Outcomes of heart failure: gaps in knowledge and needs for action

Heart failure is a substantial health concern, affecting 64 million people globally.1Savarese G Becher PM Lund LH Seferovic P Rosano GMC Coats AJS Global burden of heart failure: a comprehensive and updated review of epidemiology.Cardiovasc Res. 2023; 118: 3272-3287Crossref PubMed Scopus (360) Google Scholar In China, it is estimated that the number of patients with heart failure has reached 8·9 million.2National Center for Cardiovascular DiseasesChina cardiovascular health and disease report 2021. Science Publishing House, Beijing2022Google Scholar Furthermore, the burden of heart failure is expected to increase as a result of the rapidly ageing population and the growing prevalence of cardiometabolic disorders. Therefore, it is crucial to have a comprehensive understanding of the health outcomes of heart failure and the factors that influence them. In The Lancet Global Health, Hua Wang and colleagues3Wang H Li Y Chai K et al.Mortality in patients admitted to hospital with heart failure in China: a nationwide Cardiovascular Association Database-Heart Failure Centre Registry cohort study.Lancet Glob Health. 2024; 12: e611-e622Google Scholar have reported on the short-term and long-term mortality of patients hospitalised for heart failure in China from 2017 to 2021, using data from a nationwide registry study. All-cause mortality was 2·4% (95% CI 2·3–2·5) at 30 days, 13·7% (13·5–13·9) at 1 year, and 28·2% (27·7–28·6) at 3 years after discharge. Most of these deaths were attributed to cardiovascular disease and decrease in ejection fraction was associated with an increased mortality risk. The evidence that guideline-directed medical therapy reduced overall and cardiovascular mortality emphasises the importance of monitoring and improving the quality of heart failure management at a national level. Wang and colleagues’ study3Wang H Li Y Chai K et al.Mortality in patients admitted to hospital with heart failure in China: a nationwide Cardiovascular Association Database-Heart Failure Centre Registry cohort study.Lancet Glob Health. 2024; 12: e611-e622Google Scholar is remarkable for its large scale (more than 0·23 million patients enrolled) and extensive coverage (572 hospitals in 31 provinces included). More importantly, its findings could be a step towards improving clinical practice and research in China by highlighting what needs to be known and what should be done for management of patients with heart failure. In terms of clinical practice, the in-hospital mortality in this study was consistent with previous findings and the national medical quality report,2National Center for Cardiovascular DiseasesChina cardiovascular health and disease report 2021. Science Publishing House, Beijing2022Google Scholar which was lower than that in the USA,4Clark KAA Reinhardt SW Chouairi F et al.Trends in heart failure hospitalizations in the US from 2008 to 2018.J Card Fail. 2022; 28: 171-180Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar but the post-discharge mortality was relatively high. Two gaps in heart failure care warrant attention. On the one hand, Wang and colleagues’ study3Wang H Li Y Chai K et al.Mortality in patients admitted to hospital with heart failure in China: a nationwide Cardiovascular Association Database-Heart Failure Centre Registry cohort study.Lancet Glob Health. 2024; 12: e611-e622Google Scholar identified an independent association between a low adherence score to the guidelines and a high mortality risk among patients. Underuse of evidence-based diagnostic tests and low prescription rates of guideline-recommended medications in previous studies were also noteworthy.5Gupta A Yu Y Tan Q et al.Quality of care for patients hospitalized for heart failure in China.JAMA Netw Open. 2020; 3e1918619Crossref Scopus (12) Google Scholar On the other hand, despite the emergence of novel drugs and milestone research evidence in recent years, this study observed 1-year mortality rates of 13·6% (95% CI 12·7–14·6) in 2017, 13·8% (13·4–14·1) in 2018, 13·8% (13·6–14·1) in 2019, and 13·9% (13·3–13·8) in 2020, with no improvement. This observation is not rare or isolated. A national representative study on ST-segment elevation myocardial infarction also found that in-hospital mortality showed no reduction from 2001 to 2015, after comprehensive adjustment for demographic and clinical factors.6Li J Li X Wang Q et al.ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE-Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital data.Lancet. 2015; 385: 441-451Summary Full Text Full Text PDF PubMed Scopus (353) Google Scholar, 7Zhou T Li X Lu Y et al.Changes in ST segment elevation myocardial infarction hospitalisations in China from 2011 to 2015.Open Heart. 2021; 8e001666Crossref Scopus (5) Google Scholar This lack of improvement implies that currently in China, making good use of available care is a more urgent and practical strategy than seeking new treatment options. For policy makers, a strong emphasis on implementation science is crucial for guiding health-care system design and developing strategies to ensure that evidence is effectively translated into daily clinical care. In terms of clinical research, a passive follow-up pattern based on the National Mortality Registration Information Management System is a major methodological feature of Wang and colleagues’ study. This approach laid the foundation for collecting post-discharge outcome data from a cohort more than 15 times larger than that in previous registry studies of patients with heart failure in China.8Hu D Liu J Zhang L et al.Health status predicts short- and long-term risk of composite clinical outcomes in acute heart failure.JACC Heart Fail. 2021; 9: 861-873Crossref PubMed Scopus (0) Google Scholar, 9Zhang Y Zhang J Butler J et al.Contemporary epidemiology, management, and outcomes of patients hospitalized for heart failure in China: results from the China Heart Failure (China-HF) Registry.J Card Fail. 2017; 23: 868-875Summary Full Text Full Text PDF PubMed Google Scholar More data linkages and exchanges with administrative claims databases are needed to ideally establish a national data system covering the entire health-care system, the total population, and the whole lifecycle. This system could facilitate and enhance clinical research. It is undoubtedly a rational choice to use mortality to represent the outcomes of heart failure, as in this and previous studies, because heart failure is considered an end-stage condition of several cardiovascular diseases. Nevertheless, heart failure can lead to outcomes other than death. For instance, unplanned readmission is an important outcome measure because it is associated with both suboptimal prognosis and wastage of resources. In the USA, data from the national heart failure registry were linked to Medicare data for longitudinal follow-up, including readmission and mortality.10Shah KS Xu H Matsouaka RA et al.Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes.J Am Coll Cardiol. 2017; 70: 2476-2486Crossref PubMed Scopus (614) Google Scholar However, in China the data from social medical insurance, which covers 95% of the population, have rarely been used for research purposes. The Hospital Quality Monitoring System (HQMS), established to monitor the quality of inpatient care nationwide, could offer a new solution. This system has collected data on patient characteristics, diagnoses, treatment procedures, in-hospital outcomes, and medical costs from each inpatient medical record. Even though in around 30% of tertiary hospitals and 60% of secondary hospitals HQMS has not been implemented, its coverage has been gradually growing. Meanwhile, researchers should be open to embracing new models and preparing for new resources. There is substantial room for improvement in the outcomes for patients with heart failure and other major diseases in China. Therefore, joint efforts including smart research and purposeful actions are urgently needed. We declare no competing interests. Mortality in patients admitted to hospital with heart failure in China: a nationwide Cardiovascular Association Database-Heart Failure Centre Registry cohort studyIn China, mortality for patients with heart failure is still high, especially in patients with reduced ejection fraction. Our findings suggest that guideline-directed medical therapy needs to be improved. Full-Text PDF Open Access