Prognosis of heart failure recorded in primary care, acute hospital admissions, or both: a population-based linked electronic health record cohort study in 2.1 million people

Aims: The prognosis of patients hospitalized for worsening heart failure (HF) is well described but not that of patients managed solely in non-acute settings such as primary care or secondary outpatient care. We assessed the distribution and prognostic differences for patients with HF either recorded in primary care (including secondary out-patient care) (PC), hospital admissions alone, or known in both contexts. Methods and Results: This study was part of the CALIBER programme, comprising linked data from primary care, hospital admissions, and death-certificates for 2.1 million inhabitants of England. We identified 89,554 patients with incident HF, of whom 23,547(26%) were recorded in PC but never hospitalised, 30,629(34%) in hospital admissions but not known in PC, 23,681(26%) in both, and 11,697(13%) in death-certificates only. Highest prescription rates of ACEi, betablockers, and minerocorticoid receptor antagonists was found in patients known in both contexts. The respective 5-year survival in the first three groups was 43.9% (95%CI 43.2-44.6%), 21.7% (95%CI 21.1-22.2%), and 39.8% (95%CI 39.2-40.5%), compared to 88.1% (95%CI 87.9-88.3%) in the age and sex matched general population. Conclusion: In the general population, one in four patients with HF will not be hospitalised for worsening HF within a median follow up of 1.7 years, yet they still have a poor five-year prognosis. Patients admitted to hospital with worsening HF but not known with HF in primary care have the worst prognosis and management. Mitigating the prognostic burden of HF requires greater consistency across primary- and secondary care in the identification, profiling and treatment of patients.