Quality of care and clinical outcomes in cancer patients presenting with acute heart failure
D Noakes, D I Bromage, A Shamsi, M Sadler, Z Mohammadi, V Kaur, K Chew, S E Piper, S M C Hardman, J G F Cleland, T A McDonagh, A CannataAbstract
Background
Cancer survivorship has increased due to advances in cancer detection and treatment. Cancer survivors are at increased risk of heart failure (HF) due to shared risk factors, underlying pathophysiology, and direct cardiotoxicity from anti-cancer therapies. To date, evidence is scarce on the care of acute HF patients with cancer, particularly regarding access to specialist care, the use of newer therapies such as sodium-glucose co-transporter 2 inhibitors (SGLT2-i), and the potential inequalities of care due to different ethnicity.
Aim
To evaluate the quality of care, potential treatment inequalities according to ethnicity, and clinical outcomes in patients admitted with acute HF who have a prior or current cancer diagnosis.
Methods
We report a nationwide study including all emergency HF admissions identified by the National Heart Failure Audit (NHFA) in England between 2020 and 2023. Data on baseline characteristics, co-morbidities and key performance indicators such as place of care, access to specialist input and in hospital mortality was analysed and stratified according to HF phenotype. For those who survived to discharge, rates of prescription of guideline recommended medical therapy (GRMT) at discharge as well as follow up provisions were analysed. The main outcome of interest was all cause mortality.
Results
A total of 98,552 patients were included. 13,856 (14%) had current or prior cancer. Cancer patients were older, more likely to be from a White ethnicity, with a higher proportion having HFpEF (Table 1). During admission, cancer patients were less often cared for on cardiology wards than non-cancer patients (37% vs 44%) and were less likely to receive specialist HF input. In-hospital mortality was higher in cancer patients, who were also less likely to receive GRMT at discharge. Survival after discharge was lower in the cancer cohort (Figure 1). In a multivariable Cox regression model, prior or current cancer was independently associated with a higher mortality (HR 1.26, 95% CI 1.22–1.30, p < 0.001). Overall, compared to White patients, Asian (HR 0.82, 95% CI 0.78–0.88), Black (HR 0.85, 95% CI 0.78–0.92), and other ethnic groups (HR 0.89, 95% CI 0.84–0.95) had a lower mortality after adjusting for co-variates including patient demographics, HF type, NYHA class and co-morbidities (all p < 0.001). The lower mortality rates for non-white patients were observed both for those with and without cancer.
Conclusion
Patients with HF and current or prior cancer were less likely to receive specialist HF care. This translated into lower GRMT prescription at discharge and was associated with a poorer prognosis. The differences in care and mortality rates were consistent across all ethnic groups but more pronounced among White patients. Further research, including evaluation of cause-specific mortality, is required to understand the factors contributing to the observed differences in care and outcomes.Table 1Figure 1