Heart failure prevalence and incidence in Germany: insights in ambulatory drug therapy and comorbidities

Heart failure (HF) is associated with increased mortality, morbidity and less quality of life. Underdiagnosis and underutilization of guideline directed medical treatment (GDMT) are still an unmet need. Epidemiological health service data from Germany are limited. 

Data were extracted by the central research institute for ambulatory health care, covering 60.477.395 million governmentally insured patients, to calculate prevalence and incidence of HF in Germany from 2015 to 2023. HF diagnosis   and comorbidities were set by at least two HF coded quarters of outpatient care. Ambulatory prescribed drug therapy was derived from first diagnosis of HF patients and observed for the following four quarters of the year. The results are reported as median over the observation period. Differentiation in health care coding (ICD codes) of HF with reduced and preserved ejection fraction is lacking in Germany and a limitation for this analysis.

The prevalence ranged from 2.1 to 2.3 million patients per year, 3.5 to 3.8% of all patients with an expected continuous increase within elder age groups, highest for more than ninety years with 27.6%. Arterial hypertension was the most prevalent comorbidity (90.0%), followed by dyslipidemia (56.4%), coronary artery disease (52.1%), diabetes (44.8%), atrial fibrillation (35.3%), chronic kidney disease (35.8%), heart valve disease (31.6%), obesity (30.0%), depression (27.4%), chronic obstructive pulmonary disease (21.4%), atherosclerosis (21.1%), asthma (10.9%), obstructive sleep apnea (9.8%), anemia (9.4%), sleep disorders (2.2%) and iron deficiency (1.5%).

HF incidence was per median 364.446 persons per year (0.61%). Diagnosis was mostly coded by general practitioners (68.2%), then cardiologists (23.6%).  After the first diagnosis, quadruple therapy was low but increasing with 8.3% (2021) and 12.5% (2022). Further patients received 19.2% triple, 35.8% dual and 24.4% mono, 8.0% no HF therapy. Angiotensin-converting enzyme and angiotensin receptor blocker therapy was 63.4%, betablocker 56.9%, mineralocorticoid antagonist 15.9%, glycosides 4.6%, angiotensin-receptor-neprilysin-inhibitor (ARNI) 4.1%, sodium-glucose cotransporter-2 inhibitors (SGLT2i) 3.3%, ivabradine 1%, tafamidis 0.0002% and vericiguat 0.00008%. Prescription rates in ARNI and SGLT2i increased over time since introduction of the novel drug class (ARNI 2016: 1.5%, 2019: 6.4%, 2022: 9.4%; SGLT2i 2016: 1.2%, 2019: 3.3%, 2022: 17.6%). Despite the guideline recommendation for iron deficiency, screening and administration, both oral and intravenous, were only coded in 3.6% of HF cases.

These first data on ambulatory HF therapy in Germany reveal a low prescription of quadruple as well as iron therapy. However, positive trends in SGLT2i- and ARNI prescription rates should not be neglected and must be supported to improve HF therapy in Germany. A national HF registry is under construction for further scientific evaluation.