Patterns Of Recurrent Heart Failure Hospitalizations In Relation To Cardiovascular Death In Heart Failure With Reduced Ejection Fraction.

The accepted understanding of the patient journey in heart failure (HF) is one of recurrent episodes of deterioration which accelerate in frequency as the patient approaches death. However, this may not be true when different modes of death are considered separately. We explored patterns of HF hospitalizations (HFH) in patients who died from either sudden death or death due to progressively worsening heart failure ("pump failure") in a contemporary cohort of patients with HFrEF. We examined timing of HF hospitalizations in the PARADIGM-HF and ATMOSPHERE trials. Inclusion and exclusion for these trials were similar; NYHA class II-IV, LVEF≤35% (PARADIGM-HF LVEF≤40% reduced to ≤35% by amendment) and elevated natriuretic peptide levels. In PARADIGM-HF, patients were randomized to sacubitril-valsartan or enalapril, in ATMOSPHERE treatments were enalapril, aliskiren or both. The number of hospitalizations per patient was calculated and cross tabulated with cause of CV death. Rates of total HFH were calculated according to different causes of CV death. HFH were visualized using recurrent event plots. Of the 15415 patients enrolled, 2518 had at least 1 hospitalization after randomization and between them these 2518 participants accrued a total of 4318 admissions. There were 2872 CV deaths which accounted for 83% of all deaths. Of the 2872 CV deaths 1332 (46%) occurred suddenly and 735 (26%) were due to worsening heart failure. Of patients experiencing sudden death, only 205 (15%) had a preceding hospitalization compared with 569 (77%) patients dying from pump failure. Rates of HFH per 100 patient years were 17 [95% CI 15-19] in patients with sudden death, 93 [95% CI 88-98]) in the pump failure death group and 7 [95% CI 6-7] in patients without CV death. Recurrent event plots show a greater density of HFH in patients with pump failure deaths as compared with other CV deaths. This analysis shows that the accepted patient trajectory in HFrEF is true for individuals who die from progressive worsening of heart failure but not for sudden death where only a minority of patients experience preceding HFH. [ABSTRACT FROM AUTHOR]