Care and Outcomes of New-Onset Heart Failure Across Vulnerable Populations: Temporal Trends in Mortality and Treatment in a Danish Nationwide Cohort From 2003 to 2022

BACKGROUND: Heart failure (HF) prevalence is increasing. In a nationwide cohort study, we investigated temporal trends in care and outcomes of patients with new-onset HF within vulnerable populations. METHODS: There were 154 819 patients with new-onset HF between 2003 and 2022 identified and included using Danish nationwide registries. Eight potentially vulnerable subgroups were defined (aged ≥80 years, women, low income, living alone, mental illness, non-Western background, frail, and rural residency) and compared with their counterparts. Temporal trends in initiation of guideline-recommended HF therapy and risk of all-cause mortality were analyzed. RESULTS: Initiation of guideline-recommended HF therapies (mineralocorticoid-receptor-antagonists, β-blockers, renin-angiotensin system inhibitors) was generally successful, but initiation of mineralocorticoid receptor antagonists was insufficient in vulnerable patients. Five-year all-cause mortality decreased from 2003 to 2007 to 2018 to 2022; however, those aged ≥80 years, frail, and living alone experienced a smaller decrease (aged ≥80 years versus counterpart: adjusted hazard ratio [aHR], 0.74 [95% CI, 0.72-0.76] versus aHR, 0.63 [95% CI, 0.61-0.65]; frail versus counterpart: aHR, 0.74 [95% CI, 0.71-0.77] versus aHR, 0.67 [95% CI, 0.65-0.68]; living alone versus counterpart: aHR, 0.75 [95% CI, 0.73-0.77] versus aHR, 0.62 [95% CI, 0.60-0.64]); and patients with mental illness experienced no improvements (mental illness versus counterpart: aHR, 0.99 [95% CI, 0.87-1.12] versus aHR, 0.68 [95% CI, 0.67-0.70]). Six vulnerable groups had higher aHRs compared with their counterparts in 2018 to 2022. CONCLUSIONS: Initiation of guideline-recommended therapies improved over the past 2 decades, but initiation of mineralocorticoid receptor antagonists was inadequate in vulnerable patients. Furthermore, the overall mortality risk declined, but 4 out of the 8 vulnerable groups experienced a lesser decline than their counterparts. Despite improvements, 6 vulnerable groups still had worse outcomes than their counterparts at the end of the study period. Our findings highlight the urgent need for more effort aimed at helping vulnerable subgroups of patients with HF.