Incidence and Survival of Hospitalized Acute Decompensated Heart Failure in Four US Communities (from the Atherosclerosis Risk in Communities Study) Patricia P. Chang, MD, MHSa,*, Lloyd E. Chambless, PhDb, Eyal Shahar, MD, MPHc, Alain G. Bertoni, MD, MPHd, Stuart D. Russell, MDe, Hanyu Ni, PhD, MPHf, Max He, MSg, Thomas H. Mosley, PhDh, Lynne E. Wagenknecht, DrPHd, Tandaw E. Samdarshi, MD, MPHh, Lisa M. Wruck, PhDb, and Wayne D. Rosamond, PhDi Most population-based estimates of incident hospitalized heart failure (HF) have not differentiated acute decompensated heart failure (ADHF) from chronic stable HF nor included racially diverse populations. The Atherosclerosis Risk in Communities Study conducted surveillance of hospitalized HF events (age ‡55 years) in 4 US communities. We estimated hospitalized ADHF incidence and survival by race and gender. Potential 2005 to 2009 HF hospitalizations were identified by International Classification of Diseases, Ninth Revision, Clinical Modification, codes; 6,168 records were reviewed to validate ADHF cases. Population estimates were derived from US Census data; 50% of eligible hospitalizations were classified as ADHF, of which 63.6% were incident ADHF and 36.4% were recurrent ADHF. The average incidence of hospitalized ADHF was 11.6 per 1,000 persons, aged ‡55 years, per year, and recurrent hospitalized ADHF was 6.6 per 1,000 persons/yr. Age-adjusted annual ADHF incidence was highest for black men (15.7 per 1,000), followed by black women (13.3 per 1,000), white men (12.3 per 1,000), and white women (9.9 per 1,000). Of incident ADHF events with heart function assessment (89%), 53% had reduced the ejection fraction (heart failure with reduced ejection fraction [HFrEF]) and 47% had preserved ejection fraction (heart failure with preserved ejection fraction [HFpEF]). Black men had the highest proportion of acute HFrEF events (70%); white women had the highest proportion of acute HFpEF (59%). Age-adjusted 28-day and 1-year case fatality after an incident ADHF was 10.4% and 29.5%, respectively. Survival did not differ by race or gender. In conclusion, ADHF hospitalization and HF type varied by both race and gender, but case fatality rates did not. Further studies are needed to explain why black men are at higher risk of hospitalized ADHF and HFrEF. Ó 2014 Elsevier Inc. All rights reserved. (Am J Cardiol 2014;113:504e510) Estimates of incident heart failure (HF) rates1 are often based on hospital discharge diagnoses codes that include
Departments of aMedicine and bBiostatistics, University of North Carolina, Chapel Hill, North Carolina; cDepartment of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona; dDepartment of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina; eDepartment of Medicine, Johns Hopkins University, Baltimore, Maryland; fCenters for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Maryland; gDuke Clinical Research Institute, Durham, North Carolina; hDepartment of Medicine, University of Mississippi Medical Center, Jackson, Mississippi; and iDepartment of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. Manuscript received May 22, 2013; revised manuscript received and accepted October 5, 2013. The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute (Bethesda, Maryland) contracts (HHSN268201100005 C, HHSN268201 100006 C, HHSN268201100007 C, HHSN268201100008 C, HHSN268201100009 C, HHSN268201100010 C, HHSN268201100011 C, and HHSN268201100012 C). See page 509 for disclosure information. *Corresponding author: Tel: (919) 843-5214; fax: (919) 966-1743. E-mail address: [email protected] (P.P. Chang). 0002-9149/13/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2013.10.032
chronic HF cases and possibly non-HF cases and, thus, may not reflect the actual number of hospitalizations for acute decompensated heart failure (ADHF). Because most HF patients are likely to be hospitalized within 5 years, 17% because of acute decompensation,2 reliable estimates are needed to better understand and track the risk, burden, and outcomes of HF. To assess the impact of clinical management on survival of HF, and the effect of risk factors and their control on HF incidence, it is important to obtain community-based estimates of ADHF events and monitor their changes. Previous studies reported that approximately half of overt HF cases are heart failure with preserved ejection fraction (HFpEF),3,4 but it is unclear if this distribution exists in diverse communities or in similar proportions across race-gender groups. The Atherosclerosis Risk in Communities (ARIC) study monitors prevalence and incidence of hospitalized ADHF in 4 communities. We describe here our first 5-year estimates of validated hospitalized acute decompensated HF events and case fatality (CF) by race, gender, and HF types. Methods The 4 ARIC study communities include Forsyth County, North Carolina; Jackson, Mississippi; Minneapolis, Minnesota; www.ajconline.org
Heart Failure/Incident Acute Heart Failure and Survival: ARIC
505
Table 1 Characteristics of the validated hospitalized ADHF cases: 2005 to 2009 Atherosclerosis Risk in Communities Study Heart Failure Community Surveillance Variable
Age (yrs) Women Caucasian Black men Black women White men White women Heart function assessed*,† LVEF before hospitalization (%)*,† LVEF during hospitalization (%)* HFrEF Previous diagnosis of HF Body mass index (kg/m2)* Obesity* Current smoker Hypertension Coronary heart disease Acute MI or unstable angina pectoris Atrial fibrillation or flutter Valvular heart disease Diabetes mellitus Stroke or transient ischemic attack Peripheral vascular disease Asthma or chronic obstructive pulmonary disease Sleep apnea Chronic kidney diseasez
All ADHF (n ¼ 3,695)
Incident ADHF (n ¼ 2,252)
Mean or %
95% CI
Mean or %
95% CI
75.6 53.6% 72.4% 15.2% 12.4% 38.4% 33.9% 90.1% 40.7 41.9 58.3% 70.1% 29.0 26.0% 14.2% 83.7% 67.5% 10.7% 35.8% 23.6% 46.6% 20.0% 13.9% 37.7% 9.1% 66.1%
75.2e75.9 52.2e55.1 71.2e73.5 14.3e16.2 11.7e13.2 37.0e39.9 32.6e35.3 88.9e91.2 39.9e41.6 41.1e42.7 56.4e60.2 68.4e71.8 28.6e29.4 24.4e27.6 13.0e15.5 82.2e85.1 65.8e69.1 9.6e12.0 34.1e37.6 22.1e25.2 44.8e48.4 18.5e21.5 12.7e15.2 35.9e39.5 8.1e10.2 64.3e67.8
75.9 55.3% 78.5% 12.2% 9.3% 43.1% 35.4% 88.8% 44.2 43.4 53.0% 53.2% 29.2 27.4% 14.8% 83.2% 63.1% 11.7% 31.9% 21.2% 42.7% 20.4% 13.2% 36.0% 8.6% 63.8%
75.5e76.4 53.3e57.3 77.0e80.0 11.0e13.4 8.4e10.3 41.1e45.2 33.5e37.4 87.1e90.2 43.1e45.4 42.5e44.3 50.5e55.5 50.8e55.6 28.8e29.7 25.4e29.6 13.2e16.6 81.2e85.0 60.8e65.3 10.3e13.4 29.7e34.2 19.3e23.2 40.3e45.1 18.5e22.5 11.7e14.9 33.8e38.4 7.4e10.1 61.5e66.0
The numbers and percentages listed in the table are weighted to account for sampling probabilities (6,168 unweighted sampled events resulting in 3,695 hospitalized ADHF events and 2,252 incident hospitalized ADHF events). Data were available for 100% of each characteristic except for those noted by “*.” The co-morbidities included in this table (such as hypertension and coronary heart disease) were historical diagnoses recorded in the medical record. History of previous HF diagnosis and co-morbidities were obtained from the current hospitalization. Imaging reports of LVEF within 2 years of the current hospitalization were abstracted. Obesity was defined as body mass index 30 kg/m2. MI ¼ myocardial infarction. * The percentage of all hospitalized ADHF and all incident ADHF, respectively, with available data for each of the following characteristics: heart function assessed: 90.1%, 88.8%; LVEF before hospitalization: 54.3%, 44.2%; LVEF during hospitalization: 59.9%, 64.9%; and body mass index and obesity: 73.1%, 74.0%. † Assessment of heart function (ventricular systolic and diastolic function) was documented in the medical records (historical reference) or in reports of cardiac imaging (echocardiography, cardiac catheterization, and nuclear or other cardiac imaging tests). If there was more than 1 assessment of LVEF, the lowest value was used. z Chronic kidney disease was defined as history of dialysis dependence and/or estimated glomerular filtration rate (using the Modification of Diet in Renal Disease method) of
Departments of aMedicine and bBiostatistics, University of North Carolina, Chapel Hill, North Carolina; cDepartment of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona; dDepartment of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina; eDepartment of Medicine, Johns Hopkins University, Baltimore, Maryland; fCenters for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Maryland; gDuke Clinical Research Institute, Durham, North Carolina; hDepartment of Medicine, University of Mississippi Medical Center, Jackson, Mississippi; and iDepartment of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. Manuscript received May 22, 2013; revised manuscript received and accepted October 5, 2013. The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute (Bethesda, Maryland) contracts (HHSN268201100005 C, HHSN268201 100006 C, HHSN268201100007 C, HHSN268201100008 C, HHSN268201100009 C, HHSN268201100010 C, HHSN268201100011 C, and HHSN268201100012 C). See page 509 for disclosure information. *Corresponding author: Tel: (919) 843-5214; fax: (919) 966-1743. E-mail address: [email protected] (P.P. Chang). 0002-9149/13/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2013.10.032
chronic HF cases and possibly non-HF cases and, thus, may not reflect the actual number of hospitalizations for acute decompensated heart failure (ADHF). Because most HF patients are likely to be hospitalized within 5 years, 17% because of acute decompensation,2 reliable estimates are needed to better understand and track the risk, burden, and outcomes of HF. To assess the impact of clinical management on survival of HF, and the effect of risk factors and their control on HF incidence, it is important to obtain community-based estimates of ADHF events and monitor their changes. Previous studies reported that approximately half of overt HF cases are heart failure with preserved ejection fraction (HFpEF),3,4 but it is unclear if this distribution exists in diverse communities or in similar proportions across race-gender groups. The Atherosclerosis Risk in Communities (ARIC) study monitors prevalence and incidence of hospitalized ADHF in 4 communities. We describe here our first 5-year estimates of validated hospitalized acute decompensated HF events and case fatality (CF) by race, gender, and HF types. Methods The 4 ARIC study communities include Forsyth County, North Carolina; Jackson, Mississippi; Minneapolis, Minnesota; www.ajconline.org
Heart Failure/Incident Acute Heart Failure and Survival: ARIC
505
Table 1 Characteristics of the validated hospitalized ADHF cases: 2005 to 2009 Atherosclerosis Risk in Communities Study Heart Failure Community Surveillance Variable
Age (yrs) Women Caucasian Black men Black women White men White women Heart function assessed*,† LVEF before hospitalization (%)*,† LVEF during hospitalization (%)* HFrEF Previous diagnosis of HF Body mass index (kg/m2)* Obesity* Current smoker Hypertension Coronary heart disease Acute MI or unstable angina pectoris Atrial fibrillation or flutter Valvular heart disease Diabetes mellitus Stroke or transient ischemic attack Peripheral vascular disease Asthma or chronic obstructive pulmonary disease Sleep apnea Chronic kidney diseasez
All ADHF (n ¼ 3,695)
Incident ADHF (n ¼ 2,252)
Mean or %
95% CI
Mean or %
95% CI
75.6 53.6% 72.4% 15.2% 12.4% 38.4% 33.9% 90.1% 40.7 41.9 58.3% 70.1% 29.0 26.0% 14.2% 83.7% 67.5% 10.7% 35.8% 23.6% 46.6% 20.0% 13.9% 37.7% 9.1% 66.1%
75.2e75.9 52.2e55.1 71.2e73.5 14.3e16.2 11.7e13.2 37.0e39.9 32.6e35.3 88.9e91.2 39.9e41.6 41.1e42.7 56.4e60.2 68.4e71.8 28.6e29.4 24.4e27.6 13.0e15.5 82.2e85.1 65.8e69.1 9.6e12.0 34.1e37.6 22.1e25.2 44.8e48.4 18.5e21.5 12.7e15.2 35.9e39.5 8.1e10.2 64.3e67.8
75.9 55.3% 78.5% 12.2% 9.3% 43.1% 35.4% 88.8% 44.2 43.4 53.0% 53.2% 29.2 27.4% 14.8% 83.2% 63.1% 11.7% 31.9% 21.2% 42.7% 20.4% 13.2% 36.0% 8.6% 63.8%
75.5e76.4 53.3e57.3 77.0e80.0 11.0e13.4 8.4e10.3 41.1e45.2 33.5e37.4 87.1e90.2 43.1e45.4 42.5e44.3 50.5e55.5 50.8e55.6 28.8e29.7 25.4e29.6 13.2e16.6 81.2e85.0 60.8e65.3 10.3e13.4 29.7e34.2 19.3e23.2 40.3e45.1 18.5e22.5 11.7e14.9 33.8e38.4 7.4e10.1 61.5e66.0
The numbers and percentages listed in the table are weighted to account for sampling probabilities (6,168 unweighted sampled events resulting in 3,695 hospitalized ADHF events and 2,252 incident hospitalized ADHF events). Data were available for 100% of each characteristic except for those noted by “*.” The co-morbidities included in this table (such as hypertension and coronary heart disease) were historical diagnoses recorded in the medical record. History of previous HF diagnosis and co-morbidities were obtained from the current hospitalization. Imaging reports of LVEF within 2 years of the current hospitalization were abstracted. Obesity was defined as body mass index 30 kg/m2. MI ¼ myocardial infarction. * The percentage of all hospitalized ADHF and all incident ADHF, respectively, with available data for each of the following characteristics: heart function assessed: 90.1%, 88.8%; LVEF before hospitalization: 54.3%, 44.2%; LVEF during hospitalization: 59.9%, 64.9%; and body mass index and obesity: 73.1%, 74.0%. † Assessment of heart function (ventricular systolic and diastolic function) was documented in the medical records (historical reference) or in reports of cardiac imaging (echocardiography, cardiac catheterization, and nuclear or other cardiac imaging tests). If there was more than 1 assessment of LVEF, the lowest value was used. z Chronic kidney disease was defined as history of dialysis dependence and/or estimated glomerular filtration rate (using the Modification of Diet in Renal Disease method) of
