Cause and circumstances of death in contemporary heart failure: nationwide analysis across EF and etiological subtypes
A Lyon, M Lindgren, K Konstantinou, A Martinsson, C Hjalmarsson, E Linner, O Gidlof, M Fu, C Basic, H Sjoland, E Bollano, A Rosengren, O Braun, J G SmithAbstract
Background
Heart failure (HF) remains associated with high mortality despite therapeutic advances. In elderly patients, the cause, mode and location of death may be as clinically relevant as survival itself. However, contemporary population-level data across ejection fraction (EF) and etiological subtypes are limited.
Purpose
To assess cause, mode and location of death across EF and etiological HF subtypes in a contemporary nationwide cohort.
Methods
HF patients registered in the national SwedeHF register 2018-2023 (n=38,689, median age 74 years, 65% male) were classified as HFrEF, HFmrEF, HFpEF, ischemic cardiomyopathy (ICM), or dilated cardiomyopathy (DCM). Cause and location of death during up to 5 years of follow-up were obtained from the national Cause of Death register. Cardiovascular (CV) deaths were subclassified as sudden cardiac death [SCD] or cardiac pump failure (CPF) using predefined algorithms incorporating information from multiple registers. Cumulative incidence functions accounted for competing risks.
Results
Five-year mortality was highest in HFpEF (49.9%) and ICM (43.3%), and lowest in DCM (23.3%). More than half of deaths were CV across all subtypes, highest in DCM (63.9%) and ICM (61.4%). Excess mortality in HFpEF was primarily driven by non-CV causes. SCD was more common in HFrEF (20.0% of deaths) compared to HFmrEF (17.9%) and HFpEF (14.8%), whereas CPF rates were similar across subtypes (18.1-20.2%). Over 50% of patients died in hospital. HFpEF patients more often died in nursing homes, whereas HFrEF – particularly DCM – patients more frequently died at home. Implantable defibrillator-cardioverter carriers died more often in hospital regardless of HFrEF, DCM, or ICM and less commonly in nursing homes.
Conclusions
In contemporary HF care, most deaths remain cardiovascular and occur in hospital settings. While SCD is more common in HFrEF, excess mortality in HFpEF is largely driven by non-cardiovascular causes. These findings highlight the need for phenotype-specific prognostication and end-of-life planning strategies in HF.Figure 1Figure 2