Heart failure death rates on the rise, but local specialists say there’s more to that

Heart failure deaths are climbing after decades of a decline, starting with a reversal from 2012 to 2021, according to research in the Journal of the American Medical Association.

The study analyzed death certificate data, and researchers noted a limitation in that scope if heart failure was misattributed on records. However, they said the rise is there – particularly among people younger than 45.

Two Spokane cardiologists described a broader picture of the trend, including one key: People are living longer after heart attacks, cardiac treatments and with other diseases that affect the heart.

Also, factors impacting heart health are on the rise and might explain the number of younger patients, including more cases of diabetes, obesity, vaping and drug use.

“The article did not surprise me at all; I would say since around 2015 or so, the patients we care for have started to become more medically complex,” said Dr. Deirdre Mooney, at the Providence Center for Advanced Heart Disease and Transplantation.

“I think some of it is better awareness. We are making more diagnoses of comorbidities – sleep apnea, atherosclerotic cardiovascular disease like strokes,” Mooney said. “But I also think we’re seeing a surge of concerning behaviors – more sedentary time, more smoking or vaping, worsening obesity, worsening diabetes.

“There is also even a different overlay of just patients who have survived cancer. People are living longer with other comorbidities that are completely outside the traditional cardiac realm, and it may be they’re being treated with medications that have a cardiac side effect.”

The JAMA Cardiology report said that among Americans, the number of heart failure-related deaths as age-adjusted per 100,000 people had dropped steadily from 1999 to 2009.

From 2009 to 2012, those rates nearly plateaued, said the Duke University School of Medicine study.

Then from 2012-21, the mortality rates increased, the paper said. Larger reversals were among people younger than 45, especially in those ages 45-64, men, non-Hispanic Blacks, people living in rural areas and those living in the South and Midwest.

Dr. Marat Fudim, a Duke associate professor and lead author, said in a university article that he suspects obesity, rising diabetes and hypertension as factors. Other reasons might be heart medicine costs and health care access.

The JAMA report is interesting, said Dr. Mohit Jain, at MultiCare Pulse Heart Institute in Spokane. The paper focused on rates, so he said it doesn’t delve into details that would change current practices.

“Heart failure is the end-stage diagnosis for a lot of patients,” Jain said. “As we live longer, we have heart failure.”

Jain said new medications called SGLT2 inhibitors, or sodium-glucose cotransporter 2, have helped heart failure patients in the past three to four years.

“We have a new class of drugs that have helped reduce hospitalizations for patients with heart failure; I think the timing that they used probably did not have that impact of these, and new ways we’re thinking about it,” he said.

The Heart Failure Society of America released several updates to practice guidelines in the past two years, “because there has been such a flurry of movement of new therapies, devices and things of that nature.”

Heart failure is a chronic disease, with ups and downs, Jain added. People may go to the hospital with worsening heart failure, then improve after therapies. But the spiral continues, he said.

Mooney argued that the heart failure mortality rates are almost a marker of success, because people are surviving longer with cardiac issues or heart attacks through better, earlier interventions – from stents to new medicines.

“If you have reduced mortality from heart attacks, you have increased survival of people who had a heart attack,” Mooney added. “Their heart is not normal. There are still abnormalities. You are at high risk for another heart attack or other complications.”

“Unfortunately, I do think the overall volume of patients with cardiac disease risk is rising due to the worsening behaviors we’re seeing.”

More drug use – primarily methamphetamine – is on that list. Mooney also said fewer people seem to seek regular care from a primary care physician to manage overall health, although they might be going to specialists.

Doctors in recent years also are better trained to list contributory causes on a death certificate. During COVID-19, Mooney said if a patient had a heart attack two years prior to dying primarily of acute respiratory failure, she’d likely list heart failure on the “third or fourth line,” because the heart was mildly abnormal.

The difference between heart attacks and heart failure is often misunderstood, Mooney said.

“Heart failure is often the secondary condition,” she said. “There are cases where heart failure is the primary thing, but often it’s secondary to something else – a complication from another medicine, or a heart attack.

“A heart attack is when you have abrupt, impaired blood flow from the coronary arteries to heart muscle, and that heart muscle is injured or dies.”

She said heart failure is a more general process when the heart muscle for any reason can’t adequately meet the body’s needs. The heart becomes weak or too stiff as a pump to have enough circulating volume. There is fatigue, shortness of breath and fluid retention.

Heart failure has four stages, Mooney said. First is at-risk patients, such as if they smoke or have diabetes. That’s followed by people who are active but without obvious symptoms. The heart is affected and mildly weak.

What’s commonly called heart failure is the third stage, typically with shortness of breath and a hospital stay. The final stage is advanced heart failure, when patients get fatigued just doing basic self-care, can’t get rid of body fluids or require frequent defibrillator shocks.

“That’s where we start to think about IV medicines, experimental research trials, heart transplants, mechanical heart pumps,” Mooney said.

Doctors know more today about fighting heart failure based on genetic mutations or from some cancer treatments. Mooney said self-care includes healthy eating, exercise and limits on alcohol and red meat.

“Know your numbers – cholesterol, body weight, body mass index, blood pressure, A1C. The list goes on,” she said.