Ten-year real-world incidence and prognostic impact of new-onset heart failure after acute coronary syndromes: a population-based analysis of 83,357 patients
J Comin-Colet, O Merono, E Vela, J Folguera, M Llagostera, I Llao, R Ramos-Polo, J M Verdu-Rotellar, N Jose-Bazan, S Jovells, A E Cosa, P Moliner, M Andres-Villareal, E Olivera, C Enjuanes-GhrauAbstract
Background
The cardiovascular disease continuum encompasses a progressive trajectory from risk factors to coronary artery disease, heart failure (HF), and end-stage cardiac dysfunction. Acute coronary syndromes (ACS)—including STEMI, NSTEMI, and unstable angina—are pivotal events in this progression. While secondary prevention post-ACS has traditionally focused on reducing recurrent ischaemic events and short-term mortality, the long-term development of incident heart failure (iHF) remains underexplored. Existing evidence is limited and often derived from outdated or small-scale studies. This study aimed to characterise the real-world incidence, risk factors, clinical outcomes, and healthcare burden of iHF following ACS in a large, population-based cohort.
Methods
We conducted a retrospective cohort study using data from the Catalan Health Surveillance System, encompassing all residents discharged alive after an ACS event between 2011 and 2021 in Catalonia (7,763,362 inhabitants), Spain. Patients with prior HF or in-hospital mortality were excluded. iHF was defined as the first post-discharge HF diagnosis in hospital or primary care (with concurrent loop diuretic prescription). Multivariable competing risk regression models (Fine and Gray) were used to identify predictors of iHF. Time-to-event analyses assessed major adverse cardiovascular events (MACE), and generalised linear models evaluated healthcare resource use and costs.
Results
Among 83,357 patients (mean age 66.8 years; 71.4% male), 23.3% developed iHF during follow-up. The 10-year cumulative incidence of HF was 33% (95% CI: 33–34%). Key predictors of iHF included older age (HR=1.03 per year), Killip class II–III (HR=2.16), and very low income (HR=2.08), while PCI during index ACS was protective (HR=0.72). As shown in Table 1, patients with iHF experienced significantly higher rates of all-cause death (48.8% vs 13.5%), recurrent ACS, stroke, atrial fibrillation, and MACE (71.3% vs 33.2%). As shown in Figure 1, healthcare costs rose sharply post-ACS, particularly among iHF patients, whose first-year costs nearly tripled compared to pre-ACS levels. iHF independently predicted increased use of primary care (IRR=1.63), unplanned hospitalisations (IRR=5.56), pharmacological treatments (IRR=1.97), and long-term care services (IRR=8.19), with a significant rise in overall healthcare expenditure (β=0.73).
Conclusions
In this large, real-world cohort, nearly one in four ACS survivors developed iHF, which was associated with markedly worse clinical outcomes and a substantial healthcare burden. Older age, ACS severity, and socioeconomic deprivation were key risk factors, while PCI was protective. These findings highlight the need for early risk stratification, targeted preventive strategies, and healthcare system planning to address the long-term impact of iHF in post-ACS populations.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.