Many heart failure diagnoses may be missed in a primary care setting. Women, Black adults and individuals with lower net worth are significantly more likely to be diagnosed with heart failure in an acute care setting such as the emergency room or during a hospitalization, even if they reported symptoms of heart failure during a routine, outpatient health care appointment during the previous six months, according to new research published today in Circulation: Heart Failure, an American Heart Association journal.

“This national study raises concerns that many heart failure diagnoses may be missed in a primary care setting,” said Rebecca Tisdale, MD, MPA, co-first author and health services research and development fellow at the U.S. Department of Veterans Affairs and Stanford University in Palo Alto, California. “Our results suggest acute care diagnosis rates for heart failure may be reduced if signs and symptoms of heart failure are more closely assessed in a primary care setting, particularly among women and Black adults.”

Heart failure occurs when the heart cannot pump enough blood and oxygen to support other organs in the body. Heart failure is a serious condition that requires treatment; however, it does not mean that the heart has stopped beating. According to the American Heart Association 2021 Statistical Update, an estimated 6 million Americans ages 20 and older have been diagnosed with heart failure, with the rate of death within one year of diagnosis exceeding 20%. Previous studies have found that heart failure is frequently first diagnosed in an acute care setting.

“Patients diagnosed with heart failure in the emergency room or during inpatient hospitalization often have more advanced heart failure and complications with worse prognoses than individuals diagnosed with heart failure in a primary care setting,” said Alexander Sandhu, MD, MS, lead author of the study, an instructor of medicine in advanced heart failure in the division of cardiovascular medicine and the Stanford Cardiovascular Institute at Stanford University in Stanford, California. “Since earlier recognition and treatment may prevent some of the serious complications and costs of heart failure, our analysis focused on evaluating whether heart failure is identified before the patient is in the emergency room or the hospital.”

Researchers used a national database of commercial insurance and Medicare Advantage health care claims from 2003-2019 to evaluate if patients with new incidence of heart failure were diagnosed in an outpatient (primary care) or acute care (emergency room or urgent care) setting. The analysis included nearly one million adults ages 18 or older with a first-time heart failure diagnosis.

The results found that a large proportion of new heart failure diagnoses occurred in the emergency room or during hospitalization, particularly among women and Black adults, yet many had potential heart failure symptoms in the months before their acute care visits. Detailed analysis found:

• Among patients with newly diagnosed heart failure, 38% were diagnosed in acute care settings.
• Of the patients diagnosed in the acute care setting, 46% had potential heart failure symptoms during primary care clinic visits in the previous six months, including edema (15%), cough (12%), shortness of breath (11%), and chest pain (11%).
• Heart failure diagnosis in an acute care setting was higher for women compared with men, and also higher for Black adults compared with white adults.
• People with a net worth of under $25,000 had 39% higher odds of receiving heart failure diagnoses in an acute care setting compared to people with a net worth of over $500,000.

The disparities in heart failure diagnosis within clinical practices persisted nationally across race, gender and economic status, suggesting potential differences in either quality of care or local resource availability. In addition, acute care heart failure diagnoses increased by 3.2% annually during the 16-year study period.

Timely heart failure diagnosis can lead to referrals to specialists, prescription of specific therapies, patient counseling and ultimately, improved patient outcomes. Rapid treatment is critical for reducing the progression of heart failure and its serious complications. However, previous research has shown that both women and Black adults are less likely to be referred to a cardiologist or to promptly receive advanced heart failure treatment.

“Further research is needed to better understand the factors influencing these disparities,” Sandhu added. “It is important to note that we only analyzed patients with health insurance, raising concerns that inequities may be even larger among people who are uninsured, marginally insured or those who have less access to care.”

Co-authors are Rebecca Tisdale, MD, MPA; Fatima Rodriguez, MD, MPH; Randall S. Stafford, MD, PhD; David J. Maron, MD; Tina Hernandez-Boussard, PhD, MPH, MS; Eldrin Lewis, MD; Paul A. Heidenreich, MD, MS. Author disclosures are in the manuscript.