Heart failure patients with other illnesses got less treatment, yet still benefited

Design

Prospective multicentre registry (WET-HF2), observational

Population

2,702 patients hospitalised with heart failure in Japan

Primary outcome

2-year cardiac death or heart failure hospitalisation

Effect

Adjusted HR 0.94 per therapy-score point (95% CI 0.91–0.98)

Using a prospective Japanese multicentre registry of 2,702 patients admitted with heart failure, investigators scored how fully each patient received guideline-directed medical therapy, weighted by dose, and split their risk into cardiac and non-cardiac components using the MAGGIC score.

The more non-cardiac risk a patient carried — older age, diabetes, COPD, kidney impairment and similar — the less therapy they received (adjusted OR 0.93 per point). Greater cardiac risk went the other way. In the highest non-cardiac risk group, there was no documented reason for omitting renin-angiotensin blockers in 11% and mineralocorticoid antagonists in 16%.

Over two years, 24% died of cardiac causes or were readmitted with heart failure. Each extra point of therapy was associated with about 6% lower risk, and that association held whatever the patient's non-cardiac burden.

This is observational, so sicker patients who could not tolerate therapy will have done worse regardless. But the undocumented omissions suggest some under-treatment is inertia rather than judgement — the kind a general physician is well placed to correct.

• Review heart failure therapy at discharge in multimorbid patients, not only in those under cardiology.
• Write down the reason whenever a guideline drug is withheld, so the next team can revisit it.
• Do not assume comorbidity means a patient cannot tolerate guideline therapy; try low doses and titrate.
• Check potassium and renal function on a schedule rather than avoiding mineralocorticoid antagonists altogether.

Why it matters

It challenges the assumption that comorbidity justifies leaving heart failure therapy incomplete.

Don't overread it

This registry shows association; it cannot prove that adding therapy would have produced the same benefit in those not treated.

The statistics, in plain English

An adjusted hazard ratio of 0.94 per point means each step up the therapy score was associated with about 6% lower risk. Because sicker patients receive less treatment and also do worse, some of this association is likely to reflect who was treated rather than the treatment itself.

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