HF Stats 2024: Addressing the Growing Heart Failure Crisis

[MUSIC] >> Hello, welcome to Heart Failure Beat, a podcast produced by the Heart Failure Society of America. >> Heart Failure Beat is designed specifically for clinicians who treat heart failure patients in the United States of America and around the world. >> We are your host, I'm Dr. Preo Mopathy, an Assistant Professor of Medicine and Advanced Heart Failure and Transmon Codialogist at the Johns Hopkins School of Medicine in Baltimore, Maryland. >> And my name is Dr. Michael Beasley, Assistant Professor of Medicine and an Advanced Heart Failure and Transplant Cardiologist at the Yale School of Medicine in New Haven, Connecticut. Thank you so much for joining us today. >> Now let's get to our episode. [MUSIC] >> Hello, listening world. Michael and I are back to introduce a, I would say that she is an illustrious speaker and we are very fortunate to be able to interview her a couple of times and get a little bit of her precious time. So this is Dr. Beacon Bosker, who's our guest for today. And we are bringing her back for some hard kidding updates on the HF stats program. And it is Mike Lynn, I have a great pleasure to introduce Dr. Beacon Boser and I cannot do her justice. So I'm going to stop, let her try to introduce herself. And she will be as humble as always, but Beacon tell us who you are for the maybe 0.0011 percent of the world's population who doesn't know who you are. >> Thank you Priya for that kind introduction. I'm Beacon Bosker, I'm a professor of medicine at Baylor College of Medicine. And I had the honor of chairing the HF stats on behalf of our committee. And I am really thrilled to be here to talk about HF stats one more time. >> Yeah, absolutely. And you say one more time, Dr. Bosker, to just remind everybody, we first sat down with you back in Cleveland at the annual scientific meeting the year before last. And that was right when the 2023 report was being released to the society. And since then, the 2024 report has now been released and published in the Journal of Cardiac Failure back in September of 2024. The 2024 report offers several updates to the previously reported statistics. And just for the listening audience, this is widely available on the HFSA website. And there is also a specific website for the HF stats initiative, which is called hfstats.org or g for those that are interested in getting some more hardcore details and data about this project. But Dr. Bosker, would you mind kind of summarizing what were the biggest take homes from the 2024 report? And how did those compare to the report from 2023? So there are several important points. As is the case in all of the HF stats, we look at incidents, prevalence, mortality, hospitalization rates. And in the 2024, we saw that the incidence and prevalence of heart failure is continuing to rise. In 2024, we were able to demonstrate that the adverse trends, we had seen in 2023 regarding heart failure mortality continued to get worsened, with heart failure mortality continuing to rise even after COVID. And we also were able to demonstrate that the hospitalizations for heart failure were increasing. The other concepts that we had highlighted in 2023 were the disparities in inequities in heart failure care. And we highlighted that there are race, ethnicity, geographic location related disparities, demonstrating higher prevalence and higher mortality rates for black individuals, as well as individuals living in rural areas. And we highlighted these in the 2024 document. We also, in the 2024 document, demonstrated that there has not been a significant rise in guideline directed therapies in heart failure management, which truly makes us pause. Given the fact that the mortality is increasing, but the opportunities for treatment has not shown concordant improvement in the last couple of years. I think you wrote in fantastic editorial in Jack, this last May, talking about this rise in mortality and highlighting the disparities. Do you think there's any positive outcomes that are coming up that you've noticed in this report, and then also to go back to your first point about how mortality rates are rising, and yet we don't see a commensuous rise in GDMT, which we know has such leotropic and really amazing results. Do you have any thoughts for how to overcome these disparities? And really also congratulations on highlighting. So this is really the approach that we absolutely need to identify a problem systematically and try to understand what are the factors that contribute to them, because that's the only way we're going to be able to overcome them. Starting with the most important one is timely recognition for risk, diagnosis, and management, with appropriate utilization of guideline directed therapies. As you alluded to Priya, we must do this, and this is a deadly disease, as deadly as cancer is, but unfortunately is under-treated. We cannot imagine giving partial chemotherapy or not giving a comprehensive cancer therapy to a cancer patient. And I think for heart failure patients, we should have a similar approach. This I think is widely recognized by our clinicians and specialists, but at the same time care coordination is challenging. We need to underline the concept that a significant proportion of our patients are not diagnosed in a timely manner and come late or are referred late. And I think in this document, we also emphasize that one-third of our population in the United States have risk factors for heart failure. Another one-third is pre-heart failure. They have either structural functional or biomarker abnormality. And when the patients are diagnosed with heart failure, they're usually in the hospital setting and/or with advanced disease. So an opportunity for changing these adverse trends is timely recognition of risk, treatment of risk, because treating blood pressure in patients with hypertension does result in prevention of heart failure. An appropriate treatment strategy is can prevent structural abnormalities in the heart and progression of adverse remodeling in all of these, if done in a comprehensive manner, would probably prevent heart failure. An appropriate treatment strategy is already on can prevent progression of disease and endpoints such as mortality and hospitalization. Now, you asked me a question at the beginning. You said, "Are there any positive things that were found in this document?" One can think of it probably glass healthful, glass health empty. When we provide data, I see that presence of data is power, and now we recognize that maybe there is increased awareness. Part of the reason that maybe the prevalence is increasing, as well as attribution to heart failure, maybe increasing in mortality is, in the past, in the historical past, most of the deaths in cardiovascular disease used to be attributed to myocardial infarction or coronary artery disease. And heart failure only came as a related diagnosis, not as a cause of mortality. So maybe the reason, some of the reasons that we're seeing for increased mortality rates maybe, in the death certificates, the attribution to heart failure may be recognized. And we do recognize the gap in cardiovascular death due to heart failure from the clinical trials, because we know a significant proportion of cardiovascular death is due to heart failure. Not all of it is due to CAD or MI. We know this in clinical trials. Our heart failure mortality rates in the clinical trials is much higher than what the death certificates imply. That gap still exists. So maybe the increase in mortality since 2012, maybe attributed to increasing awareness, and the clinician's identifying heart failure as a proximate cause to death, as the cause of death. But again, this is glass health, anti- and health, full approach. The awareness still needs to further increase, because as I mentioned, the death rates that are identified in the death certificates is only a small minority of what we think is attributable to heart failure. One of the things I would like to kind of jump back to if you don't mind Dr. Bozkirt is something you had talked about, I think, in their response to my first question is kind of the disparities that were brought to light as part of the report. And one thing we know is that from the data that that was presented, there's racial and regional variabilities and outcomes and prevalence of heart failure. Report continues to highlight racial and ethnic disparities and heart failure outcomes, particularly among black and Hispanic populations, which you've mentioned, but also regionally and morality, if that's the correct word to use, but are other important considerations, and especially in places like the Midwest and Southeast, it seems like those regions of the country are particularly hit with a great burden of heart failure with poor outcomes. What do you think is contributing to these disparities and what can we do to help improve the situation? There are probably a variety of factors that are playing a role. Lack of access to health care is truly a major risk for heart failure. It's a deadly disease not having access to care for diagnosis, for management, for care coordination, for being able to be admitted to hospitals, I think is a critical feature. And currently we're seeing truly consolidation in health care. A lot of the rural hospitals are closing. The proximity to an advanced center is declining in rural health. And sometimes people need to drive three to four hours to be able to have access to an emergency health care center. And that can result in very adverse outcomes in heart failure populations. As we are all aware, these patients do need access to care, access to interventions, access to at times emergency room or intensive care unit, or other modalities of advanced care, be it devices and consideration for other intravenous therapies. The other reason is clustering of comorbidities. And we are recognizing that the disparities not only exist for access to care or coverage or pay for care, but also for a variety of risk factors. For example, we do see a rise in clustering of comorbidities, especially with cardiometabolic, obesity, diabetes, hypertension, chronic kidney disease, especially in south, as well as in midwest, and in rural areas. So the obesity, incidence and prevalence is exponentially rising in rural areas, access to fresh food, access to balanced diet, access to healthy lifestyle, tends to be more challenging in socioeconomically deprived areas or areas with lesser access to fresh produce and food markets. There are now growing food deserts, even in urban areas. But in those zip codes, we are seeing a significant rise in mortality rates, especially cardiovascular mortality rates. The third component is the environmental factors. We do recognize that both pollution, as well as perhaps exposure, industrial exposure, or stress, and/or having a variety of other social concepts are playing a role. So we are seeing intersectionality of increased risk for certain communities. And these could include the intersectionality of race, ethnicity, zip codes, social stressors, as well as clustering of comorbidities. And I think these trends that we're seeing with the mortality rates being significantly higher amongst black populations and increasing at a rate higher than any other race in black individuals, seeing also increased rates amongst American Indian Alaska Native individuals for increased mortality rates, along with increased incidence and prevalence amongst black individuals and Latinx individuals are very concerning trends. And what you also alluded to about what's happening in Midwest. Historically, we've always seen cardiovascular risk and cardiovascular disease rates being higher in southern states. There used to be a terminology of the stroke belt being in southern states like Texas, Louisiana, Mississippi. And we had in the last two decades by CDC heatmaps recognize that the cardiovascular mortality, including heart failure mortality rates, being higher in southern states. But now in the last 5, 10 years we're seeing a different trend. Midwest mortality rates are increasing. And among southern states, we are seeing differences in zip codes. So rural areas have higher mortality rates than the urban area. So the urban southern states compared to rural southern states may have different mortality rates. So I think Midwest's increase in mortality is a reflection of possibly rurality because a lot of the rural areas are represented in those states. And when one examines the mortality rates according to zip codes, the disparity becomes more apparent, especially rural areas, communities of color, communities that are underinsured with lack of access to health care are at significantly higher risk. I think Peacumutuschepan so many points that are really salient to this discussion. And I think the report very dramatically highlighted that one of the more startling things to me was that younger patients with heart failure that proportion of the demographic is what's exponentially rising in comparison to what traditionally used to be a high prevalence of your older. You accumulate comorbidities and you are diagnosed with heart failure. And now you have almost a third of the US population at risk for heart failure at what we would call stage A. And between a quarter and a third of the population has pre-heart failure or stage B, which is mind-blowing to me. How do you envision or see us doing a better job in sort of getting to those folks and arming our entire team so it's not a Swiss cheese model of care to bolster that? I know that's a really big question, so feel free to break that down. Very important question. I'm going to start with what must we do? First, I think we need to recognize the risk factors. The risk factors, which traditionally have been named as hypertension, diabetes, coronary R2 disease, obesity. But now have evolved to include chronic kidney disease, heterofibulation, familial genetic abnormalities, cardiotoxicity, as well as a variety of other potential cardio toxins. I think are important for us to recognize. And if an individual has these risk factors, there are treatment strategies for each one of these risk factors. And also a screening. Screening approach, we do have recommendations in the heart failure guidelines about how to screen patients who have risk factors. So potentially following them closely, being sensitive to symptoms of heart failure, recognizing the symptoms already on when they have shortness of breath, a dima, fatigue, and/or being able to do echocardiography to assess their cardiac function or biomarkers, such as anti-proBNP, can help us identify the individuals who have heart failure. So early recognition and diagnosis, I think, is going to be critical. And then as soon as they're recognized, there are a large, our momentarium of guideline directed therapies, both for heart failure with reduced EF. And now with an evolving platform for heart failure with preserved EF, as well as specific cardiomyopathies, individuals with a specific etiology. Now back to your initial statements about the adverse transverse seeing in young individuals. So heart failure is not only a disease of elderly. There used to be, I guess, a misperceived concept that it is only seen in older individuals because the prevalence was the highest amongst older individuals, especially amongst the Medicare population, created that perception that it is not a disease of young individuals. We're now recognizing that the proportion of younger patients with heart failure is increasing compared to the proportion of older patients. And as you said, this may be due to both the increases in risk factors, comorbidities, we're now seeing younger individuals having hypertension, obesity, and diabetes, as well as maybe reclicition of the disease and being able to diagnose by earlier screening. So both of these, I think, are playing a role. We're able to identify, the modified cardiotoxicity and myocardial injury and imaging and/or biomarkers. But at the same time, this may be solely if one were to think that this may be due to predominantly increased awareness and recognition and diagnosis, we're also recognizing that the mortality rates are increasing. I would say in a significant manner compared to the older populations amongst the younger populations. So, the annual increase in mortality rates among individuals between the ages of 35 to 64 is higher than over 64. And we've been looking at these trends since 2012 very closely. The mortality rates have been followed by CDC since 1999. And what happened for the older population is almost like a U-shaped curve. Mortality rates went down after 1999 all the way to 2012. Possibly due to improvement in treatment of myocardial infarction and ischemic heart disease because we were able to do a lot of interventions to be able to treat heart attacks in a timely manner. So, I think we saw the outcome of these very effective treatment strategies for treatment of ischemic heart disease. So, the mortality rates in heart failure went down between 1999 and 2012. But since 2012, the mortality rates went up and have been steadily increasing and have now exceeded that of what we used to see in 1999. And we see a U-shaped curve in older populations. In younger populations, since 1999, we had a flat pattern of low mortality rates until 2012. And since 2012, it's almost like a flat and an increase almost like a j-cur for the younger populations. Age between 25 and 64 were seeing this rise since 2012. So these may be due to also clustering of risk in younger populations. And we are seeing higher prevalence, higher rates of diabetes, obesity and hypertension in younger individuals. And I think these are reflection both for an increased risk that is now being recognized or seen at younger ages than older ages. So, Dr. Bosch here, thank you so much for giving us such an excellent overview of the H of a stats report. I do want to give a shout out again to the website hfstats.org and the great work that was really put into designing this website. For those of you that haven't visited the website, there's slides there that you can make use of if you're giving presentations on heart failure to a variety of different groups of individuals. If you want to try to share this information amongst the community at large, the team has really went through a lot of effort to create some great images to depict all this information that Dr. Bosch here has shared with us today. So Dr. Bosch here, just lastly, as Priya had mentioned, our listenership is made up of a variety of individuals outside of heart failure clinicians, family practitioners, other members of this cardiovascular team like nurses, there's practitioners, pharmacists. And of course, as I have found out, patients themselves listen to our podcast as well. So what words of wisdom would you pass along to everybody out there and kind of words of encouragement or motivation as we all try to strive together in this battle against heart failure? Number one, heart failure is a treatable disease. And I think we right now need to recognize comprehensive, complete therapy is critical. In complete therapy, just starting one or two medications would be analogous to giving one of the four indicated chemotherapies in cancer. So complete therapy, complete guideline directed therapy is critical to prevent death. And this is a deadly disease as deadly as cancer is. The mortality rates are comparable to ovarian cancer in women and colorectal cancer death rates in men. So keep in mind, time is of essence. We do lose a significant proportion of our patients, those individuals who are repeatedly hospitalized or have NYHA class three to four heart failure will have 50% 50% mortality rate within two years. So with this kind of a death rate, it's critical for us to diagnose our patients in a timely manner and then treat them appropriately with comprehensive and complete therapy. And I started using this terminology of complete therapy for us to recognize that treating with only one of the quadruple agents amongst patients with heart failure with reduced EF is not acceptable and we will need to make efforts to initiate all of the indicated therapies recognizing that they do have significant residual risk. And also recognize that heart failure with preserved EF now has guideline directed class one recommendations for treatment. And also be aware that those individuals at risk should be screen and there are now evolving treatment strategies for prevention of heart failure either for individuals with obesity or with diabetes or hypertension and CKD. So this is an era where therapies can make significant changes both in morbidity and mortality rates for our patients. That's an amazing last message to leave our listeners with. It's a message of hope and cooperation and collaboration and it is a complete message for our entire team to take to the bank. Really Dr. Baskert, thank you so much. You are always a fantastic guest and thank you so much for your work spearheading this effort. My it's really a Michael and my pleasure to have you on this podcast to share your wisdom with us. Really appreciate it. On behalf of Michael and myself, we want to thank you for tuning into the Heart Failure Beat. We'll catch you next time with more exciting news and discussions from the world of heart failure. The opinions expressed by the hosts and guests of this podcast are their own and not necessarily those of the heart failure society of America. For more information and to subscribe to the podcast, visit hfsa.org/hfb. Follow hfsa on Twitter and look for us at #hfb. [MUSIC]