Multicentre observational registry of patients hospitalized for heart failure and real-life adherence to international guidelines (REAL-HF): first two years (2020-2021) experience

Abstract Background Heart failure (HF) is associated with high mortality and costs mainly due to hospitalizations. Real-world data deriving from registries demonstrate gaps between guidelines recommendations and clinical practice. Purpose The REAL-HF registry aims to provide a comprehensive overview of hospital management of HF patients in Italy, and to identify critical issues and their potential determinants. Methods The registry involves 11 centers, including all adult patients hospitalized for HF in the period 2020-2026. Data are derived from discharge letters and electronic hospital records. Patients are screened based on Diagnosis Related Groups codes. Inclusion criteria are: 1. Hospitalization for HF (except for elective procedures); 2. Decompensated HF in conjunction with other pathological conditions; 3. De novo or decompensated HF during hospitalization due to non-cardiac causes. Results This analysis included 3918 patients over two years (2020-2021) from 4 tertiary hospitals (males 2135 [54%], median age of 80[IQR 71-86] years). Only 39% of patients were hospitalized in a cardiology unit. Hospital length of stay was 9(6-15) days. Median left ventricular ejection fraction (LVEF) was 45(32-55%) (HFrEF n = 1462[37%], HFmrEF n = 420[11%], HFpEF n = 1675[43%]). Coronary artery disease was the leading cause (n = 1082[28%]) of HF, and atrial fibrillation was highly prevalent (history - 22%; during hospitalization - 33%). Arterial hypertension was the most prevalent (71%) cardiovascular risk factor. Chronic kidney disease (47%) and chronic obstructive pulmonary disease (26%) were frequent comorbidities, and they resulted to be independent predictors of adverse outcomes in multiple regression analysis. Only 67% of patients with HFrEF were treated with ACEi/ARB/ARNi, 84% with a beta-blocker, 73% with MRAs, and only 48% with all three drugs classes. New SGLT2i were prescribed in 4%. Only 16% of patients with HFrEF had a defibrillator, and 13% were treated with cardiac resynchronization therapy. Patients hospitalized in non-cardiology units were older (83 vs 73 years, p<0.0001), more frequently females (52% vs 44%, p<0.001), with HFpEF (54% vs 24%, p<0.001), and less frequently treated with ARNi, beta-blockers, or MRAs (p<0.001). Overall 30-days hospital readmission rate was 8.4%, without significant differences between cardiology and non-cardiology units (7.8 vs 8.7%, p = 0.347). However, 1-year rehospitalizations and mortality were significantly higher in patients hospitalized in non-cardiac units (33.4% vs 25.3% and 23% vs 9.57%, respectively - p<0.001). Conclusions The REAL-HF registry confirms the clinical impact of HF, and the poor outcomes of patients hospitalized with this condition. Adherence to the guidelines is still inadequate and this may impact on patients' outcomes. Moreover, the significant differences in terms of patients’ profiles might further increase the gap between highly specialized cardiology units and internal medicine departments.