Heart failure patients without echocardiography are more commonly diagnosed in hospital care and are associated with higher mortality compared to primary care

Figures & data

Figure 1. A flow chart illustrating the inclusion of heart failure patients without echocardiogram from the onset heart failure and the follow-up period of one year during the period 2013–2019.

Table 1. Baseline characteristics and distribution of patients first diagnosed with HF in hospital care and primary health care.

	Hospital care	Primary health care	Total cohort	p-value
Total	2272 (58)	1631 (42)	3903 (100)
Women, n (%)^1	1239 (54)	864 (53)	2103 (54)	0.34^1
Age, mean (SD)^2	82.3 (11,3)	82.5 (10,2)	82.4 (10,9)	0.51^2
Age groups
18–74 years, n (%)	442 (20)	285 (18)	727 (19)	<0.001^1
>75 years, n (%)	1830 (80)	1346 (82)	3176 (81)
Comorbidities
Hypertension, n (%)	1693 (74)	1187 (73)	2880 (74)	0.22^1
IHD, n (%)	880 (39)	551 (31)	1391 (36)	<0.001^1
CVI, n (%)	458 (20)	270 (17)	728 (19)	0.004^1
Atrial fibrillation, n (%)	1122 (49)	708 (43)	1830 (47)	<0.001^1
Diabetes, n (%)	537 (24)	289 (18)	826 (21)	<0.001^1
COPD, n (%)	397 (18)	204 (12)	601 (15)	<0.001^1
Psychiatric, n (%)	344 (15)	212 (13)	556 (14)	<0.001^1
Dementia, n (%)	604 (27)	341 (21)	945 (24)	<0.001^1
Kidney function
eGFR ml/min, mean (SD)	50,6 (18,7)	52,9 (15,3)	51,6 (17.4)	<0.001^2
>60 ml/min, n (%)	922 (41)	709 (44)	1631 (42)	<0.001^1
30–60 ml/min, n (%)	997 (44)	785 (48)	1782 (46)
<30 ml/min, n (%)	349 (15)	135 (8)	484 (12)
eGFR missing	4 (0)	2 (0)	6 (0)
NT-proBNP levels
NT-proBNP ng/l, mean (SD)	5482 (9938)	2625 (5457)	4269 (8452)	<0.001^2
HF unlikely, n (%)	195 (9)	269 (16)	464 (12)	<0.001^1
Grey zone, n (%)	524 (23)	510 (31)	1034 (26)
HF likely, n (%)	990 (44)	482 (30)	1472 (38)
Missing, n (%)	563 (25)	370 (23)	933 (24)
Chest X-ray, n (%)	1481 (65)	387 (24)	1868 (48)	<0.001^1

Note: IHD = ischemic heart disease; CVI = cerebrovascular disease; COPD = chronic obstructive pulmonary disease; eGFR = estimated glomerulofiltration rate; SD = standard deviation; NT-proBNP = N-terminal pro b-type natriuretic peptide. ¹Chi-2 test, ²Kruskal-Wallis test.

Table 2. Illustrates a Cox regression for 30-days, 100-days and 365-days all-cause mortality adjusted for age groups, diagnosed in primary care versus hospital care, eGFR, NT-proBNP levels and comorbidities.

	30-day period				100-day period				365-day period
	HR	95.0% CI		P-value	HR	95.0% CI		P-value	HR	95.0% CI for HR		P-value
		for HR				for HR
		Lower	Upper			Lower	Upper			Lower	Upper
>75 years	1.92	1.32	2.78	0.001	2.10	1.56	2.83	<0.001	2.06	1.62	2.62	<0.001
Diagnostic caregiver
Hospital care	Reference				Reference				Reference
Primary care	0.21	0.15	0.30	<0.001	0.30	0.24	0.38	<0.001	0.43	0.36	0.51	<0.001
Kidney function
eGFR >60 ml/min	Reference			<0.001	Reference			<0.001	Reference			<0.001
eGFR 30-60 ml/min	0.93	0.71	1.22	0.59	0.92	0.75	1.13	0.45	0.99	0.84	1.18	0.95
eGFR <30 ml/min	2.31	1.72	3.11	<0.001	1.97	1.55	2.51	<0.001	1.95	1.60	2.39	<0.001
NT-proBNP levels
HF unlikely	Reference			<0.001	Reference			<0.001	Reference			<0.001
Grey zone	1.17	0.73	1.87	0.51	1.31	0.90	1.91	0.15	1.33	0.98	1.81	0.07
HF likely	1.90	1.21	2.97	<0.001	2.27	1.59	3.26	<0.001	2.58	1.92	3.45	<0.001
Comorbidities
IHD	0.92	0.73	1.15	0.46	0.89	0.74	1.07	0.21	0.89	0.77	1.04	0.14
CVI	1.36	1.06	1.76	0.02	1.27	1.03	1.56	0.02	1.22	1.02	1.45	0.03
Atrial Fibrillation	0.69	0.55	0.86	0.001	0.67	0.56	0.81	<0.001	0.69	0.59	0.80	<0.001
Diabetes mellitus	1.22	0.95	1.56	0.12	1.11	0.91	1.36	0.30	0.99	0.84	1.18	0.94
COPD	1.49	1.15	1.94	0.003	1.28	1.03	1.58	0.03	1.30	1.09	1.55	0.004

Note: HR = hazards ratio; CI = confidence interval; eGFR = estimated glomerulofiltration rate; NT-proBNP = N-terminal pro b-type natriuretic peptide; IHD = ischemic heart disease; CVI = cerebrovascular disease; COPD = chronic obstructive pulmonary disease.

Figure 2. Cumulative survival from index for patients first diagnosed in hospital and in primary health care.

Table 3. Illustrates a logistic regression for diagnosed in primary care adjusted for age groups, eGFR, NT-proBNP levels and comorbidities.

	OR	95% C.I. for OR
		Lower	Upper	p-value
>75 years	1.33	1.01	1.65	0.008
Comorbidities
IHD	0.80	0.69	0.94	0.007
CVI	0.74	0.60	0.90	0.003
Atrial Fibrillation	0.93	0.79	1.10	0.40
Diabetes mellitus	0.69	0.57	0.84	<0.001
COPD	0.63	0.52	0.78	<0.001
Kidney function
eGFR >60 ml/min	Reference			0.002
eGFR 30-60 ml/min	1.18	1.00	1.40
eGFR <30 ml/min	0.77	0.58	1.00
NT-proBNP levels
NT-proBNP-HF unlikely	Reference			<0.001
NT-proBNP-grey zone	0.66	0.52	0.83
NT-proBNP-HF likely	0.43	0.26	0.43

Note: OR = Odds ratio; CI = confidence interval; eGFR = estimated glomerulofiltration rate; NT-proBNP = N-terminal pro b-type natriuretic peptide; IHD = ischemic heart disease; CVI = cerebrovascular disease; COPD = chronic obstructive pulmonary disease; BB = beta-blockers; RAASi = renin angiotensin aldosterone system inhibitors (including angiotensin converting enzyme inhibitors, angiotensin receptor blockers and angiotensin receptor neprilysin inhibitors); MRA = mineralocorticoid receptor antagonist.

Table

Disease	ICD-10 codes
Heart failure	I110, I420, I423 – I432, I438, I500 – I501, I509
Hypertension	I10 – I15
Ischemic heart disease	I20 – I25
Cerebrovascular insult	I60 – I69
Atrial fibrillation	I48
Diabetes mellitus	E10 – E14
Chronic obstructive pulmonary disease	J44
Psychiatric disorders	F32, F33, F419
Dementia	F01 – F03, G318

Table

	Cut-off levels (pg/mL)
	Age < 50	Age 50–75	Age > 75
HF unlikely	<300
”Grey zone”	300–450	300–900	300–1800
HF likely	>450	>900	>1800

Note: HF = heart failure; NT-proBNP = N-terminal pro brain natriuretic peptide.