A 72-year-old man with a history of coronary artery disease is admitted with acute pulmonary edema secondary to acute coronary syndrome (confirmed by 12-lead ECG and a positive high-sensitivity troponin test). Following initial emergency management with intravenous loop diuretics, nitrate therapy, and continuous-positive airway pressure support, he is admitted to the hospital’s coronary care unit for 2 days and then spends a further 5 days in a general medical unit. A coronary angiogram shows that a previous drug-eluting stent in the right coronary artery remains patent, but there is evidence of progressive diffuse disease in the left anterior descending and circumflex artery. Echocardiography reveals morphological and functional changes indicative of ischemic cardiomyopathy with left ventricular systolic dysfunction (left ventricular ejection fraction of 38%). Discharged to home on gold-standard medical therapy with follow-up by an outpatient heart failure management team, he is diagnosed with chronic heart failure (NYHA class II-III but clinically stable) requiring ongoing surveillance and treatment.

This de novo, heart failure–related event did not occur in isolation. Nor does it prove to be the last time this patient’s quality of life and prognosis are influenced by a costly syndrome that is as malignant as many forms of cancer.¹

In the United States and Europe alone, there are currently more than 20 million people affected by heart failure.² Heart failure is routinely ascribed to be the number one cause of hospitalizations in those aged >65 years; hospital care traditionally consumes more than two-thirds of health care costs.³

As shown in Figure 1-1, the genesis of this particular case of heart failure began almost 20 years ago when, as a middle-aged man, the patient’s increasingly sedentary lifestyle and diet contributed to the development of metabolic syndrome and undiagnosed and untreated hypertension. The sequence of events highlights the key economic aspects of heart failure.

PRIMARY AND SECONDARY CARE

Heart failure patients experience regular visits with primary care personnel and are mainly cared for by their primary care physician by requesting clinic appointments. Secondary care presents when the heart failure patient is admitted into hospital.

TREATMENT AND MANAGEMENT

Once established, the syndrome of heart failure (usually presenting as acute decompensation requiring hospitalization) is typically characterized by progressive cardiac dysfunction, multimorbidity (including concurrent cerebrovascular and renal disease), and costly inpatient and outpatient management and treatment prior to death. Additionally, treatment and management options are rarely curative, but target achieving clinical stability (by reducing costly rehospitalization) and prolonged life.⁴

EFFECTS OF HEART FAILURE

For the affected individual, activities of daily living (including employment if appropriate) and quality of life are progressively impaired leading to loss of independence and residential care placement. Therefore, palliative management for those with advanced intractable heart failure is becoming an increasing and additionally costly feature of the syndrome.

As reflected in contemporary guidelines,⁴ there are a myriad of increasingly expensive health care costs associated with the diagnosis and treatment of acute and chronic forms of heart failure, as well as the complex multimorbid conditions that typically contribute to poor and very costly health outcomes; isolated heart failure being rare (<10% of cases). Despite a plethora of cost-effective analyses to support reimbursement for individual therapeutic strategies, there is no definitive analysis of the cost-effectiveness of multifaceted management of the syndrome. The widely accepted threshold for proving cost-effectiveness (and therefore willingness to pay for that health improvement) is $50,000 per quality-adjusted life-year gained. Given variable health systems, reimbursement mechanisms, and health insurance plans, there is no definitive source for health care costs associated with heart failure. Indicative costs (mainly derived from 2 key sources^2,5) in this section are for the United States only, represent the lower price range, and are presented in U.S. dollars.

DIRECT COSTS

The direct cost of heart failure typically comprises any investigations typically directed toward determining an individual’s cardiac function (eg, echocardiography and brain natriuretic peptide levels), the treatment of that individual (pharmacological and nonpharmacological), and health care contacts and activity specifically related to an acute heart failure event or its ongoing management. The most obvious, and often most costly, component of management is a primary hospital admission (where heart failure is the principal diagnosis) for the syndrome.

Initial Screening and Diagnosis

The initial screening process of heart failure involves clinical profiling (Figure 1-2), plasma concentrations of natriuretic peptides (>$50 per assay), 12-lead ECG (>$200 per test, Figure 1-3), and transthoracic echocardiography (>$1000 per test) that require both trained technicians and expert cardiology review to determine the extent and type of cardiac dysfunction present (Figure 1-4).⁴

Other imaging modalities of increasing cost include chest x-ray ($200), stress echocardiography (>$2500), cardiac magnetic resonance imaging (>$2500), positron emission tomography (>$5000), coronary angiography (>$5000), and cardiac computed tomography (>$500).⁴

Pharmacological Treatment

A combination of angiotensin-converting enzyme inhibitors (noting the potential substitution with angiotensin receptor neprilysin inhibitor) and beta blockers supplemented by loop diuretics, mineralocorticoid (aldosterone) receptor antagonists, and I_r channel inhibitor, forms the basis for the primary treatment of heart failure with reduced ejection fraction⁴ at a cost of >$1000 per person/annum for the simplest of drug regimes.