Heartbeat: reducing inequities in cardiovascular disease mortality FREE Catherine M Otto Author affiliations View Full Text http://sci-hub.tw/10.1136/heartjnl-2019-316324 Statistics from Altmetric.com See more details Tweeted by 1 Request Permissions Cardiovascular disease (CVD) remains a leading cause of death in Europe with persistent geographic and socioeconomic inequities even though overall CVD mortality has declined substantially over the past 30 years. In a prospective registry-based study of CVD mortality from the 1990s to early 2010s in 12 European populations, Girolamo and colleagues1 observed similar and rapid declines in absolute CVD mortality in both high and low socioeconomic groups. However, relative declines were faster among higher socioeconomic groups so that relative differences in CVD mortality have not been eliminated when considering gender, educational level, occupational class or geographic location (figure 1). Total cardiovascular disease age-standardised mortality rates (ASMR) and 95% CI among low and high educated, by population and gender, 35–79 years, 2010–2014. " data-icon-position="" data-hide-link-title="0" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; color: rgb(42, 110, 187); box-shadow: none; border: 0px;"> Download figure Open in new tab Download powerpoint Figure 1 Total cardiovascular disease age-standardised mortality rates (ASMR) and 95% CI among low and high educated, by population and gender, 35–79 years, 2010–2014. In the accompanying editorial, Leyland and Dundas2 discuss the value of considering both absolute and relative inequities in seeking to improve outcomes across the socioeconomic spectrum. In our efforts to reduce inequities in medical care and clinical outcomes, we should ponder their recommendations: ‘An effective and fair health system will be responsive to the needs of its population regardless of social circumstances; perhaps the greatest opportunity for medical care to reduce inequalities is if more disadvantaged groups are encouraged to seek healthcare earlier in the progress of the disease. The greatest opportunity to reduce inequalities, however, must be through the modification of lifestyle risk factors including smoking, alcohol consumption, diet and physical activity. These can bring about rapid change, show strong social patterning and are amenable to population-wide intervention such as through policy.’ Advances in diagnosis and treatment of acute myocardial infarction (AMI) have primarily been evaluated in terms of ‘hard endpoints’ including mortality and major adverse event rates. The patient experience has received less consideration with limited data on health-related quality of life (HRQoL) and long-term changes (or trajectories) in HRQoL after AMI. In a study of 9655 survivors of AMI between 2011 and 2015, Munyombwe and colleagues3 found that patients with no improvement (22%) or a decline (10%) in HRQoL after AMI, compared with those with improved HRQoL (68%) were more likely to be women with an non-ST elevation myocardial infarction and have additional long-term health issues (figure 2). The authors suggest that targeted interventions are needed to improve HRQoL in these patients.
Format: Abstract Send to Eur J Heart Fail. 2019 Dec 17. doi: 10.1002/ejhf.1682. [Epub ahead of print] Relationship between heart rate and outcomes in patients in sinus rhythm or atrial fibrillation with heart failure and reduced ejection fraction. Docherty KF1, Shen L1, Castagno D2, Petrie MC1, Abraham WT3, Böhm M4, Desai AS5, Dickstein K6, Køber LV7, Packer M8, Rouleau JL9, Solomon SD5, Swedberg K10, Vazir A11, Zile MR12, Jhund PS1, McMurray JJV1. Author information 1 BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK. 2 Division of Cardiology, Città della Salute e della Scienza Hospital, Department of Medical Sciences, University of Turin, Torino, Italy. 3 Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA. 4 Department of Internal Medicine III, University Hospital of Saarland, Saarland University, Homburg/Saar, Germany. 5 Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA. 6 Department of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway. 7 Department of Cardiology, The Heart Centre, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark. 8 Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA. 9 Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada. 10 Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; National Heart and Lung Institute, Imperial College London, London, UK. 11 Department of Cardiology, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, UK. 12 Department of Medicine, Medical University of South Carolina, Charleston, SC, USA. Abstract AIMS: To investigate the relationship between heart rate and outcomes in heart failure and reduced ejection fraction (HFrEF) patients in sinus rhythm (SR) and atrial fibrillation (AF) adjusting for natriuretic peptide concentration, a powerful prognosticator. METHODS AND RESULTS: Of 13 562 patients from two large HFrEF trials, 10 113 (74.6%) were in SR and 3449 (25.4%) in AF. The primary endpoint was the composite of cardiovascular death or heart failure hospitalization. Heart rate was analysed as a categorical (tertiles, T1-3) and continuous variable (per 10 bpm), separately in patients in SR and AF. Outcomes were adjusted for prognostic variables, including N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), and also examined using change from baseline heart rate to 1 year (≤ -10 bpm, ≥ +10 bpm, < ±10 bpm). SR patients with a higher heart rate had worse symptoms and quality of life, more often had diabetes and higher NT-proBNP concentrations. They had higher risk of the primary endpoint [T3 vs. T1 adjusted hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.35-1.66; P < 0.001; per 10 bpm: 1.12, 95% CI 1.09-1.16; P < 0.001]. In SR, heart rate was associated with a relatively higher risk of pump failure than sudden death (adjusted HR per 10 bpm 1.17, 95% CI 1.09-1.26; P < 0.001 vs. 1.07, 95% CI 1.02-1.13; P = 0.011). Heart rate was not predictive of any outcome in AF. CONCLUSIONS: In HFrEF, an elevated heart rate was an independent predictor of adverse cardiovascular outcomes in patients in SR, even after adjustment for NT-proBNP. There was no relationship between heart rate and outcomes in AF. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifiers NCT01035255 and NCT00853658. © 2019 The Authors.European Journal of Heart Failure © 2019 European Society of Cardiology
