Temporal trends in heart failure epidemiology during the COVID-19 pandemic years in Germany

Tina Stegmann (Leipzig)1, U. Riemer (Nürnberg)2, V. Herrmann (Nürnberg)2, S. Klebs (Nürnberg)2, T. Uhe (Leipzig)1, M. Alibone (Berlin)3, L. Bovy (Berlin)3, D. Häckl (Leipzig)4, M. Dörr (Greifswald)5, R. Wachter (Leipzig)1

1Universitätsklinikum Leipzig Klinik und Poliklinik für Kardiologie Leipzig, Deutschland; 2Novartis Pharma GmbH Medical Affairs Nürnberg, Deutschland; 3Ingef - Institut für angewandte Gesundheitsforschung Berlin GmbH Berlin, Deutschland; 4Wissenschaftliches Institut für Gesundheitsökonomie und Gesundheitssystemforschung (WIG2) Health Economics and Management Leipzig, Deutschland; 5University Medicine Greifswald DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald & University Medicine Greifswald, Department of Cardiology Greifswald, Deutschland


Background: Heart failure (HF) is a major global public healthcare burden and one of the leading causes of mortality. This study aimed to investigate the temporal burden of HF in Germany, changes in the prescription of HF drug treatment, as well as hospitalization rates and all-cause mortality during the COVID-19 pandemic in Germany.

Methods: This retrospective, descriptive analysis used a sample of 4.8 million insured persons from the InGef research database, which is representative of the German population and compromises anonymized longitudinal healthcare claims data from more than 60 German statutory health insurance providers. Analyses are presented by calendar year (study year) from 2016 to 2021. Patients had to be at least 18 on January 1st of the respective study year and required continuous insurance throughout the complete study year or until death. HF prevalence and incidence, all-cause mortality, all-cause hospitalization rates, and HF-related hospitalization rates for prevalent and incident HF cases were calculated by study year, respectively. Changes in the prescription of HF drug treatment during the study period were recorded and analyzed.

Results: From 2016 to 2021, the HF prevalence continuously increased from 4,371 to 4,754 per 100,000 persons. The incidence of HF between 2016 and 2021 ranged from 1.2% to 1.4% and remained overall stable during the observation period.

All-cause hospitalization rates in prevalent HF cases were comparable in the observed study years from 2016 to 2019 (~59%), with an abrupt decrease to ~55% in 2020 and 2021 (Figure 1A). On the contrary, no effect on all-cause hospitalization rates during the COVID-19 years was seen for incident HF (ranging from 79% to 82%). HF-related hospitalization rates remained stable in prevalent HF patients (ranging from 9.0% to 9.7%), whereas a peak was seen in 2021 in incident HF cases (Figure 1B).

All-cause mortality in patients with prevalent HF slightly decreased from 10.1% to 9.7% from 2016 to 2019 and then increased in the COVID-19 pandemic years 2020 and 2021 up to 11.1% (Figure 1C). The mortality rate in incident HF cases did not change between 2016 and 2019 (12.1% to 12.7%) but markedly increased in 2020 and 2021 (13.6% and 15.2%, respectively). The intake of angiotensin-neprilysin receptor inhibitors (ARNI) and sodium–glucose cotransporter 2 inhibitors (SGLT2i) continuously increased, while the intake of diuretics continuously decreased. The beta-blocker use was consistent throughout the complete investigated study period, whereas a higher percentage intake was observed for mineralocorticoid antagonists over time.

Conclusion: Despite the still slightly increasing burden of HF in Germany, its incidence did not significantly change between 2016 and 2021. Implementing new medical drug therapies into the guidelines for treating chronic heart failure represented an increased percentage of the particular use of SGLT2i and ARNI. During the years of the COVID-19 pandemic, a significant increase in both the all-cause mortality rate and the all-cause hospitalization rate was observed, reflecting the vulnerable and high-risk population of heart failure patients.

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