Heart failure treatment in the last years of life - a nationwide study of 364,000 individuals

Abstract Background Heart failure treatment patterns towards the end of life have rarely been studied at large scale. Yet, this is important to assess, since heart failure is a chronic condition with patients on treatment for potentially many years. Purpose To investigate treatment patterns in the last years of life in patients with heart failure. Methods In a register-based study covering the whole Swedish population between 2007 and 2020, we investigated treatment patterns in the last years of life in 364,480 individuals who died with heart failure. We combined binomial models (to estimate proportion on treatment at death) and Poisson models (to estimate discontinuation rate), to estimate the proportion on each heart failure treatment up to 5 years prior to death, using penalized splines to allow for non-linearities. We also assessed comorbidity patterns over time. Results All heart failure treatments saw a gradual discontinuation closer to death, but the discontinuation rate of beta blockers decreased over time, resulting in an increasing proportion of patients on treatment at the time of death (Fig). Also, the pattern of comorbidities changed over time, with an increase in e.g., hypertension and atrial fibrillation, but a decline in ischemic heart disease (63% in 2007 gradually declining to 54% in 2020). Conclusions In this nationwide study, we observed a changing pattern of medical treatment of heart failure during the last years of life, most notably with an increasing use of beta blockers. Comorbidities and the shares of heart failure etiologies also changed over time, with an increase in several conditions but a decline in ischemic heart disease. Taken together, this may have important implications for planning and optimizing care for these patients.