Comorbidities, risk factors and outcomes in patients with heart failure and an ejection fraction of more than or equal to 40% in primary care- and hospital care-based outpatient clinics

Abstract

Objective: The aim of this study is to describe patients with heart failure and an ejection fraction (EF) of more than or equal to 40%, managed in both Primary- and Hospital based outpatient clinics separately with their prognosis, comorbidities and risk factors. Further to compare the heart failure medication in the two groups.

Design: We used the prospective Swedish Heart Failure Registry to include 9654 out-patients who had HF and EF ≥40%, 1802 patients were registered in primary care and 7852 in hospital care. Descriptive statistical tests were used to analyze base line characteristics in the two groups and multivariate logistic regression analysis to assess mortality rate in the groups separately.

Setting: The prospective Swedish Heart Failure Registry.

Subjects: Patients with heart failure and an ejection fraction (EF) of more than or equal to 40%.

Main outcome measures: Comorbidities, risk factors and mortality.

Results: Mean-age was 77.5 (primary care) and 70.3 years (hospital care) p < 0.0001, 46.7 vs. 36.3% women respectively (p < 0.0001) and EF ≥50% 26.1 vs. 13.4% (p < 0.0001). Co-morbidities were common in both groups (97.2% vs. 92.3%), the primary care group having more atrial fibrillation, hypertension, ischemic heart disease and COPD. According to the multivariate logistic regression analysis smoking, COPD and diabetes were the most important independent risk factors in the primary care group and valvular disease in the hospital care group. All-cause mortality during mean follow-up of almost 4 years was 31.5% in primary care and 27.8% in hospital care. One year-mortality rates were 7.8%, and 7.0% respectively.

Conclusion: Any co-morbidity was noted in 97% of the HF-patients with an EF of more than or equal to 40% managed at primary care based out-patient clinics and these patients had partly other independent risk factors than those patients managed in hospital care based outpatients clinics. Our results indicate that more attention should be payed to manage COPD in the primary care group.

KEY POINTS

• 97% of heart failure patients with an ejection fraction of more than or equal to 40% managed at primary care based out-patient clinics had any comorbidity.

• Patients in primary care had partly other independent risk factors than those in hospital care.

• All-cause mortality during mean follow-up of almost 4 years was higher in primary care compared to hospital care.

• In matched HF-patients RAS-antagonists, beta-blockers as well as the combination of the two drugs were more seldom prescribed when managed in primary care compared with hospital care.

Keywords:

• Heart failure
• preserved ejection fraction
• primary care
• risk factors
• outcome

Acknowledgements

The authors thank all local center investigators and study personnel for data collection and entry.

Disclosure statement

There are no conflicts of interest related to the work submitted.

Outside the work submitted, there are the following potential conflicts of interest:

BE: none declared.

PW: none declared.

PN: none declared.

UD: research grants to author´s institution from AstraZeneca Inc. and speaker´s and consulting honoraria from Novartis Inc.

LHL: research grants to author’s institution, speakers and consulting fees, Astra-Zeneca, Inc.; Novartis, Inc.

ME: none declared.

No funding agency had any role in the design and conduct of the study, in the collection, management, analysis, or interpretation of the data, or in the preparation, review, or approval of the manuscript.

Additional information

Funding

The Swedish Heart Failure Registry is funded by the Swedish National Board of Health and Welfare, the Swedish Association of Local Authorities and Regions, and the Swedish Society of Cardiology. The work was funded by Stockholm County Council.

Notes on contributors

B. Eriksson

Björn Eriksson is a General Practitioner and head of the Physicians section at Gustavsbergs primary care centre. He is a PHD student focusing on heart failure in primary care.

P. Wändell

Per Wändell is a professor in General medicine at Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Huddinge. He has contributed with expert knowledge on primary care research.

U. Dahlström

Ulf Dahlström is a professor in Cardiology at Department of Cardiology and Department of Medical and Health Sciences, Linköping University. He is an experienced researcher on heart failure and founder of the Swedish Heart Failure Registry together with Magnus Edner.

P. Näsman

Per Näsmanis a PhD and Senior Statistician at Centre for Safety Research, KTH Royal Institute of Technology. He has contributed with expert knowledge on statistics.

L. H. Lund

Lars Lund is a researcher and cardiologist at Karolinska Institutet, Department of Medicine, Dept. of Cardiology, Karolinska University. He has contributed with expert knowledge on heart failure research.

M. Edner

Magnus Edner is an associate professor in Cardiology at Department of Medicine, Karolinska Institute and University Hospital. He is an experienced researcher on heart failure and founder of the Swedish Heart Failure Registry together with Ulf Dahlström. He is supervisor to Björn Eriksson.