, the mortality of HF. METHODS: Prospective population-based study in a white, low-middle class Mediterranean community of 267,231 inhabitants in Spain. Participants were all the patients (=>14 years), newly diagnosed with HF (4793), according to the Framingham criteria, from January 1, 2000 through December 31, 2007. Main outcome were incidence and mortality following an HF diagnosis. RESULTS: Incidence of HF increased among both men and women, and among persons with systolic and non-systolic HF. Incidence of HF increased from 296 per 100,000 person-years in 2000 to 390 per 100,000 person-years in 2007 (RR 1.32, CI 95% 1.27-13.7, P<.01). Although, risk-adjusted mortality declined from 2000 to 2007, the prognosis for patients with newly diagnosed HF remains poor. In 2007, risk-adjusted 30-day, 1-year, and 4-years mortality was 12.1%, 28.8%, and 61.4%, respectively. Incidence and mortality of systolic HF were higher than those of non-systolic HF (P<0.05). CONCLUSIONS: During the last 8 years, in a white, middle class population of the south of Europe, the increased incidence and the decreased mortality of heart failure have resulted in an increased prevalence of heart failure. Incidence and mortality of systolic heart failure were higher than those of non-systolic heart failure.

Mortality of newly diagnosed heart failure treated with amiodarone A propensity-matched study.

BACKGROUND: Studies on the safety of amiodarone therapy in heart failure (HF) presented conflicting results. We evaluated the relationship of commencing treatment with amiodarone (CTA) with the mortality and the morbidity of patients newly diagnosed with HF. METHODS: Prospective cohort study over 7 years on 3734 patients with HF. Main outcomes were all-cause and cardiovascular mortality, hospitalizations and visits. 739 patients who commenced treatment with amiodarone were propensity-matched with another 739 patients. Non-commencing treatment with amiodarone. We analyze the independent relationship of commencing treatment with amiodarone, with the mortality and the morbidity, stratifying patients for cardiovascular co-morbidity, after propensity score-matching. RESULTS: During a median follow-up of 46.1 months, 644 (43.6%) died, and 1086 (73.5%) were hospitalized. Commencing treatment with amiodarone was associated with a higher all-cause mortality (HR 1.70 [CI 95%, 1.50 to 1.91]), particularly among women (HR: 1.77 [1.55 to 2.00]), and among patients with non-systolic HF (HR: 1.87 [1.66 to 2.09], P<0.001 in all the cases), even after adjustment for the propensity to take amiodarone, or other medications, and other potential confounders. Commencing treatment with amiodarone was not associated with cardiovascular mortality, hospitalizations, or visits. CONCLUSION: The commencement of treatment with amiodarone is associated with an increased mortality of patients with heart failure, mainly in women and in patients with non-systolic heart failure.

Mortality and morbidity of newly diagnosed heart failure with preserved systolic function treated with ß-blockers: a propensity-adjusted case-control populational study.

BACKGROUND: The effect of treatment with ß-blockers on the prognosis of patients newly diagnosed with heart failure with preserved systolic function (HF-PSF) is unknown. OBJECTIVES: To analyze the relationship of commencing treatment with the ß-blockers bisoprolol or carvedilol (CT-ßB) with the mortality and the morbidity of newly diagnosed HF-PSF. METHODS: Prospective propensity-adjusted cohort study over 5 years on 1085 adults diagnosed with HF-PSF for the first time, in an integrated university-based health organization in Spain. The independent relationship between CT-ßB and mortality and morbidity was analyzed, stratifying patients for comorbidity, after a multivariable adjustment for potential confounders. RESULTS: The 378 patients (34.8%) who CT-ßB were more frequently older women, with more cardiovascular comorbidity. Of the total patients 554 (51.0%) died, and 711 (65.5%) were hospitalized. Using an intent-to-treat approach, CT-ßB was associated with a lower risk of mortality (all-cause: RR [CI 95%] 0.37 [0.21 to 0.50], and cardiovascular: 0.31 [0.18 to 0.45]), and a lower age- and sex-adjusted hospitalization rate (per 100 persons/year), 13.6 vs. 19.2, (P<0.001 in all cases), even after adjustment for the propensity to take ß-blockers, or other medications, comorbidities, and other potential confounders. CONCLUSIONS: In this observational study, commencing treatment with the ß-blockers bisoprolol or carvedilol is associated with a reduced mortality and morbidity of patients with newly diagnosed heart failure with preserved systolic function.

Mortality and morbidity of non-systolic heart failure treated with angiotensin-converting enzyme inhibitors: a propensity-adjusted case-control study.

BACKGROUND: The effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) on the prognosis of patients newly diagnosed with heart failure with preserved systolic function (HF-PSF) is unclear. We evaluate the relationship of commencing ACEI therapy (C-ACEI-T) with the morbidity and mortality of patients with HF-PSF. METHODS: Prospective propensity-adjusted cohort study over 5 years on 1120 adults diagnosed with HF-PSF for the first time, within an integrated health organization in Spain. We analyzed the independent relationship between C-ACEI-T and mortality, and morbidity, stratifying patients according to comorbidity, after a multivariable adjustment for potential confounders. RESULTS: The 865 patients (77.2%) who C-ACEI-T were younger, with more cardiovascular comorbidity. During the median follow-up of 908.3 days (interquartile range 558.6-1302.0) 580 patients (51.8%) died, and 727 (64.9%) were hospitalized. Using an intention-to-treat analysis, C-ACEI-T was associated with a lower risk of all-cause (RR [CI 95%] 0.34 [0.23 to 0.46]), and cardiovascular (RR 0.28 [0.20 to 0.36]) mortality, and a lower age- and sex-adjusted rate of hospitalization (per 100 persons-year), 12.3 vs. 19.4, (P<0.001 in all cases), even after adjustment for the propensity to take ACEIs, or other medications, comorbidities, and other potential confounders. CONCLUSION: In this prospective observational study the establishment of ACEI therapy is associated with a reduced mortality and morbidity of patients with newly diagnosed non-systolic heart failure.

Mortality and morbidity of newly diagnosed heart failure treated with statins: a propensity-adjusted cohort study.

BACKGROUND: The effect of treatment with statins on the prognosis of newly diagnosed heart failure (ndHF) is not established. We evaluate the relationship of commencing treatment with statins (CTS) with the mortality and the morbidity of ndHF, systolic (HF-DSF) and non-systolic (HF-PSF). METHODS: Prospective propensity-adjusted cohort study over 5 years on 2573 patients with ndHF. The main outcomes were all-cause and cardiovascular mortality, hospitalizations and visits. We analyze the independent relationship of CTS with the mortality and the morbidity, stratifying patients for cardiovascular co-morbidity, after adjusting for potential confounders. RESULTS: 1343 patients (52.2%) CTS, 1071 (39.5%) died, and 1729 (67.2%) were hospitalized. CTS was associated not only with a lower mortality: RR for HF-overall (CI 95%) 0.23 (0.10 to 0.36), RR for HF-PSF 0.34 (0.21 to 0.47), and RR for HF-DSF 0.20 (0.09 to 0.31), but with dose-dependency (statin>20 mg/day vs. statin<=20 mg/day): RR for HF-overall 0.49 (0.33 to 0.67), RR for HF-PSF 0.53 (0.39 to 0.70), and RR for HF-DSF 0.37 (0.26 to 0.52), and with a lower rate of hospitalization (per 100 persons-year): HF-overall (13.3 vs. 18.2), HF-PSF (13.9 vs. 19.7), and HF-DSF (12.7 vs. 16.6), (P<0.001 in all cases), even after adjustment for the propensity to take statins, or other medications, and other potential confounders. CONCLUSION: The commencement of treatment with statins is associated with a dose-dependent reduction of the mortality and of the morbidity of patients with ndHF (systolic or non-systolic).

Consultation between specialists in Internal Medicine and Family Medicine improves management and prognosis of heart failure.

BACKGROUND AND OBJECTIVE: To evaluate if consultation between specialists in Internal Medicine and family doctors (CIMFD) improves the clinical management and prognosis of patients with heart failure (HF). DESIGN: prospective case-control study (5 years of follow-up). SETTING: community-based sample within the area of a university teaching hospital. SUBJECTS: 1857 patients (> or = 14 years) diagnosed for the first time with HF (1stDxHF), in the CIMFD. CONTROL GROUP: 1981 patients (from health centres not covered by the CIMFD), 1stDxHF, in the external consultations of the hospital. MAIN OUTCOME MEASURES: mortality rate (MR). Admissions (HA). Emergency services visits (ESV). Delays in receiving specialist attention (DRSA), and the resolution of the process (DRP). Number (NTP) and delays in reporting (DTP) tests performed. Proportion (PRC) and delay (DRC) in resolving cases. RESULTS: We observed a reduction of: MR (by 10.8%, CI 95%, 8.6-13.0, p < 0.005); HA, per patient per year (ppy) (by 1.8, 1.3-2.3, p < 0.01); ESV, ppy (by 1.9, 1.2-2.6, p < 0.01); DRSA (by 26.5 days, 21.8-31.2, p < 0.001); DRP (by 21.0 days, 18.3-23.7, p < 0.001), and DRC (by 25.8 days, 20.3-31.4, p < 0.01). The PRC (17.2%, CI 95%, 15.5-18.9, p < 0.01) was higher for the CIMFD. CONCLUSION: The CIMFD approach improves prognosis and efficacy in the clinical management of patients with HF because it reduces mortality and morbidity (HA and ESV), shortens the delays in receiving care and in resolving the diagnostic and therapeutic process (DRSA, DRP, DRC), and increases the proportion of diagnosed and treated patients.