Trends in mortality and use of heart transplantation and left ventricular assist devices in advanced heart failure patients between 2003 and 2022: data from the swedish heart failure registry
F Guidetti, L Benson, F Lindberg, C Basile, A Villaschi, D Stolfo, C Hage, M Melin, R Scorza, L H Lund, O Braun, G Baudry, M Metra, G SavareseAbstract
Background/Introduction
Advanced heart failure (AdvHF) remains a major clinical challenge, yet contemporary epidemiological real-world data on AdvHF patients are limited.
Aims
Aims were to explore 20-year (2003 and 2022) trends in clinical characteristics, outcomes, use of left ventricular assist devices (LVAD) and heart transplantation (HTx) in AdvHF patients with reduced left ventricular ejection fraction (LVEF) in Sweden.
Methods
We included patients enrolled in the Swedish Heart Failure Registry who fulfilled the adapted ESC-HFA criteria for AdvHF (NYHA [New York Heart Association] III–IV, LVEF <30%, ≥ 1 HF hospitalization within the prior 6 months). Among these patients, we identified those potentially eligible for AdvHF therapies by meeting the following additional criteria: ≤ 70 years, no history of dialysis within prior 5 years, and no history of active cancer within prior 3 years. Time trends in incidence of outcomes, i.e. all-cause death, cardiovascular [CV] death, non-CV death, HTx and LVAD implantation, were presented as estimated annual per cent change (eAPC), calculated using Poisson regression.
Results
Out of 246,769 patients with HFrEF, 5,323 (2.16%) patients with AdvHF were identified (median age 76, [IQR 68-82] years, 23% females). Of these, 1520 (29%) were eligible for AdvHF therapies (median age 60 [IQR 57-67] years, 18% females). In the overall cohort with AdvHF and those eligible for AdvHF therapies, patient characteristics changed over the study period, highlighting increasing age, higher comorbidity burden and greater use of GDMT. Age- and sex-adjusted 1-year overall mortality declined significantly over time in the AdvHF overall cohort (from 58.8/100 person-years in 2003 to 33.0/100 person-years in 2022); eAPC -4.1%, 95% CI -5.4 - -2.8) as well as in the subgroup eligible for AdvHF therapies (from 19.6 person-years in 2003 to 19.8 /100 person-years in 2022); eAPC -3.5%, 95% CI -6.3 - -0.6) (Figure 1). These improvements were primarily driven by a reduction in CV mortality (overall cohort: eAPC -4.7%, 95% CI -6.1 - -3.2; eligible cohort: eAPC -6.1%, 95% CI -9.5 - -2.4), with non-CV mortality not significantly changing. Use of LVAD therapy increased markedly over the study period, while HTx showed a modest, non-significant rise, although in both settings remaining below 10 cases/100 eligible patient-year (Figure 2).
Conclusions
In a nationwide cohort of patients with AdvHF, overall and CV mortality declined significantly over the past two decades, in patients both eligible and not eligible for AdvHF-therapies, likely reflecting improvements in AdvHF treatment and management. Although the use of LVAD and HTx increased over time, their absolute utilisation remained low. Substantial opportunities remain to further improve outcomes in these patients through earlier recognition of AdvHF, timely referral to specialized centers, and expanded use of advanced therapies.Trends in Hard OutcomesFor image description, please refer to the figure legend and surrounding text.Trends in use of advanced HF therapiesFor image description, please refer to the figure legend and surrounding text.