Temporal Variation in the Prognosis and Treatment of
               Advanced Heart Failure - Before and After 2000

Carlo, Carlos Henrique Del; Cardoso, Juliano Novaes; Ochia, Marcelo Eidi; Oliveira Jr., Mucio Tavares de; Ramires, José Antonio Franchini; Pereira-Barretto, Antonio Carlos

doi:10.5935/abc.20140050

Brasil

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Original Articles • Arq. Bras. Cardiol. 102 (05) • 10 June 2014 • https://doi.org/10.5935/abc.20140050 linkcopy

Temporal Variation in the Prognosis and Treatment of Advanced Heart Failure - Before and After 2000

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background: The treatment of heart failure has evolved in recent decades suggesting that survival is increasing.

Objective: To verify whether there has been improvement in the survival of patients with advanced heart failure.

Methods: We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis.

Results: The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7).

Conclusions: Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.

Heart Failure / therapy; Prognosis; Heart Failure / mortality; Chagas Disease

Characteristics	Population (n = 632)	Year of treatment		p value
Characteristics	Population (n = 632)	Before 2000 (n = 353)	After 2000 (n = 279)	p value
Age (years)	54.8 ± 15.1	59.0 ± 14.8	51.5 ± 14.5	< 0.001
Male gender	435 (68.8)	255 (72.2)	180 (64.5)	0.037
Etiology:
Ischemic	132 (20.9)	56 (15.0)	76 (27.2)	< 0.001
Non-ischemic (non- chagasic)	312 (49.4)	173 (49.0)	139 (49.8)	0.839
Chagasic	188 (29.7)	124 (35.1)	64 (22.9)	0.001
LVEF (%)	28.2 ± 7.2	30.8 ± 5.9	24.7 ± 7.3	< 0.001
Creatinine (mg/dL)	1.5 ± 0.7	1.5 ± 0.5	1.5 ± 0.5	0.239
Sodium (mEq/L)	135.7 ± 5.0	136.7 ± 4.7	134.9 ± 5.1	< 0.001
SBP (mmHg)	103.6 (25.4)	102.6 ± 21.9	105.0 ± 30.1	0.163
Mortality (1 year)	264 (41.8)	200 (56.7)	63 (22.8)	< 0.001

Characteristics	Population (n = 333)	Year of treatment		p value
Characteristics	Population (n = 333)	Before 2000 (n = 70)	After 2000 (n = 263)	p value
Age (years)	58.7 ± 15.4	54.2 ± 15.8	59.9 ± 15.1	0.011
Male gender	213 (64.0)	48 (68.6)	165 (62.7)	0.366
Etiology:
Ischemic	94 (28.2)	18 (25.7)	76 (28.9)	0.599
Non-ischemic (non-chagasic)	163 (48.9)	33 (47.1)	130 (49.4)	0.734
Chagasic	76 (22.8)	19 (27.1)	57 (21.7)	0.333
LVEF (%)	28.0 ± 11.4	31.3 ± 8.4	27.1 ± 11.9	< 0.001
Hemoglobin (g/L)	13.2 ± 2.0	13.9 ± 2.1	13.0 ± 1.9	0.001
Urea (mg/dL)	74.7 ± 42.5	72.9 ± 35.2	75.1 ± 44.2	0.842
Creatinine (mg/dL)	1.5 ± 0.7	1.4 ± 0.5	1.5 ± 0.8	0.699
Sodium (mEq/L)	136.6 ± 4.9	135.9 ± 5.4	136.7 ± 4.7	0.083
SBP (mmHg)	105.3 ± 23.3	111.7 ± 25.4	103.5 ± 22.4	0.017
DBP (mmHg)	68.7 ± 18.1	76.7 ± 17.9	66.3 ± 17.5	< 0.001
Medications:
Dobutamine	187 (57.9)	36 (51.4)	151 (57.4)	0.216
Dobutamine	6 (1.9)	0 (0.0)	6 (2.3)	0.346
Levosimendan	16 (5.0)	0 (0.0)	16 (6.1)	0.028
ACEI	241 (72.4)	60 (85.7)	181 (68.8)	0.005
Beta-blockers	199 (59.8)	8(11.4)	191 (72.6)	< 0.001
Losartan	42 (12.7)	0 (0.0)	42 (16.0)	< 0.001
Nitrates	117 (35.2)	39 (55.7)	78 (29.7)	< 0.001
Hydralazine	108 (32.5)	16 (22.9)	92 (35.0)	0.052
Digoxin	194 (58.6)	64 (92.8)	130 (49.4)	< 0.001
Spironolactone	48 (14.5)	0 (0.0)	48 (18.3)	< 0.001
Furosemide	261 (78.6)	70 (100.0)	191 (72.6)	< 0.001
Hydrochlorothiazide	59 (17.8)	0 (0.0)	59 (22.4)	< 0.001
Clinical results:
Mortality in-Hospital	37 (11.1)	14 (20.0)	23 (8.7)	0.008
Mortality at follow-up (1 year)	106 (31.8)	44 (62.9)	62 (23.6)	< 0.001
Rehospitalization	109 (32.8)	36 (51.4)	73 (27.9)	< 0.001
Clinical events	168 (49.2)	56 (80.0)	108 (41.1)	< 0.001

Characteristics	1-year mortality		p value
Characteristics	Yes (n = 106)	No (n = 227)	p value
Age (years)	58.2 ± 17.3	58.9 ± 14.5	0.928
Male gender	63 (59.4)	150 (66.1)	0.239
Etiology:
Ischemic	27 (25.5)	67 (29.5)	0.445
Non-ischemic (non-chagasic)	44 (41.5)	119 (52.4)	0.063
Chagasic	35 (33.0)	41 (18.1)	0.002
LVEF (%)	28.9 ± 9.5	27.6 ± 12.1	0.116
Hemoglobin (g/L)	13.3 ± 2.2	13.1 ± 1.8	0.311
Hemoglobin (g/L)	80.8 ± 42.8	71.8 ± 42.1	0.016
Creatinine (mg/dL)	1.5 ± 0.5	1.5 ± 0.8	0.043
Sodium (mEq/L)	135.3 ± 4.9	137.1 ± 4.8	0.001
SBP (mmHg)	103.1 ± 20.7	106.4 ± 24.5	0.505
DBP (mmHg)	69.3 ± 15.3	68.4 ± 19.3	0.503
Medications
Inotropic agents	75 (71.4)	127 (57.5)	0.015
ACEI	69 (65.1)	172 (75.8)	0.042
Beta-blocker	36 (34.0)	163 (71.8)	< 0.001
Losartan	12 (11.3)	30 (13.2)	0.649
Nitrates	47 (44.3)	70 (30.8)	0.014
Hydralazine	38 (35.8)	70 (30.8)	0.333
Digoxin	76 (71.7)	118 (52.0)	< 0.001
Spironolactone	11 (10.4)	37 (16.3)	0.161
Furosemide	90 (84.9)	171 (75.3)	0.032
Hydrochlorothiazide	18 (17.0)	41 (18.1)	0.839

Predictor (univariate analysis)	Hazard ratio	95% Confidence Interval (95%CI)	p value
Age > 60 years	1.0	0.7 - 1.5	0.998
Male gender	0.8	0.5 - 1.2	0.247
Etiology:
Ischemic	0.8	0.5 - 1.3	0.389
Non-ischemic (non-chagasic)	0.7	0.5 - 1.1	0.124
Chagasic	1.8	1.2 - 2.7	0.008
LVEF < 0.25	0.8	0.6 - 1.3	0.382
Anemia	1.0	0.7 - 1.6	0.939
Urea ≥ 60 mg/dL	1.7	1.1 - 2.5	0.013
Creatinine ≥ 1.4 mg/dL	1.6	1.1 - 2.4	0.013
Sodium ≤ 135 mEq/L	1.8	1.2 - 2.6	0.004
SBP < 90 mmHg	0.9	0.5 - 1.5	0.640
Medications
Inotropic agents	1.7	1.1 - 2.7	0.008
ACEI	0.6	0.4 - 0.9	0.020
Beta-blocker	0.3	0.2 - 0.5	<0.001
Losartan	1.1	0.6 - 2.0	0.788
Nitrates	1.6	1.1 - 2.4	0.017
Hydralazine	1.4	0.9 - 2.1	0.097
Digoxin	1.4	0.9 - 2.2	0.106
Spironolactone	0.7	0.4 - 1.3	0.274
Hydrochlorothiazide	1.2	0.7 - 2.0	0.483
Furosemide	1.4	0.8 - 2.4	0.205
Predictor (multivariate analysis)	Hazard ratio	95% confidence Interval	p value
Creatinine ≥ 1,4 mg/dL	2.0	1.3 - 3.0	0.002
Chagasic etiology	1.9	1.3 - 3.0	0.002
ACEI	0.6	0.4 - 0.9	0.040
Beta-blocker	0.3	0.2 - 0.5	< 0.001
Sodium ≤ 135 mEq/L	1.8	1.2 - 2.7	0.003

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[1] LVEF: left ventricular ejection fraction; SBP: systolic blood pressure.