EVOLUTION HF Data Paint Bleak Picture of GDMT Following First HF Hospitalization


The study investigated event rates for several outcomes in the year following a first hospitalization for heart failure (HF), including implementation of guideline-directed medical therapy (GDMT).

Risk management and cost reduction following a first hospitalization for heart failure (hHF) should be top priorities among the clinicians caring for this patient population, with a new analysis of EVOLUTION HF data showing lack of change in guideline-directed medical therapy (GDMT) and persistent high medical costs and rehospitalization risks in the ensuing 12 months.

“There are few contemporary data on outcomes, costs, and treatment following an hHF in epidemiologically representative cohorts,” the authors wrote in JACC Heart Failure. “EVOLUTION HF is a multinational, observational study that provides insights into the management of patients after discharge from an hHF.”

Electronic health records (EHRs) from Japan, Sweden, the United Kingdom, and the United States provided the data for this analysis. Japan had the most patients in the study (n = 87,787), followed by the United States (n = 73,763), the United Kingdom (n = 64,635), and Sweden (n = 37,340). Each country also had 2 patient cohorts: clinical outcomes and hospital health care costs for 2018 to 2020 (cohort 1) and HF medicine use (renin-angiotensin system inhibitors, sacubitril/valsartan, β-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors) after hHF discharge for the second quarter of 2020 through 2023 (cohort 2). For cohort 1, there were HF was defined using International Classification of Diseases, Tenth Revision diagnosis codes I50, I11.0, I13.0, and I13.2.

At baseline, the top patient comorbidities were ischemic heart disease in Japan (46%) and the United States (47%) and atrial fibrillation in Sweden (47%) and the United Kingdom (46%). The most common medications were loop diuretics in Japan (37%), β-blockers in Sweden (58%) and the United States (52%), and renin-angiotensin system inhibitors in the United Kingdom (49%).

Overall, there were 28 deaths per 100 patient-years in this study’s 12-month follow-up. In addition, 14 patients reported a second HF event; 5, chronic kidney disease (CKD); 3, a stroke; 2, myocardial infarction (MI, or heart attack); and 1, peripheral artery disease. The use of HF medications was highest in Sweden, at 11.3%, followed by 7.1% in Japan and 1.5% each in the United Kingdom and United States.

All-cause rehospitalization was the most frequent event seen during the 12-month follow-up, at 96.8 events per 100 patient-years—with the United Kingdom having the most, at 106.0—and rehospitalization for CKD was the least frequent, at 4.5 events per 100 patient-years. All-cause mortality data were available only for Sweden and the United Kingdom, at 29.2 and 27.7 deaths per 100 patient-years, respectively. Of these deaths, 13.8 and 18.6, respectively, had cardiovascular causes and patients tended to be older (≥70 years) vs younger (<70 years).

Hospital health care costs varied among the 4 countries during the follow-up period, but data trends show that cardiorenal event (HF, CKD)–related expenses outpaced those for atherosclerotic events (MI, stroke) in all countries in the year following an hHF.

For HF medication use, incorporating 2 or more concurrent treatments ranged from 40% to 80% in the first 3 months after an hHF, but the overall increase was “slight,” according to the authors, over the entire 12 months of follow-up. However, although the overall use of 3 or more concurrent HF medications was lower, ranging from 10% to 30%, the increase from the first to the last quarter of the follow-up was “notable,” per the authors.

GDMT findings were dismal, with results showing that concurrent use of 4 GDMTs remained low across the board. By 3 months after first hHF, the rates were 21% in Sweden, 10% in Japan, 3% in the United States, and 2% in the United Kingdom.

“In patients following a first hHF, postdischarge rates for rehospitalization and death were high. Rehospitalization rates and hospital health care costs were mainly driven by HF and CKD, highlighting the unmet need and causes of the related high health care burden,” the study authors concluded. “Optimized GDMT use may reduce risks and costs during the vulnerable post-hHF period and improve patient outcomes.”


Bozkurt B, Savarese G, Eryd SA, et al. Mortality, outcomes, costs, and use of medicines following a first heart failure hospitalization: EVOLUTION HF. JACC Heart Fail. Published online June 8, 2023. doi:10.1016/j.jchf.2023.04.017

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