Five-year mortality and readmission rates in patients with heart failure in India: Results from the Trivandrum heart failure registry

doi:10.1016/j.ijcard.2020.10.012

International Journal of Cardiology

Volume 326, 1 March 2021, Pages 139-143

https://doi.org/10.1016/j.ijcard.2020.10.012 Get rights and content

Highlights

•
The THFR is the first heart failure registry in India with 5-year follow-up and low attrition rate.
•
Median survival time of HF patients in the Trivandrum Heart Failure Registry(THFR) is 3.1 years.
•
In this relatively younger cohort of HF patients, 3 out of 5 patients had died at 5-years.
•
Those who received guideline directed medical therapy at discharge from index hospitalization(25%) had better survival.
•
Interventions aimed at increasing guideline directed medical therapy may improve HF outcomes in India.

Abstract

Introduction

Heart failure (HF) has emerged as an important and increasing disease burden in India. We present the 5-year outcomes of patients hospitalized for HF in India.

Methods

The Trivandrum Heart Failure Registry (THFR) recruited consecutive patients admitted for acute HF among 16 hospitals in Trivandrum, Kerala in 2013. Guideline-directed medical therapy (GDMT) was defined as the combination of beta-blockers (BB), renin angiotensin system blockers (RAS), and mineralocorticoid receptor antagonists (MRA) in patients with HF with reduced ejection fraction (HFrEF, EF < 40%) at discharge. We used Cox proportional hazards models and Kaplan-Meier survival plots for analysis. The MAGGIC risk score variables were included as exposure variables.

Results

Among 1205 patients [69% male, mean (SD) age = 61.2 (13.7) years], HFrEF constituted 62% of patients and among them, 25% received GDMT. The 5-year mortality rate was 59% (n = 709 deaths), and median survival was 3.1 years. Sudden cardiac death and pump failure caused 46% and 49% of the deaths, respectively. In the multivariate Cox model, components of GDMT associated with lower 5-year mortality risks were discharge prescription of BB, RAS blocker, and MRA. Older age, lower systolic blood pressure, NYHA class III or IV, and higher serum creatinine were also associated with higher 5-year mortality.

Conclusions

Three out of every 5 patients had died during 5-years of follow-up with a median survival of approximately 3 years. Lack of GDMT in patients with HFrEF and frequent readmissions were associated with higher 5-year mortality. Quality improvement programmes with strategies to improve adherence to GDMT and reduction in readmissions may improve HF outcomes in this region.

Introduction

Heart failure (HF) is a global public health problem affecting more than 26 million people worldwide [1]. Most longitudinal outcome data for patients with HF are from high-income countries [2,3]. Available data from low- and middle-income countries (LMICs) are limited to short-term outcomes of patients with HF or single-centre studies and suggest that mortality rates for patients with HF are higher in LMICs than high-income countries [4,[5], [6], [7], [8]]. Further, wide heterogeneity in the causes and associated comorbidities in patients with HF across the globe [9,10] limits the extrapolation of long-term mortality data from high-income regions to LMICs.

Long-term outcome data and identifying factors associated with long-term prognosis are important for devising policy strategies to address the growing burden and management strategies for HF in India. We describe 5-year outcomes of patients with HF and evaluate factors associated with mortality in the Trivandrum Heart Failure Registry (THFR), which is India's first HF registry.

Section snippets

Study sample

The design of THFR has been reported previously [[5], [6], [7], [8]]. Briefly, THFR is a prospective, hospital-based registry of patients admitted with acute HF who were longitudinally followed over time. Patients were recruited from 16 hospitals in the region of Trivandrum, Kerala, India that cared for patients with HF from January 2013 to December 2013. The registry covered the Trivandrum city area (urban area: 215 km², population: 957,000 people) and an adjacent suburban rural area,

Results

Baseline characteristics of 1205 participants (69% males, mean [SD] age 61.2 [13.7] years) are reported in Table 1. Ischaemic heart disease (72%) was the most common aetiology of HF followed by dilated cardiomyopathy and rheumatic heart disease (Table 2). Hypertension and diabetes mellitus were prevalent in 55% and 52% of the study participants, respectively. HFrEF was the most common group (62%), followed by HFpEF (20%) and HFmEF (18%). The in-hospital mortality was 8.4%. At discharge, beta

Discussion

We report that 59% of patients with HF in THFR died at 5 years, which represents the longest follow-up data of patients with HF in India. Our cohort of patients with acute HF is a much younger cohort compared to high-income country cohorts. The younger mean age of patients in the THFR also contrasts with the median age of 73 years among patients hospitalized with heart failure in China [13]. The in-hospital mortality of 8.4% and one year mortality of 30.8% is higher than the observed figures in

Conclusions

Three out of every 5 patients died during the 5-year follow-up period in the first HF registry in India. Only 25% of patients were discharged from the index hospitalization on GDMT and importantly, prescription of GDMT at discharge was associated with lower 5-year mortality rates in patients with HFrEF. Quality improvement interventions to increase evidence-based management and prevention of hospital readmissions may substantially improve outcomes of patients with HF in India.

Funding

We thank Indian Council of Medical Research (ICMR), India (Project No. 5/4/1-11/11-NCD-II - Comprehensive heart failure intervention program) and Indian Council of Medical Research (ICMR), India - Trivandrum Heart Failure Cohort. File number 50/1(5) / TF CVD / 16 / NCD-II for funding this study.

Disclosures

SH has received project funds from ICMR for Trivandrum HF Cohort, National HF registry and CARE HF (2019–2023). PJ is supported by a Clinical and Public Health intermediate fellowship (grant number IA/CPHI/14/1/501497) from the Wellcome Trust-Department of Biotechnology, India Alliance (2015–2020). MDH has received previous support from the World Heart Federation via Boehringer Ingelheim, Bupa, and Novartis and the American Heart Association, Verily, and AstraZeneca for work unrelated to this

CRediT authorship contribution statement

Conceptualization: SH, SG, SV, MS, GV, CB, TN, NR, KS, MH. Data curation: SH, SG, SV, MS, GV, CB, RB, TN, NP, KK, NR, KS. Formal analysis: PJ, SH, MH, AA. Funding acquisition: SH, SG. Methodology: SH, SG, MH. Project administration: SH SG. Writing - original draft; SH, SG, PJ, AA, MH. Writing - review & editing. SH, SG, PJ, AA, MH, SV, MS, GV, CB, RB, TN, NP, KK, NR, KS.

Acknowledgements

The authors thank Kochumoni, Suresh Babu, Vineeth Purushothaman, Anand Kumar, Ajeesh C, Krishna Sanker and Manas Chacko for data collection, data entry and follow-up data collection. The contributions of Dr. Jayapal and Dr. Arun of General Hospital, Dr. BVR Kumar of Jubilee hospital and Dr. Suman of KIMS hospital are acknowledged. We also thank Dr. Priya Sosa James, Dr. Abdul Salam and Dr. Anil Balachandran for data collection.

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Heart failure (HF) represents a complex clinical syndrome affecting multiple organs and systems of the body, which is a global public health concern because of its high prevalence, mortality, and medical cost. Asia, with its vast population, diverse ethnicities, and complex health care systems, faces challenges in the prevention and management of HF. However, unlike in Western nations, data on HF epidemiology is still limited in Asia. In this review, we will summarize available information regarding the burden of HF in Asia from the aspects of occurrence, etiology and risk factors, outcome, and management of HF, to provide insights for reducing the burden of HF and improving the prognosis of patients with HF.
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To develop and validate a sensitive tool for assessment of quality of life (QoL) in heart failure (HF) patients in Indian settings.
The authors conducted literature review, in depth interviews, clinical observations and designed the first draft of the QoL tool. The tool was validated using content and face validity by a panel of experts. For internal consistency reliability, the questionnaire was administered among 270 HF patients. Test-retest reliability was assessed in 20 HF patients. Principal component factor analysis with varimax rotation was employed to assess the dimensionality and to reduce the number of items. Cronbach's alpha, and Intra-class correlation coefficients (ICCs) were employed to investigate reliability of questionnaire. The responsiveness data were collected 6 months after the baseline data collection from 30 HF patients. IBM® SPSS® Statistics Version 21 was used for statistical analysis.
The principal component factor analysis revealed mainly 5 domains. The final tool included 25 items. Cronbach's alpha (α) for the overall tool was 0.915. Intra-class correlation coefficients (ICCs) based on test-retest was 0.734. The final tool showed good responsiveness to changes with a mean ± SD of the change in response of 46 ± 12.4 and a standardized mean response of 3.7 within six-months.
The HF specific QoL tool developed for Indian patients is a valid and reliable instrument and it can be applied in daily clinical practice, and research.
We had developed and validated a quality-of-life tool for heart failure patients in India. This is the first ever attempt to develop a measure for heart failure patients in India. We had used a mixed methodology approach to identify all the domains in the tool. The newly developed tool is a valid, reliable, sensitive and responsive tool to measure quality of life in HF patients in India. This tool can be applied in daily clinical practice, research and health system for patients with HF in India.
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Citation Excerpt :
In a meta-analysis of 60 studies with data from 1.5 million people with HF, although the 5-year survival rates have improved in the last years (from 29.1% between 1970–1979 to 59.7% in 2000–2009), these remain very high.34 A recent study showed in patients with HF that 3 out of every 5 patients had died within 5 years of follow-up, with a median survival of 3 years.35 However, the elevated risk of outcomes in this population, particularly as renal function worsens, many patients do not receive evidence-based medical therapies, what worsens the prognosis.36
To assess mortality, cardiovascular and renal outcomes among patients with heart failure (HF) (primary objective), with a particular focus on the risk of developing chronic kidney disease (CKD) (secondary).
Observational cohort study, comprising cross-sectional and longitudinal retrospective analyses using secondary data from electronic health records. For the primary objective, adults with prevalent HF, defined as at least one diagnosis of HF prior to the index date (1 January 2017) were included. For the secondary objective, adults with incident HF in 2017 were enrolled.
A total of 21 575 patients had HF in the prevalent population (8391 with CKD at baseline), whereas 3045 patients were included in the incident population. In the prevalent population, the risk of all-cause death (HR, 1.227; 95%CI, 1.172–1.285), CKD hospitalization (HR, 1.427; 95%CI, 1.379–1.479) and acute kidney failure (HR, 1.377; 95%CI, 1.222–1.524) was greater in those patients with HF and CKD vs HF only after 3 years of follow-up. For the incident population, within 24 months from HF diagnosis, 5.9% of patients developed CKD. Overall, 23.4% were taking angiotensin-converting enzyme inhibitors, 26.3% angiotensin receptor blockers, 7.9% sacubitril/valsartan, 64.2% beta blockers, 11.5% aldosterone antagonists and 4.5% sodium-glucose Cotransporter-2 inhibitors.
In Spain, patients with HF have a high risk of developing cardiovascular and renal complications. Despite that, there is a substantial proportion of patients that are not taking guideline recommended drugs. A higher use of these drugs could reduce HF burden and complications in clinical practice.
Determinar la mortalidad y los eventos cardiovasculares y renales en pacientes con insuficiencia cardiaca (IC) (objetivo primario), en particular sobre el desarrollo de enfermedad renal crónica (ERC) (secundario).
Estudio observacional, con análisis transversal y retrospectivo, empleando datos secundarios de registros electrónicos de salud. Para el objetivo primario se incluyeron adultos con IC prevalente, definida como al menos un diagnóstico de IC antes de la fecha índice (1 de enero de 2017). Para el secundario se incluyeron adultos con IC incidente en 2017.
Se incluyeron 21.575 pacientes con IC en la población prevalente (8.391 con ERC basal) y 3.045 en la población incidente. En la población prevalente el riesgo de muerte (HR = 1,227; IC 95%, 1,172-1,285), hospitalización por ERC (HR = 1,427; IC 95%, 1,379-1,479) y fallo renal agudo (HR = 1,377; IC 95%, 1,222-1,524) fue mayor en los pacientes con IC y ERC frente a IC sola, tras 3 años de seguimiento. En la población incidente, a los 24 meses del diagnóstico el 5,9% desarrollaron ERC. Globalmente, el 23,4% tomaban inhibidores de la enzima convertidora de angiotensina, el 26,3% antagonistas de los receptores de angiotensina II, el 7,9% sacubitrilo/valsartán, el 64,2% bloqueadores beta, el 11,5% antialdosterónicos y el 4,5% inhibidores del cotransportador sodio-glucosa tipo 2.
En España, los pacientes con IC tienen un riesgo elevado de desarrollar complicaciones cardiovasculares y renales. Sin embargo, existe una proporción importante de pacientes que no toman los fármacos recomendados por las guías. Un mayor uso podría reducir la carga de IC y las complicaciones en la práctica clínica.
Distribution and Correlates of Incident Heart Failure Risk in South Asian Americans: The MASALA Study
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Citation Excerpt :
Cardiovascular mortality owing to HF is increasing and represents the subtype of cardiovascular disease with the fastest increases in mortality rates in the United States over the last decade.4 HF also has an increasing global prevalence with emerging data identifying a growing burden of HF in South Asia, where the prevalence of cardiometabolic risk factors for HF is high, age of HF onset is younger than among US populations, and HF outcomes are worse.5,6 Prior studies in international settings indicate that patients with HF of South Asian ancestry were younger than patients in European or US registries or patients in other Asian regions, that South Asian individuals had a 3–5 times higher HF admission rates than White individuals in the United Kingdom, and that age-adjusted HF mortality rates in South Asian American women were the highest compared with mortality rates in other Asian American subgroups.5
South Asian Americans experience disproportionately high burden of cardiovascular diseases. Estimating predicted heart failure (HF) risk distribution may facilitate targeted prevention. We estimated the distribution of 10-year predicted risk of incident HF in South Asian Americans and evaluated the associations with social determinants of health and clinical risk factors.
In the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study, we calculated 10-year predicted HF risk using the Pooled Cohort Equations to Prevent Heart Failure multivariable model. Distributions of low (<1%), intermediate (1%–5%), and high (≥5%) HF risk, identified overall and by demographic and clinical characteristics, were compared. We evaluated age- and sex-adjusted associations of demographic characteristics and coronary artery calcium with predicted HF risk category using ordinal logistic regression. In 1159 participants (48% women), with a mean age of 57 ± 9 years, 40% had a low, 37% had an intermediate, and 24% had a high HF risk. Significant differences in HF risk distribution existed across demographic (income, education, birthplace) and clinical (diabetes, hypertension, body mass index, coronary artery calcium) groups (P < .01). Significant associations with high predicted HF risk were observed for a family of income 75,000/year or more (adjusted odds ratio 0.5 [95% confidence interval (CI) 0.4–0.7]), college education (0.6 [95% CI 0.4–0.9]), birthplace in another South Asian country (1.9 [95% CI 1.2–3.2], vs. born in India), and prevalent coronary artery calcium (2.6 [95% CI 1.9–3.6]).
Almost two-thirds of South Asian Americans in the MASALA cohort are at intermediate or high predicted 10-year HF risk, with varying risk across demographic and clinical characteristics.
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Five-year mortality and readmission rates in patients with heart failure in India: Results from the Trivandrum heart failure registry

Highlights

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Study sample

Results

Discussion

Conclusions

Funding

Disclosures

CRediT authorship contribution statement

Acknowledgements

J. Am. Coll. Cardiol.

J. Card. Fail.

Am. Heart J.

Lancet Glob. Health

Lancet Glob. Health

J. Am. Coll. Cardiol.

Int. J. Cardiol.

Indian Heart J.

Indian Heart J.

Trends in survival after a diagnosis of heart failure in the United Kingdom 2000-2017: population based cohort study

BMJ.

Temporal trends and patterns in mortality after incident heart failure: a longitudinal analysis of 86 000 individuals

JAMA Cardiol.