Sweden’s Heart Failure Care: Are We Following the New Map?

Hey there! So, I’ve been looking into something pretty important for folks in Sweden dealing with heart issues, specifically heart failure. You know, that condition where your heart isn’t quite pumping as strongly as it should. It’s a big deal, affecting loads of people, and getting the right treatment is absolutely key to living better and longer.

Recently, like in early 2022, Sweden got some shiny new treatment recommendations for heart failure, based on the European guidelines from 2021. This got me wondering: are doctors and patients actually using these new guidelines? Are things changing on the ground? That’s exactly what a recent study, based on some really comprehensive Swedish registry data, set out to discover. They peeked into the treatment patterns of over 212,000 heart failure patients between 2021 and 2023 to see how things were evolving, especially around these new recommendations.

The Heart of the Matter: What is Heart Failure?

First off, let’s quickly touch on what heart failure is. It’s often a chronic, progressive condition where the heart struggles to pump blood effectively. It affects a good chunk of the population, especially as we get older. In Sweden, we’re talking about around 300,000 people. While it’s manageable, the sad truth is that the 5-year mortality rate is still pretty high, around 50%. A big reason for this? Sometimes, the treatment isn’t quite hitting the mark – maybe due to late diagnosis, other health issues, or just not fully implementing the best strategies.

Heart failure isn’t just one thing; it comes in a few flavors depending on how well the left ventricle (the main pumping chamber) is squeezing. We’ve got:

• HFrEF (Heart Failure with reduced Ejection Fraction, LVEF ≤ 40%)
• HFmrEF (Heart Failure with mildly reduced Ejection Fraction, LVEF 41–49%)
• HFpEF (Heart Failure with preserved Ejection Fraction, LVEF ≥ 50%)

Interestingly, with better ways to diagnose and an aging population, HFpEF is becoming more common, particularly among older folks and women.

New Rules of the Road: The Guidelines

The big news in the 2021 ESC guidelines (and the subsequent 2022 Swedish ones) was the strong recommendation for quadruple therapy for HFrEF patients. This isn’t just one pill; it’s a powerful combination of four drug classes working together:

• RAAS-inhibitors (RAASi) or angiotensin receptor‐neprilysin inhibitor (ARNI)
• β-blockers (BB)
• Mineralocorticoid receptor antagonist (MRA)
• Sodium-glucose cotransporter-2 inhibitors (SGLT2i)

The idea is to start this combo ideally within 6 weeks of diagnosis to really knock down the risk of things getting worse. These drugs have synergistic effects, meaning they work even better together.

Then, in 2023, both the ESC and Swedish guidelines got updated again. A major change was that SGLT2i got a top-tier recommendation (IA) for *all* heart failure patients, regardless of their LVEF (HFrEF, HFmrEF, *and* HFpEF). The other drugs (RAASi/ARNI, BB, MRA) were also suggested for HFmrEF patients.

Implementing these guidelines is crucial. It’s not just about ticking boxes; it’s about improving lives, reducing hospital stays, and frankly, saving money in the long run. So, how well are these recommendations actually being put into practice in Sweden?

What the Study Looked At

This study dug into data from national registers – prescription data, patient records, even cause of death. They looked at a huge number of patients (over 212,000!) diagnosed with heart failure between 2017 and 2023. They specifically focused on the 2021-2023 period, splitting it into six-month chunks before and after the Swedish recommendations came out in January 2022.

They analyzed prescription patterns, looking at which drugs were used, in what combinations, if patients switched treatments, or stopped them. They also broke down the data by age, gender, and whether patients had diabetes, and for those with a specified diagnosis, by LVEF type (HFrEF, HFmrEF, HFpEF).

So, What Did We Find?

Okay, here’s the scoop. The study found that the use of guideline-directed medical therapy (GDMT) definitely increased between 2021 and 2023. And get this – the upward trend actually started *before* the official Swedish recommendations were introduced in 2022! This suggests that maybe the European guidelines from 2021 or just general awareness among doctors and early adopters were already having an effect.

Specifically, the use of quadruple therapy and SGLT2 inhibitors (both alone and in combinations) saw a significant rise. Meanwhile, combinations that *didn’t* include SGLT2i started to decrease, which makes sense given the new recommendations for SGLT2i across the board.

By the end of 2023, about 16% of patients who had been living with heart failure (prevalent patients) and about 30% of newly diagnosed patients (incident patients) had tried quadruple therapy at some point. That’s a good number trying it! However, the proportion of patients who were *consistently* on quadruple therapy without switches or stops was much lower, around 2.8% for prevalent and 3.2% for incident patients. This hints that while initiation is happening, sticking with the full regimen might be a challenge.

The most common drug combo overall was still RAASi/ARNI plus BB. But the study also noticed something kinda cool: the *variety* of treatment pathways patients were taking increased over time. In early 2021, they saw just over 900 different pathways, with about a quarter including quadruple therapy. By late 2023, there were over 1900 different pathways, and more than half of them included quadruple therapy at some point. This growing diversity might suggest that doctors are increasingly tailoring treatments to individual patients, which is a good thing!

Digging into the Details: Who Gets What?

The study also looked at different groups of patients, and here’s where some interesting differences popped up:

• Patients with Diabetes: These folks were more likely to receive combination therapies that included SGLT2i (which makes sense, as SGLT2i also treat type 2 diabetes). They were also more likely to try quadruple therapy, especially if they were newly diagnosed.
• Age: Age made a big difference. Younger patients (under 65) were much more likely to receive quadruple therapy (over 55% of incident patients in late 2023 had tried it). This likelihood went down significantly with age. For patients over 80, only about 20% of incident patients had tried it. In fact, the study found that every single year increase in age was associated with significantly lower odds of getting quadruple therapy.
• Gender: Women were less likely to receive quadruple therapy compared to men (around 29% of incident women vs. 40% of incident men in late 2023). Women were also more likely to be on monotherapy (just one drug). Like age, being female was significantly associated with lower odds of receiving quadruple therapy.
• HF Diagnosis Type (for those specified): For the patients where the specific type of heart failure was noted (which was less than 30% of the total study group, a limitation!), the picture was clearer. Around 77% of incident HFrEF patients had tried quadruple therapy by 2023. This dropped to 44% for HFmrEF and 23% for HFpEF incident patients. This aligns somewhat with the recommendations initially focusing on HFrEF, although the 2023 updates broadened SGLT2i use.

These subgroup findings are important because they highlight potential disparities in care. Why are older patients and women less likely to get the recommended therapy? The study touches on some possible reasons.

Why the Differences?

The study suggests a few reasons for the observed patterns. The early uptake of quadruple therapy and SGLT2i before the official Swedish guidelines might be due to the earlier European guidelines or just doctors and patients being quick to adopt new, promising treatments.

As for the differences in age and gender, it might partly be related to the type of heart failure. HFpEF, which is more common in older patients and women, didn’t have as strong recommendations for the full quadruple therapy until the very recent 2023 updates (and even then, only SGLT2i got the top recommendation across all LVEF types). However, previous studies have also shown that older patients and women are generally less likely to receive optimal GDMT, regardless of HF type. Factors like other health conditions (comorbidities), challenges with adjusting dosages, monitoring side effects, and ensuring patients stick to complex regimens (especially four drugs!) can make doctors hesitant to start quadruple therapy, particularly in older, frailer patients or those with multiple conditions.

Patient preference also plays a role. If a patient is feeling okay on their current treatment, they might not be keen to add more medications, even if guidelines suggest it could be better. This might explain why patients who have been living with HF for a while (prevalent patients) are less likely to switch to quadruple therapy compared to newly diagnosed patients (incident patients).

Wrapping Up: Good News, But Room to Grow

So, the big takeaway? Sweden is definitely moving in the right direction! There’s been a noticeable increase in the use of quadruple therapy and SGLT2 inhibitors for heart failure, which is fantastic and aligns with the latest recommendations. This shift was happening even before the official Swedish guidelines were published, which is pretty cool and shows a proactive approach. The increasing variety in treatment pathways also suggests a move towards more personalized care.

However, the study also points out that we’re not quite at optimal implementation yet. While many patients *try* quadruple therapy, consistent use is still low. And there are clear disparities: older patients and women are less likely to receive these guideline-recommended treatments.

The study has its limitations, like the fact that the specific type of heart failure wasn’t recorded for most patients, and it didn’t look at whether patients were getting the *right dose* of their medications (which is super important!). But its strengths, like using a huge, high-quality national dataset, make the findings really robust.

Ultimately, while Sweden is making good progress in adopting the new heart failure treatment guidelines, there’s still work to be done to ensure *all* patients, regardless of age or gender, have the opportunity to benefit from the best available therapies. Understanding the barriers to full implementation and dose optimization is the next crucial step.

Source: Springer