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Background Understanding the magnitude of cardiovascular disease (CVD) inequalities is the first step toward addressing them. The linkage of socioeconomic and clinical data in universal health care settings provides critical information to characterize CVD inequalities. Methods and Results We employed a prospective cohort design using electronic health records data from all residents of Catalonia aged 18+ between January and December of 2019 (N=6 332 228). We calculated age-adjusted sex-specific prevalence of 5 CVD risk factors (diabetes, hypertension, hyperlipidemia, obesity, and smoking), and 4 CVDs (coronary heart disease, cerebrovascular disease, atrial fibrillation, and heart failure). We categorized income into high, moderate, low, and very low according to individual income (tied to prescription copayments) and receipt of welfare support. We found large inequalities in CVD and CVD risk factors among men and women. CVD risk factors with the largest inequalities were diabetes, smoking, and obesity, with prevalence rates 2- or 3-fold higher for those with very low (versus high) income. CVDs with the largest inequalities were cerebrovascular disease and heart failure, with prevalence rates 2 to 4 times higher for men and women with very low (versus high) income. Inequalities varied by age, peaking at midlife (30-50 years) for most diseases, while decreasing gradually with age for smoking. Conclusions We found wide and heterogeneous inequalities by income in 5 CVD risk factors and 4 CVD. Our findings in a region with a high-quality public health care system and universal coverage stress that strong equity-promoting policies are necessary to reduce disparities in CVD.

Introduction and Objectives: Potassium derangements are frequent among patients with chronic cardiovascular conditions. Studies on the associations between potassium derangements and clinical outcomes have yielded mixed findings, and the implications for health care expenditure are unknown. We assessed the population-based associations between hyperkalemia, hypokalemia and clinical outcomes and health care costs, in patients with chronic heart failure, chronic kidney disease, diabetes mellitus, hypertension, and ischemic heart disease., Methods: Population-based, longitudinal study including up to 36 269 patients from a health care area with at least one of the above-mentioned conditions. We used administrative, hospital and primary care databases. Participants were followed up between 2015 and 2017, were aged ≥ 55 years and had at least 1 potassium measurement. Four analytic designs were used to evaluate prevalent and incident cases and the use of renin-angiotensin-aldosterone system inhibitors., Results: Hyperkalemia was twice as frequent as hypokalemia. On multivariable-adjusted analyses, hyperkalemia was robustly and significantly associated with an increased risk of all-cause death (HR from Cox regression models ranging from 1.31-1.68) and with an increased odds of a yearly health care expenditure >85th percentile (OR, 1.21-1.29). Associations were even stronger in hypokalemic patients (HR for all-cause death, 1.92-2.60; OR for health care expenditure> percentile 85th, 1.81-1.85)., Conclusions: Experimental studies are needed to confirm whether the prevention of potassium derangements reduces mortality and health care expenditure in these chronic conditions. Until then, our findings provide observational evidence on the potential importance of maintaining normal potassium levels., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: To evaluate the associations between individual income, all-cause mortality and use of healthcare resources in a very large population of chronic heart failure (CHF) patients living in Catalonia (Spain), where access to public healthcare is granted by law., Methods and Results: We used 2016 data from the Catalan Health Surveillance System, a large, exhaustive, administrative healthcare database which includes information on medical diagnoses, healthcare resource use, and individual income for all Catalan residents (N = 7,638,524). Individual annual income was categorized as high (>100,000€), medium (18,000-100,000€), low (<18,000€), and very low (welfare support). Among 155,883 CHF patients, lower individual income was associated with a shorter life expectancy at age 50 (life expectancy for high income patients 22.2 years, for very low income patients 12.8), and were independently associated with higher all-cause mortality adjusting for age, sex, comorbidities, and duration of the CHF diagnosis (odds ratio very low vs. medium income 1.21 [95% CI 1.11, 1.33]). Also, in patients with lower income levels the burden of public healthcare resource use was displaced towards urgent hospitalizations and frequent emergency department visits, as opposed to regular, specialized CHF ambulatory-based care., Conclusion: In a very large population of CHF patients with access to universal healthcare, lower income was independently associated with higher mortality and with lower use of ambulatory-based healthcare resources. Our findings suggest that CHF patients may benefit from systematic assessment of their socioeconomic status, as this may aid the identification of vulnerable subgroups who may benefit from tailored health education and management., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Epidemiological studies on heart failure (HF) using large health care databases are becoming increasingly frequent, as they represent an invaluable opportunity to characterize the importance and risk factors of HF from a population perspective. Nevertheless, because of its complex diagnosis and natural history, the heterogeneous use of the relevant terminology in routine clinical practice, and the limitations of some disease coding systems, HF can be a challenging condition to assess using large health care databases as the main source of information. In this narrative review, we discuss some of the challenges that researchers may face, with a special focus on the identification and validation of chronic HF cases and acute HF decompensations. For each of these challenges, we present some potential solutions inspired by the literature and/or based on our research experience, aimed at increasing the internal validity of research and at informing its interpretation. We also discuss future directions on the field, presenting constructive recommendations aimed at facilitating the conduct of valid epidemiological studies on HF in the coming years., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction and Objectives: Heart failure (HF) is associated with a high rate of readmissions within 30 days postdischarge. Strategies to lower readmission rates generally show modest results. To reduce readmission rates, we developed a STructured multidisciplinary outpatient clinic for Old and frail Postdischarge patients hospitalized for HF (STOP-HF-Clinic)., Methods: This prospective all-comers study enrolled patients discharged from internal medicine or geriatric wards after HF hospitalization. The intervention involved a face-to-face early visit (within 7 days), HF nurse education, treatment titration, and intravenous medication when needed. Thirty-day readmission risk was calculated using the CORE-HF risk score. We also studied the impact of 30-day readmission burden on regional health care by comparing the readmission rate in the STOP-HF-Clinic Referral Area (∼250000 people) with that of the rest of the Catalan Health Service (CatSalut) (∼7.5 million people) during the pre-STOP-HF-Clinic (2012-2013) and post-STOP-HF-Clinic (2014-2015) time periods., Results: From February 2014 to June 2016, 518 consecutive patients were included (age, 82 years; Barthel score, 70; Charlson index, 5.6, CORE-HF 30-day readmission risk, 26.5%). The observed all-cause 30-day readmission rate was 13.9% (47.5% relative risk reduction) and the observed HF-related 30-day readmission rate was 7.5%. The CatSalut registry included 65131 index HF admissions, with 9267 all-cause and 6686 HF-related 30-day readmissions. The 30-day readmission rate was significantly reduced in the STOP-HF-Clinic Referral Area in 2014-2015 compared with 2012-2013 (P < .001), mainly driven by fewer HF-related readmissions., Conclusions: The STOP-HF-Clinic, an approach that could be promptly implemented elsewhere, is a valuable intervention for reducing the global burden of early readmissions among elder and vulnerable patients with HF., (Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Heart failure (HF) is frequent and its prevalence is increasing. We aimed to evaluate the epidemiologic features of HF patients, the 1-year follow-up outcomes and the independent predictors of those outcomes at a population level., Methods and Results: Population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on December 31st, 2012. Patients were divided in 3 groups: patients without a previous HF hospitalization, patients with a remote (>1 year) HF hospitalization and patients with a recent (<1 year) HF admission. We analyzed 1year all-cause and HF hospitalizations, and all-cause mortality. Logistic regression was used to identify the independent predictors of each of those outcomes. A total of 88,195 patients were included. Mean age was 77 years, 55% were women. Comorbidities were frequent. Fourteen percent of patients had never been hospitalized, 71% had a remote HF hospitalization and 15% a recent hospitalization. At 1-year follow-up, all-cause and HF hospitalization were 53% and 8.8%, respectively. One-year all-cause mortality rate was 14%, and was higher in patients with a recent HF hospitalization (24%). The presence of diabetes mellitus, atrial fibrillation or chronic kidney disease was independently associated with all-cause and HF hospitalization and all-cause mortality. Hospital admissions and emergency department visits the previous year were also found to be independently associated with the three study outcomes., Conclusions: Outcomes are different depending on the HF population studied. Some comorbidity, an all-cause hospitalization or emergency department visit the previous year were associated with a worse outcome.

Aims: Heart failure (HF) is one of the diseases with greater healthcare expenditure. However, little is known about the cost of HF at a population level. Hence, our aim was to study the population-level distribution and predictors of healthcare expenditure in patients with HF., Methods and Results: This was a population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on 31 December 2012 (n = 88 195). We evaluated 1-year healthcare resource use and expenditure using the Health Department (CatSalut) surveillance system that collects detailed information on healthcare usage for the entire population. Mean age was 77.4 (12) years; 55% were women. One-year mortality rate was 14%. All-cause emergency department visits and unplanned hospitalizations were required at least once in 53.4% and 30.8% of patients, respectively. During 2013, a total of €536.2 million were spent in the care of HF patients (7.1% of the total healthcare budget). The main source of expenditure was hospitalization (39% of the total) whereas outpatient care represented 20% of the total expenditure. In the general population, outpatient care and hospitalization were the main expenses. In multivariate analysis, younger age, higher presence of co-morbidities, and a recent HF or all-cause hospitalization were independently associated with higher healthcare expenditure., Conclusions: In Catalonia, a large portion of the annual healthcare budget is devoted to HF patients. Unplanned hospitalization represents the main source of healthcare-related expenditure. The knowledge of how expenditure is distributed in a non-selected HF population might allow health providers to plan the distribution of resources in patients with HF., (© 2016 The Authors. European Journal of Heart Failure © 2016 European Society of Cardiology.)

Introduction and Objectives: The efficacy of heart failure programs has been demonstrated in clinical trials but their applicability in the real world practice setting is more controversial. This study evaluates the feasibility and efficacy of an integrated hospital-primary care program for the management of patients with heart failure in an integrated health area covering a population of 309,345., Methods: For the analysis, we included all patients consecutively admitted with heart failure as the principal diagnosis who had been discharged alive from all of the hospitals in Catalonia, Spain, from 2005 to 2011, the period when the program was implemented, and compared mortality and readmissions among patients exposed to the program with the rates in the patients of all the remaining integrated health areas of the Servei Català de la Salut (Catalan Health Service)., Results: We included 56,742 patients in the study. There were 181,204 hospital admissions and 30,712 deaths during the study period. In the adjusted analyses, when compared to the 54,659 patients from the other health areas, the 2083 patients exposed to the program had a lower risk of death (hazard ratio=0.92 [95% confidence interval, 0.86-0.97]; P=.005), a lower risk of clinically-related readmission (hazard ratio=0.71 [95% confidence interval, 0.66-0.76]; P<.001), and a lower risk of readmission for heart failure (hazard ratio=0.86 [95% confidence interval, 0.80-0.94]; P<.001). The positive impact on the morbidity and mortality rates was more marked once the program had become well established., Conclusions: The implementation of multidisciplinary heart failure management programs that integrate the hospital and the community is feasible and is associated with a significant reduction in patient morbidity and mortality., (Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Background and Objective: The N-terminal brain natriuretic peptide (NT-proBNP) is a new tool for the diagnosis of patients with evidence of heart failure (HF). The diagnosis of HF is improbable in patients with a level of NT-proBNP<300 pg/ml. Our objective is to determine the validity of the cut-off points proposed by literature (inclusion/exclusion) regarding the age for NT-proBNP in patients admitted to our service., Patients and Method: We gathered consecutively the data of 76 patients admitted to our service with the diagnosis of HF (n=37) and with other diseases (n=39), taking a sample of plasma to determine NT-proBNP. We studied the sensitivity, specificity and predictive values of this test, as well as the relation between the levels of that marker and the clinical and echocardiographic variables., Results: The ventricular diameter was larger and the ejection fraction was lower in patients with HF. Sensitivity for the diagnosis of exclusion reached a value of 97% and the negative predictive value was 94%., Conclusions: The cut-off point proposed for exclusion (300 pg/ml) shows high sensitivity and negative predictive value in the diagnosis of HF in patients admitted to our service.