Heart Failure, Aging, and Us

By Michael Hodin

When the European Society of Cardiology (ESC) holds its annual meeting with the World Congress of Cardiology in Paris this weekend, the assembled leaders have a chance to make history. How? Focus on heart failure — a widespread, debilitating, deadly, and expensive condition, but one that has been underrecognized and inadequately addressed for far too long. In particular, attendees can build on the new World Heart Federation Roadmap for Heart Failure, which provides a framework for policymakers and cardiac advocacy groups to guide national initiatives on heart failure. This roadmap can help innovators, scientists, providers, patients, payers, and others to seize unrealized opportunities for improved health outcomes and cost savings.

Experts and policymakers are beginning to recognize that heart failure, now increasingly driven by 21st century longevity, is one of the biggest missed opportunities in health care today. In other European locations — not too far from Paris where the ESC will meet — there is parallel momentum powerfully linked to aging and heart failure. In Geneva, the World Health Assembly will declare the Decade of Healthy Ageing starting next May, and in Brussels, the Finnish European Presidency is carrying out a healthy aging theme, which they announced as they assumed their Presidency at the Silver Economy Forum in Helsinki this July. These leaders are drawing attention to the links between cardiovascular health and aging, which requires a reframing of how we detect, diagnose, and treat cardiovascular diseases. And, yes, heart failure is a disease; it is not a normal part of getting older.

This is the central challenge of heart failure: its early symptoms are too often overlooked or dismissed as normal parts of aging. As a result, diagnosis or treatment too often only takes place in the acute hospital setting, leading to high rates of mortality and soaring costs. Heart failure, in fact, is the world’s leading cause of hospitalization. This is further exacerbated by high rates of hospital readmissions, which cause even more pain to the patient, as well as increased costs for families and society itself.

How do we move forward?

After discussing this issue at a number of expert convenings, the newly formed Global Heart Failure Alliance has found that a number of persistent barriers are preventing countries and health systems around the world from driving progress against heart failure. We must now work to understand and address these challenges:

· Patients, family members, providers, and even cardiology experts often misunderstand the early symptoms of heart failure as if they were only the normal parts of aging.These symptoms include shortness of breath, swelling, rapid weight gain, fatigue, and dizziness. They should be critical red flags that lead to heart failure diagnosis and treatment, but they are currently written off as just “getting old.”

· Stakeholders lack education to ensure that heart failure patients receive evidence-based care. Evidence-based care could help to reduce hospitalization and readmission rates — currently sky-high and very expensive — while also dramatically improving quality of life and meeting the social, emotional, and financial needs of patients. You can imagine this is especially true as we age.

· There is insufficient research, communication, and advocacy on how heart failure and aging impact health care systems. By increasing awareness of heart failure, advocacy efforts could build the foundation for greater action. However, the misunderstanding of heart failure symptoms and a lack of urgency for diagnosis and treatment hold back progress in this area.

· Heart Failure with Preserved Ejection Fraction (HFpEF), which is increasingly prevalent with age, lacks approved pharmacologic treatment.This is a key outstanding need where innovation could deliver important benefits. But regulators must align with patient needs in order to help enable a more welcoming environment for innovation itself.

There are also compelling statistics about the prevalence, impacts, and costs of heart failure, both globally and in Europe. Here are some key numbers that leaders in Paris and, frankly, anyone with a heart should care about:

· High, rising prevalence: Globally, 26 million people suffer from heart failure, and this number is rising steadily as more of us live longer. As the home of some of the oldest countries in the world, Europe is at the center of the issue — creating an opportunity and need for global leadership. The 1 billion of us over 60 on the planet, leading to 2 billion by mid-century is a baseline for demographically based analysis that heart failure will only explode in the coming decades.

· A lethal condition: Studies in the U.S. and Europe find that heart failure patients have a 90-day mortality rate of 9–12%. When we consider one-year mortality, the rate climbs to 24–35%.

· Hospitalizations and re-admissions: Heart failure is a leading cause of hospitalization, accounting for 1–3% of all U.S. and European hospital admissions. On average, these patients stay in the hospital for between 5 and 10 days — and they often return. In Europe, rates of readmission range from 27–44%, and they’re even higher in the U.S.

· High costs from acute care:Heart failure is an expensive condition — accounting for 1–2% of total health care spending in Europe. These costs are driven by high rates of hospitalization, readmission, and other acute care. For example, in the U.K., heart failure costs the NHS more than £980 million — largely driven by hospitalization.

· “Invisible” economic costs: Beyond its direct medical costs, heart failure also generates significant indirect costs through missed work, lost productivity, and premature retirement for both patients and caregivers.

Given these dramatic impacts, it’s clear that the cardiology community should use Paris to put heart failure at the top of the cardiovascular health agenda. Indeed, heart failure’s effects are significant enough that it should be a focus not just for cardiologists, but also the global health community, national policymakers, the private sector, the geriatrics and gerontology community, payers, patients, nursing, and hospital leaders.

We need urgent and creative partnerships to bring attention to heart failure, which especially problematic as we age, for more effective monitoring, better and earlier diagnosis, and much earlier and improved treatment — before the patient needs a costly hospital visit. We need leaders working across disciplines and sectors to address the key misperceptions and barriers to diagnosis, care, and high quality of life. More fundamentally, we need to battle ageist assumptions and reframe heart failure as a progressive condition that requires early intervention.

This weekend in Paris, the ESC Congress can move us one step closer to those goals — and can play its role in helping to achieve healthier and more active aging, which will be declared as the WHO theme for the next decade at the May 2020 General Assembly.