We need greater investment in heart failure services with improved GP access to diagnostics such as natriuretic peptide testing, rapid referral pathways for echocardiography, and specialist assessment and early treatment initiation, according to primary care researchers from the University of Oxford. Their large study,* published today in The BMJ, found that survival in the UK after a diagnosis of heart failure has shown only modest improvement in the 21st century and lags behind other serious conditions, such as cancer. They also called for more primary care-led research to improve understanding of the complexity of heart failure diagnosis and management in the community, and to develop and test new strategies to achieve better outcomes for patients.
The team analysed data from the Clinical Practice Research Datalink (CPRD), linked to inpatient Hospital Episode Statistics and Office for National Statistics mortality data, for the period from 1 January 2000 to 31 December 2017. These data covered 55,959 patients aged 45 and over with a new diagnosis of heart failure, and 278,679 age- and sex-matched controls.
They reported that overall one-year survival improved by just 6.6 percentage points over time for people with a new diagnosis of heart failure, from 74.2% in 2000 to 80.8% in 2016. Five-year survival improved by 7.2 percentage points, from 41.0% in 2000 to 48.2% in 2012. And ten-year survival improved by 6.4 percentage points, from 19.8% in 2000 to 26.2% in 2007. All trends remained when survival rates were standardised by age and sex, and across age groups. Of the 30,906 deaths in the heart failure group over the study period, heart failure was listed on the death certificate in 13,093 (42.4%) patients, and in 2,237 (7.2%) it was the primary cause of death.
The study authors noted that improvement in survival was significantly greater for patients not requiring admission to hospital around the time of diagnosis (median difference 2.4 years; 5.3 v 2.9 years). They also found that there was a statistically significant deprivation gap in median survival, of 2.4 years, between people who were least deprived and those who were most deprived (11.1 v 8.7 years).
They acknowledged that as theirs was an observational study it cannot establish cause, and it was also limited in being unable to identify type of heart failure, as well as by possible misclassification. But they commented: “Survival after a diagnosis of heart failure has shown only modest improvement in the 21st century and lags behind other serious conditions, such as cancer.”
They concluded: “The lack of substantial progress in improving heart failure survival rates should alert policy makers to the need for further investment in heart failure services. Improved general practitioners access to diagnostics such as natriuretic peptide testing, rapid referral pathways (such as the “two-week wait cancer” pathways) for echocardiography, and specialist assessment and early treatment initiation might be areas for improvement. Primary care led research is also needed to understand the complexity of heart failure diagnosis and management in the community, and to develop and test new strategies to achieve better outcomes for patients.”
* Taylor CJ, Ordóñez-Mena JM, Roalfe AK, et al. Trends in survival after a diagnosis of heart failure in the United Kingdom 2000-2017: population based cohort study. BMJ 2019; 364: l223 DOI: 10.1136/bmj.l223