Heart Failure Mortality Higher Now Than in 1999

Any gains made in reducing heart failure mortality more than a decade ago seem to have been erased in the current era, with that reversal exacerbated but not exclusively caused by the COVID-19 pandemic, new data show.

“It is actually not that new of an observation that the mortality related to heart failure has been increasing over the last few years,” senior author Marat Fudim, MD (Duke University, Durham, NC), told TCTMD. “The important statement is that this is not purely COVID-related because the trend has been present for 10 years but [then] just accelerated. It's been like putting fuel on a smoldering fire.”

The study, published as a research letter online ahead of print this week in JAMA Cardiology with lead author Ahmed Sayed, MBBS (Ain Shams University, Cairo, Egypt), showed that among Americans, the number of age-adjusted heart failure-related deaths per 100,000 people declined by 1.62% annually between 1999 and 2005 and by 3.29% each year between 2005 and 2009 before reaching a plateau between 2009 and 2012. But deaths then started to climb, increasing by 1.82% per year from 2012 to 2019 and by 7.06% per year from 2020 to 2021.

Sadiya Khan, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who was not involved in this study but published a similar analysis of trends in heart failure mortality in 2019, told TCTMD the new data are “unfortunately not surprising.”

It’s not likely that the pandemic was the direct cause of an uptick in deaths from heart failure, but the disruption it brought to the healthcare system “diffusely infiltrated our ability to provide healthcare" and patients’ ability to receive it, she said. "Altogether, it was like a . . . spark that just accelerated or worsened it.”

In the analysis, the researchers used data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research (CDC WONDER) resource to identify all heart failure-related deaths between 1999 and 2021. The increases in heart failure-related death rates from 2012 to 2021 were larger than the declines reported from 1999 to 2012, resulting in a 103.2% reversal in mortality.

These reversals occurred in all subgroups of patients, but they were greatest in people younger than 45 (906.3%), those aged 45 to 64 years (384.7%), males (119.0%), non-Hispanic Black individuals (166.5%), rural residents (92.3%), and patients from both the South (118.2%) and Midwest (115.3%).

Fudim said it will be interesting to see how these trends evolve in the coming years given the growing prevalence of metabolic disease and other comorbidities that are associated with worse heart failure-related outcomes. “It leads to a slow shift of the mortality curve to occur earlier and earlier,” he said, noting “one particularly striking finding” in the study was that heart failure deaths were growing out of proportion in younger patients. “That is probably explained by the fact that we are moving this obesity, kidney disease, diabetes crisis to younger and younger ages,” Fudim noted.

Coding changes might have also played a small role in the trends observed here, according to Fudim. “We have been coding for heart failure and heart failure-related mortality differently over the years,” he said, explaining that 20 years ago, certain deaths may have been attributed to uncontrolled hypertension but are now recognized as heart failure. “We are now capturing a lot of more patients that we wouldn't have called heart failure before.”

Once heart failure has developed, the cat is out of the bag. Marat Fudim

Training and prevention efforts are needed to begin reversing these trends, Fudim said. “Probably the most important thing is you've got to prevent this disease, meaning once heart failure has developed, the cat is out of the bag,” he said. “You want to delay it as long as you can, and sometimes you can't prevent it all entirely. But certainly if you have metabolically driven diseases—comorbidities such as hypertension, hyperlipidemia, diabetes, obesity—these are the diseases we can treat, but we need to focus on them, and it might actually require some degree of focus on prevention of diseases and a redesign of how we deliver care.”

With the disparities in care observed between patients in urban and rural settings, Fudim added that the current healthcare system is worsening the problem by closing rural hospitals and not training enough heart failure doctors. “I am a personal believer in preventive care, increased support of remote patient monitoring and remote patient care in rural areas,” he said. “We need to train more people; we need to train differently.”

There should be less of a “focus on fancy toys and fancy drugs,” he said, and a greater emphasis on “the good old drugs we have, good interventions, lifestyle interventions. Just teach people to eat right. Teach people to focus on their comorbidities.”

Glucagon-like peptide-1 (GLP-1) receptor agonists will also be “game changers” if accessible to the heart failure patients who need them, Fudim added.

Khan agreed on the need “to disrupt our current approach” to heart failure, noting: “Two things that have been repeatedly reported now are that mortality rates are going up and unacceptable disparities exist with higher mortality for Black Americans. And it doesn't seem like those things are changing, so clearly what we're doing isn't working.”

Addressing both access to and the cost of medical care have proven to be important components of improving care quality, she said, noting that the best medications for these patients cost upwards of thousands of dollars. “We continue to make this progress and there is amazing trial data that are being published, but we have a huge implementation gap, and that's what we're seeing.”

Lastly, Fudim added that among patients with heart failure today, there is a greater prevalence of the more complex phenotype, heart failure with preserved ejection fraction, which is “very hard to decipher.”

A heterogeneous disease, heart failure cannot be fixed with a single solution, Fudim said, adding that he would like to see future research “drill down deeper into what type of disease is driving this mortality, phenotypes that might be missing, and then keep looking at what interventions might help.”