Long-term survival after hospitalization for acute heart failure — Differences in prognosis of acutely decompensated chronic and new-onset acute heart failure

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Abstract

Aims

To analyze the five-year mortality after hospitalization for acute heart failure (AHF) and compare predictors of prognosis in patients with and without a previous history of heart failure.

Methods

Patients with AHF (n = 620) from the prospective multicenter FINN-AKVA study were classified as acutely decompensated chronic heart failure (ADCHF) or de-novo AHF if no previous history of heart failure was present. Both all-cause mortality during five years of follow-up and prognostic factors were determined.

Results

The overall mortality was 60.3% (n = 374) at five years. ADCHF was associated with significantly poorer outcome compared to de-novo AHF; five-year mortality rate 75.6% vs. 44.4% (p < 0.001). Initially, mortality was high (33.5% in ADCHF and 21.7% in de-novo AHF after 12 months), but in de-novo AHF the annual mortality declined markedly already after the first year. Compared to de-novo AHF, patients with ADCHF had an increased risk of death for several years after the index hospitalization. A previous history of heart failure was an independent predictor of five-year mortality (adjusted hazard ratio 1.8 (95% CI 1.4–2.2; p < 0.001). Older age and impaired renal function were associated with adverse long-term prognosis in both ADCHF and de-novo AHF, while higher systolic blood pressure on admission predicted better outcome.

Conclusion

The long-term prognosis after hospitalization for AHF is poor, with a significantly different survival observed in patients with de-novo AHF compared to ADCHF. A previous history of heart failure is an independent predictor of five-year mortality. Distinction between ADCHF and de-novo AHF may improve our understanding of patients with AHF.

Introduction

Acute heart failure (AHF) is characterized by rapid worsening of symptoms and signs of heart failure requiring urgent treatment, often with hospitalization. Recent guidelines recognize that patients presenting with AHF may not have a previous history of heart failure, and thus are new-onset (de-novo) cases [1], [2]. The proportion of patients with de-novo AHF has been variable, between 12% and 63% [3], [4], [5], [6]. Clinical presentation and management of AHF does not differ between acutely decompensated chronic heart failure (ADCHF) and de-novo AHF. Initial treatment is directed at relieving symptoms, stabilizing hemodynamic derangements and recognizing the precipitating factor(s). Initiation or adjustment of medical therapy for heart failure during the index hospitalization is also advocated.

The prognosis of patients with AHF remains poor. In-hospital mortality is as high as 5–10%, and around 25% of patients die within the first year after hospital admission [3], [7], [8], [9]. Factors related to bad short-term prognosis, such as older age, impaired renal function, low blood pressure, and higher levels of natriuretic peptide, are well known. Epidemiological studies have found little or no difference in mortality in patients with preserved compared to patients with impaired left ventricular ejection fraction (LVEF) [10], [11], [12]. An exacerbation of AHF has been suggested to cause deterioration in the prognosis of patients with chronic heart failure [13], [14]. However, data on long-term survival after hospitalization for AHF are limited [11], [15], [16], [17], [18]. Even less is known about the long-term prognosis and factors related to outcome in patients with de-novo AHF.

The aim of this study was to investigate the five-year mortality and identify factors associated with long-term prognosis after hospitalization for AHF with special emphasis on possible differences between patients with ADCHF and de-novo heart failure.

Section snippets

Material and methods

FINN-AKVA is a prospective observational multicenter study on AHF [7]. During three months in 2004, consecutive patients from 14 hospitals in Finland hospitalized for AHF were enrolled. For inclusion in the study, the diagnosis of AHF had to be confirmed during the hospital stay. Clinical data on admission was recorded in detail and patients were systematically characterized with regard to demographics, co-morbidities and medication. Subjects with a previous history of heart failure were

Results

The study population consisted of 620 patients, of which 307 (49%) were women. Patients were on average 75 years old. Medical history and clinical presentation are shown in Table 1. A history of heart failure was present in about half of patients (n = 316) which thus were classified as ADCHF, whereas 304 subjects (49%) had new onset (de-novo) AHF. Patients presenting with de-novo AHF had higher systolic and diastolic blood pressures and higher heart rates on admission. They also had less

Discussion

Long-term prognosis after hospitalization for AHF is very poor; more than half of the patients die within five years. Moreover, this study shows significantly different outcome in ADCHF from that in de-novo AHF. In particular, the mortality rate drops considerably after the first year in de-novo AHF, whereas ADCHF patients have high annual mortality several years after the index hospitalization. A history of heart failure is one of the strongest independent predictors of five-year mortality in

Conclusion

The long-term prognosis in AHF is very poor, with only one fourth of patients with ADCHF surviving five years. In de-novo AHF, the initial mortality is high, but clearly diminishes after the first year. Indeed, a previous history of chronic heart failure is a strong and independent factor associated with increased five-year mortality after hospitalization for AHF. Risk factors known to affect early outcome are also predictors of long-term prognosis. Older age, systolic blood pressure, renal

Acknowledgments

The FINN-AKVA study was supported by grants from the Finnish Foundation for Cardiovascular Research and by an unrestricted grant from Orion Pharma. Roche Diagnostics kindly provided kits for the analysis of NT-proBNP and a grant for the study of sample logistics. J.L. has received personal grants from Finska Läkaresällskapet.

We are thankful to Mervi Pietilä and Pirjo Tanner for technical assistance.

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    FINN-AKVA Study group: V-P. Harjola, K. Siirilä-Waris, MS. Nieminen, Helsinki University Central Hospital; J. Melin, Central Finland Central Hospital; K. Peuhkurinen, Kuopio University Hospital; M. Halkosaari, Keski-Pohjanmaa Central Hospital ; K. Hänninen, Kymenlaakso Central Hospital; T. Ilva, T. Talvensaari, Kanta-Häme Central Hospital; H. Kervinen, Hyvinkää Hospital; K. Kiilavuori, Jorvi Hospital; K. Majamaa-Voltti, Oulu University Hospital; H. Mäkynen, V. Virtanen, Tampere University Hospital; T. Salmela-Mattila, Rauma Hospital; K. Soininen, Kuusankoski Hospital; M. Strandberg, H. Ukkonen, Turku University Hospital; I. Vehmanen, Turku Hospital; E.-P. Sandell, Orion Pharma, Espoo, Finland. Study nurses: K. Hautakoski, Keski-Pohjanmaa Central Hospital; J. Lamminen, Hyvinkää Hospital; M.-L. Niskanen, Kuopio University Hospital; M. Pietilä, Helsinki University Central Hospital; and O. Surakka, Central Finland Central Hospital.

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