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• W2994862632 abstract "This article refers to ‘Heart failure in Norway, 2004–2014: analysing incident, total and readmission rates using data from the Cardiovascular Disease in Norway (CVDNOR) Project’ by G. Sulo et al., published in this issue on pages xxx. For many years, the heart failure (HF) community tracked the incidence of a first hospitalisation for HF as a marker of the ‘epidemic’ of HF.1-3 With the advent of better treatments for myocardial infarction, there was a fear that the consequence of more survivors with a damaged left ventricle would be a continuing rise in the number of people admitted to hospital for the first time with HF. The maturation of a number of healthcare record databases founded in the 1960s and 1970s allowed such epidemiological studies to be conducted. Indeed a rising incidence of HF hospitalisation was observed in many countries in the world until the mid-1990s.1-3 However, at around the mid-1990s we started to see a decline in the incidence of hospitalisations for HF.1-3 The greater use of therapies to prevent the onset of HF, and the expanding treatment of HF, was thought underlie this reversal. But these disease-modifying treatments also brought with them improvements in survival with the consequence that there was an increase in the prevalence of HF and extension of the time a person lived with HF, thereby increasing the time at risk of further episodes of decompensation. Before the era of effective therapies, HF was a disease that killed very quickly (with a matter of months4) but since the introduction of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists, there has been a transition into a more chronic disease. While HF remains one of the most deadly cardiovascular diseases, patients with HF are readmitted multiple times for decompensation of their HF during the course of their lifetime.5 The current problem therefore faced by many healthcare systems around the world is the issue of recurrent hospitalisations for HF. These admissions exert a tremendous burden on healthcare systems around the world and account for the majority of costs associated with HF.6 Yet while we have multiple sources of evidence that incident HF hospitalisations have been declining, less is known about patterns of recurrent HF hospitalisations. This is surprising given what we know about recurrent HF hospitalisations. They are a marker of poor prognosis, and the period following a hospitalisation is a particularly high-risk period for further recurrent hospitalisations and death. In this issue of the Journal, Sulo et al.7 present an analysis of incident and total hospitalisations for heart failure in Norway between 2000 and 2014. The data from this nationwide retrospective cohort study (which contains all hospital stays with a cardiovascular-related diagnosis) confirm that there has been a continual decline in the incidence of first hospitalisation for HF. However, they also, and more importantly, report that there has been an increase in the risk of 30-day and 3-year readmissions for HF over this time. There was a 1.7% (95% confidence interval 0.7–3%) per year increase in 30-day HF readmission rates in men and 1.1% (95% confidence interval −0.01 to 2.3%) in women. The risk of 3-year recurrent hospitalisation was similar while in-hospital mortality decreased in both men and women. Are these trends simply a reflection of making patients live longer and keeping them alive to have further hospitalisations? We know from analyses of randomised trials that many of the therapies that we use to treat HF with reduced ejection fraction (HFrEF) also reduce recurrent HF hospitalisations.8-11 Therefore, why do we not see this translating into changes in epidemiological trends? There may be a number of factors at play. The changing demographics of patients with more co-morbidities and older age could be one explanation, although the authors found similar trends in each age group. The perhaps more worrying potential explanation for this trend is that there has been a failure to use those therapies which have been shown to be effective in reducing the risk of recurrent HF hospitalisations. A consistent finding from HF registries around the world is the underuse of guideline-recommended therapies for HF.12 Finally, it may be a methodological issue with the database used by Sulo et al.7 They were unable to differentiate HFrEF from HF with preserved ejection fraction (HFpEF). No therapies have yet been shown to be effective in HFpEF. Given that HFpEF is characterised by recurrent hospitalisations, more so than HFrEF, therefore the growing burden of HFpEF could explain these trends. Perhaps counter intuitively, these trends could be viewed as a win for the HF community. Making patients survive longer will lead to a further prolongation of the period at which they are at risk for a recurrent hospitalisation and consequently increasing the total number of recurrent hospitalisations occurring which Sulo et al. observed. If we are the victims of our own success, we must look at other ways to reduce the risk of HF hospitalisation. We can improve the use of medications and therapies shown to reduce the risk of HF hospitalisation. A more specific method may be to identify those patients at risk of hospitalisation or developing early signs of decompensation and intervening earlier through monitoring devices.13 Finally, an attractive option is reorganising care to prevent hospital admissions. However, we must ask if this is actually solving the problem or shifting it somewhere else? After recognising the issue of rehospitalisation costs there has been a shift towards treating HF in outpatient setting. This may involve using therapies in the community that were previously used to treat HF in the hospital such as intravenous diuretics or to treat patients in special outpatient units. While this leads to some reduction in costs, it must be recognised that these episodes of treatments for HF are as significant an event in the prognosis of the patient as the hospitalisation for HF.14 The decompensation of a patient requiring treatment outpatient is associated with a higher risk of mortality, much the same as a hospitalisation for HF. Therefore, our ultimate aim should be a reduction in the episodes of decompensation, wherever they may be treated, rather than on hospitalisations per se. This will require further work to understand the epidemiology of these episodes of worsening HF in the community and will need our registries and databases to accurately collect information on these events. Analyses of trials of therapies for HFrEF have demonstrated that these events can be modified and that it is important to do so given the prognosis they confer.14, 15 For the HF specialist practising today, the best method of reversing these trends is still giving the patient all of the guideline-recommended therapies that they are eligible for. However, to monitor our progress in preventing and treating HF we will have to expand our field of vision to capture all the potential HF events that occur, both in and out of the hospital. Conflict of interest: none declared." @default.
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• W2994862632 date "2020-01-11" @default.
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• W2994862632 title "The recurring problem of heart failure hospitalisations" @default.
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• W2994862632 doi "https://doi.org/10.1002/ejhf.1721" @default.
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