An Update on Heart Failure: World-Wide Burden, Rural Versus Urban Adults, Ethnic Disparities, and Remote Monitoring

Heart failure is highly prevalent, complex, multifactorial syndrome with high morbidity and mortality rates.¹ There have been and continue to be advances in medical therapy and device assistance which have dramatically improved heart failure outcomes.² This blog is written to provide the reader with up-to-date information on heart failure across the world, related mortality in rural versus urban adults, ethnic disparities in US outcomes, and potential innovations of heart failure care. 

World-Wide Burden

In a systematic analysis of 195 countries and territories from 1990 to 2017, the investigators collected detailed information on the prevalence, disability years, and underlying causes of heart failure.³  The age-standardized prevalence rates and years lived with disability from heart failure were 831.0 and 128.2/100,000 people, a decrease of -7.2% and -0.9% from 1990.  The absolute numbers, however, increased by 91.9% and 106.0% respectively, over the same time period.  Ischemic heart disease accounted for 26.5% of age-standardized prevalence rate of HF in 2017, followed by hypertensive heart disease (26.2%), and chronic obstructive pulmonary disease (23.4%).  Heart failure continues to grow in numbers across the globe, especially in countries with a low socio-demographic index.   

Rural versus Urban HF in Adults

Investigators queried the U.S. Centers for Disease Control and Prevention Wide Ranging Online Data for Epidemiologic Research Multiple Causes of Death Online Database (CDC WONDER) for heart failure deaths between 2011-18.⁴ There were 162,314 and 580,305 heart failure-related deaths in rural and urban counties.  Age-adjusted mortality rates (AAMR) were consistently higher for rural compared with urban counties (73.2 [95% CI: 72.2-74.2] vs. 57.2 [95% CI: 56.8-57.6]) in 2018.  The highest AAMR was observed in black men with the greatest increases in heart failure-related mortality in those 35-64 years old.  The need for increased efforts to reduce rural heart failure-related deaths will require a national public health intervention, including pharmacists. 

Ethnic Disparities in Heart Failure Outcomes

A study from Kaiser Permanente Northern California health care system, examined >4.5 million members across 21 hospitals from 2012 to 2016, for hospitalizations and clinical outcomes.⁵ The mean age of the cohort was 74.3±12.3 years with 54.1% men.  The largest majority (59.3%) had heart failure with preserved ejection fraction (HFpEF), 23.2% had heart failure with reduced ejection fraction (HFrEF), and 17.5% had heart failure with midrange ejection fraction (HfmrEF). Most of the members were Caucasian (66.1%), 11.9% were Hispanic, 11.5% were Asian or Pacific Islander, and 10.5% were Black.  Black patients had the highest rate of heart failure hospitalization, whereas Asian and Pacific Islanders was less frequent.  Black versus Caucasian with HFrEF were more likely to be hospitalized. Heart failure mortality was highest among white patients (12.4%/100 patients). A similar pattern was observed for HfpEF.  There continues to be a need to increasingly understand the ethnic disparities in heart failure outcomes.

Home-Based Heart Failure Care

Heart failure care is increasingly moving towards various forms of telehealth or televisits for patients.  The biggest advantage is convenience of these visits and patients reflect their satisfaction with these visits.⁶ There are fewer no-shows with virtual visits, enhanced security of PHI, and patients are more likely to have difficult conversations with their clinicians.  However, challenges exist.  These include access to smart phones, computers or the internet, willingness to try something new, difficulty for the hearing impaired, and lack of being able to conduct a physical examination.  Nonetheless, these visits are here to stay.  Remote patient monitoring including information from heart monitors, cardiovertor-defibrillators, and cardiac resynchronization devices providing heart rhythm and other information are now commonplace.  The pandemic has allowed these technologies to grow in popularity.  Using the virtual platform for optimizing medication management should be a focus of pharmacists.

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.

Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of the Population Health Learning Network or HMP Global, their employees, and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, or anyone or anything. 

References

1. Ziaeian B, Fonarow GC.  Epideminiology and aetiology of heart failure. Nat Rev Cardiol 2016;13:368-78.
2. Maddox TM, Januzzi JL Jr, Allen LA, et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021;11:[Epub ahead of print]. https://pubmed.ncbi.nlm.nih.gov/33446410/
3. Bragazzi NL, Zhong W, Shu J, Much AA, Lotan D, Grupper A, Younis A, Dai H. Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017. Eur J Prev Cardiol 2021;doi: 10.1093/eurjpc/zwas147.
4. Pierce JB, Shah NS, Petito JC, Pool L, Lloyd-Jones DM, Feinglass J, Khan SS. Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011-2018: A cross-sectional study. PloS ONE; 2021;16(3):e0246813. Doi.org/10.1371/journal.pone.0246813
5. Savitz ST, Leong T, Sung SH, et al. Contemporary Reevaluation of race and ethnicity with outcomes in heart failure. J Am Heart Assoc 2021;10(3):e016601.doi:10.1161/JAHA.120.016601.
6. Innovations Countdown: Home-based Heart Failure Care. https://hfsa.org/innovations-countdown-home-based-heart-failue-hf-care