Au. Khand et al., Clinical events leading to the progression of heart failure: insights froma national database of hospital discharges, EUR HEART J, 22(2), 2001, pp. 153-164
Aims To describe the sequence of clinically apparent events causing readmis
sion and antedating death, subsequent to a first-time hospital admission fo
r heart failure, in order to give insights into the natural history and mec
hanisms of progression of heart failure.
Methods A national database of linked hospital discharge and mortality data
for Scotland (population 5.1 million) was used. Patients with a first-time
admission to hospital with heart failure in 1992 (index population) were i
dentified and, using a record linkage system, hospital readmissions and the
ir cause according to the hospital physician and deaths were recorded over
the subsequent 3 years. A flowchart showing the sequence of events leading
to death or recurrent admission was constructed.
Results 12 640 patients had first-time admissions with heart failure in 199
2; their mean age was 74 years and 46.2% were men. A cohort of 2922 (23%) p
atients died on their first admission. Among the remaining 9718 patients th
ere were 22 747 readmissions and 4877 deaths over the subsequent 3 years; o
nly 15% had neither event reported. Nine per cent of patients died without
any readmission and a further 6% without a further readmission for cardiova
scular reasons. A cohort of 5992 (61% of patients at risk) had at least one
cardiovascular readmission and half of these had occurred within 6 months.
Heart failure without a report of any cardiovascular precipitating event w
as responsible for 37% (2188 patients) of first cardiovascular readmissions
and of these patients approximately 12% had evidence of renal failure or a
cute respiratory infection as possible triggers for readmission. Acute isch
aemic events including myocardial infarction (19%), myocardial infarction a
lone (8%) and atrial fibrillation (11%) were associated with a substantial
number of first readmissions. First readmission precipitated by acute myoca
rdial infarction was associated with a particularly poor prognosis (40% inp
atient mortality).
Conclusions Recurrent ischaemic events and atrial fibrillation may be the p
redominant mechanisms leading to exacerbation of and progression of heart f
ailure and death. A substantial proportion of readmissions appear related t
o heart failure alone. Whether this reflects progressive ventricular remode
lling leading to worsening heart failure or other unidentified mechanisms c
annot be discerned from this data. (C) 2001 The European Society of Cardiol
ogy.