Heart failure (HF) is a chronic, progressive condition in which patients suffer from typical signs and symptoms such as dyspnea and edema due to cardiac dysfunction. Since many of these symptoms are non-specific, the final diagnosis can only be made by echocardiography.1 The diagnosis is most frequently made during an initial hospital admission for shortness of breath. After institution of guideline-based treatments, the patient usually has a quasi-normalization of functional status. He is then treated and monitored on an outpatient basis. A typical marker for the severity of the disease is the need for rehospitalization. Unfortunately, hospital readmissions are a common occurrence in patients with heart failure.2
Further disease progression usually leads to recurrent heart failure-related hospital admissions and progressively deteriorating functional status and quality of life. If these admissions become frequent (more than 2 per year), with persistent congestion and refractory symptoms, there may be advanced heart failure (also called end-stage or terminal heart failure).3 At this stage, there is a very limited prognosis, with survival of 70% at 6 months but only 8% at 2 years in randomized studies.4, 5
The general prognosis of a patient with heart failure, including the risk of sudden death, is difficult to estimate and depends on many variables.1, 6 However, the impact of mortality from heart failure in the general population is underestimated and is comparable to some of the most frequently diagnosed cancers (see Figure 1).7 It is sometimes argued that heart failure mainly affects older people, and that age is the driving factor for the limited prognosis. However, for every age category there is a clearly worse prognosis compared to people without heart failure.8
Heart failure is considered a universal pandemic that impacts at least 26 million people annually. Although there is believed to be a stable incidence of the disease, its prevalence will increase in the coming years due to a combination of life-prolonging treatments for heart failure and the aging of the population.9 It is currently estimated that 1 to 2% of the total health budget is spent on direct costs of heart failure.10 The global impact of heart failure is estimated at more than 64 million diagnoses per year, with a total healthcare cost of approximately US$108 trillion, mainly due to direct costs in high-income countries.11,12 In Belgium, the incidence of heart failure is estimated at 2.6 to 2.7 per 1000 patient years.13 Unfortunately, no high-quality hospital data are available from Europe, but in the United States heart failure is one of the most important indications for hospital admissions, and the most frequent indication for rehospitalization within 30 days (a widely used parameter in medical and social sciences for quality of care and/or severity of illness).14 Not in the least because hospital admissions lead to both morbidity and mortality and are responsible for more than 50% of direct costs, heart failure has become a target for healthcare policy changes to avoid premature readmissions – albeit with disappointing results.12, 15, 16, 17, 18 ,19 It is estimated that in the United States, both prevalence (46%) and direct costs (127%) for heart failure will increase by the year 2030.20
Indirect costs, such as impact on quality of life, loss of income due to inability to work due to heart failure and psychosocial impact associated with chronic illness, will be significant but even more difficult to quantify than the direct costs.
As mentioned earlier, the incidence of heart failure in the population will increase partly due to life-prolonging therapeutic interventions. There is indeed a decreasing trend in mortality, risk of sudden death and hospitalization reported in the randomized studies.21 However, the decrease in relative risk must be seen in perspective of the substantial residual risk in the intervention groups. Despite current treatments, patients with heart failure still have a risk of disease progression, hospitalizations and death. This is the residual risk, which varies between different heart failure phenotypes (Figure 2 & Table 1).
Overall, the residual risks of mortality and heart failure are greater in patients with HFrEF (heart failure with reduced ejection fraction, LVEF < 40%) than patients with a higher ejection fraction (> 40% for the studies marked 'HFpEF' in the figure – NB: a normal LVEF is >50%). In studies that specifically included patients with a high risk of recurrent heart failure after initial admission, the so-called 'transition patients', there remains a very high residual risk of both mortality and rehospitalization.
Integrated care for the multimorbid complex patient becomes the challenge, not progress in one specific domain. Costs of individual interventions (medication or devices) will only prove to be more cost-efficient if they succeed in keeping the patient out of the hospital for longer, because as mentioned, admissions are responsible for more than half of the direct total costs of heart failure care.12 Indirectly, the number of days spent outside the hospital is also a parameter for quality of life for patients with chronic heart failure. The costs of any new therapeutic interventions, rather than increased survival, will therefore drive the costs of heart failure care in the future.
