Survival of patients with heart failure: a systematic review and meta-analysis protocol

Survival of patients with heart failure: a systematic review and meta-analysis protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Survival of patients with heart failure: a systematic review and meta-analysis protocol Solmaz Norouzi, Alireza Molaei, Samira Ahmadi, Fahimeh Farrokhzadeh, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3950855/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Heart failure (HF) is a chronic syndrome that necessitates patients' active management of symptoms and adherence to a complex medication regimen. Identifying and treating symptoms early are crucial components of heart failure care, aiming to enhance quality of life and reduce the risk of hospitalization and mortality. Methods and analysis: This review included observational studies or studies that incorporated both interventional and observational phases. Three independent reviewers will search multiple databases, including PubMed, Web of Science, and Scopus. There was no geographical restriction, and the languages of the studies were written in English. The studies were published from August 2018 to August 2023. Three independent reviewers will carry out the literature screening, research selection, and data extraction. Stata 17.0 software was used to construct a funnel map, assess heterogeneity, perform subgroup analysis, and complete sensitivity analysis. Ethics and dissemination: This systematic review aimed to present the most recent findings regarding the survival rates and prognostic indicators of individuals with HF. By comparing outcomes over time, we seek to gain insights into the influence of evidence-based treatment advancements on the average survival of patients. The outcomes of this review are expected to be advantageous for various stakeholders, such as patient advocacy groups, the medical community, policymakers, and researchers. PROSPERO registration number: CRD42023456390 Heart failure Prognosis Protocol Survival Systematic review Meta-analysis. Key messages Chronic heart failure affects millions of people globally, with survival rates varying from 95.7% to 50%, and physical performance strongly influences prognosis. One-year survival in acute HF is between 55-65%, compared to 80-90% in chronic HF. This is the second meta-analysis on HF survival, which spans August 2018 to August 2023, seeking to update information and awareness in the field of HF. By assessing survival rates and prognostic indicators, the study aimed to enhance the understanding of public health and healthcare provider strategies. The study's findings can benefit stakeholders such as patient advocacy groups, the medical community, policymakers, and researchers by enhancing patient management, raising awareness, and proposing future solutions. It facilitates advanced care planning, especially for older populations, and aids in developing comprehensive treatment strategies. Background Heart failure (HF) is a complicated clinical syndrome arising from either functional or structural deficiencies in the ventricles, leading to symptomatic dysfunction in the left ventricle (LV). Despite advancements in therapies and prevention, it remains a primary cause of cardiovascular morbidity and mortality globally ( 1 ), affects approximately 63 million people worldwide, and is becoming more prevalent as the population ages( 2 ). HF is a major health concern with a high incidence and prevalence rate, resulting in significant morbidity, mortality, and financial burden. Heart failure imposes greater burdens of morbidity and mortality in low- and middle-income countries than in higher-income countries. This is attributed to challenges such as limited diagnostic capacity, restricted access to therapeutics and advanced care, and deficiencies in provider awareness and prescribing patterns( 8 ). Traditionally, heart failure has been classified into two types: acute and chronic HF. Acute HF is a condition marked by a sudden deterioration of symptoms, which can also be evident at the time of initial diagnosis. On the other hand, chronic HF refers to a situation in which patients have been dealing with HF for a significant duration and their symptoms have remained stable for at least a month( 4 ). Additionally, heart failure can be classified into different categories based on measurements of the left ventricular ejection fraction (LVEF)( 5 ). The increase in HF incidence can be attributed to the growing incidence of conditions such as renal failure, arterial hypertension, chronic obstructive pulmonary disease (COPD), diabetes mellitus, and metabolic syndrome( 5 ). According to previous research, unhealthy eating habits, tobacco use, excessive sugar consumption, and overweight or excess body fat are among the common causes of heart disease. The prevalent symptoms may include discomfort in the arms and chest ( 3 ). Today, many patients live for extended periods after being diagnosed with CVD. Treatment of conditions such as hypertension, diabetes, chronic kidney disease, atrial fibrillation, and ischemic heart disease can delay heart failure but is not considered preventive( 6 ). Hospitalization is an event with clear prognostic value. However, hospital records may not encompass all instances of heart failure, especially because patients with chronic heart failure are receiving increasing amounts of care on an outpatient basis and may not always be referred( 7 ). The economic strain of heart failure on healthcare systems is substantial and is expected to escalate with the growing prevalence of this condition ( 9 ). While HF is commonly perceived as a condition impacting elderly individuals, recent studies have highlighted an escalating burden of HF among the younger population (those < 50 years old)( 10 ). Younger patients with HF are more likely to have nonischemic causes, tend to adhere less to medical and dietary guidelines, and have higher readmission rates than older patients are( 11 ). In developed countries, it is generally estimated that heart failure, which is recognized by the medical community, affects approximately 1–2% of the overall adult population( 7 ). As comprehension of its pathophysiology improves each day, notable progress is evident in the treatment of heart failure. Over the last decade, substantial advancements have been made in both technological approaches and drug treatments for HF( 12 ). The incidence of HF notably increases with advancing age, impacting approximately 20% of individuals aged 75 years and older ( 13 ). The incidence of HF varies significantly across countries and regions, even when standardized for age( 14 ). A study that included 4 million people from the UK revealed that the incidence of HF, adjusted for age and sex, was 1.6% between 2002 and 2014( 15 ). The INTER-CHF study revealed varied 1-year mortality rates globally for HF, with the highest occurring in Africa (34%) and India (23%), the intermediate occurring in Southeast Asia (15%), and the lowest occurring in China (7%). Recognizing these differences emphasizes the importance of tailoring HF-related public health policies and strategies to local conditions( 16 ). Among these factors, it is crucial to comprehend the disease trajectory, mean survival time, and distinctive prognostic indicators for heart failure( 4 ). We aim to identify, evaluate, and summarize pertinent existing studies on survival in patients with heart failure who are treated in either primary or secondary care. We believe that the obtained information can provide better insight into and awareness of heart failure. Additionally, these findings are expected to be useful for improving the health of heart failure patients and others in care settings. We also hope to take a step toward future studies. Methods Objectives The objective of this systematic review was to identify risk factors and evaluate survival in patients with HF according to the 2016 ESC guidelines(17). Patient survival after being diagnosed with HF was the main focus of this study (primary outcome). Secondary outcomes included hospital admissions and factors that contribute to an elevated risk of mortality, such as age, left ventricular systolic dysfunction, treatment, and comorbidities. Protocol and registration The protocol was developed in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols) recommendations(17). The protocol was submitted for registration on the International Prospective Register of Systematic Reviews (PROSPERO) website on 21 August 2023 ahead of any data extraction. PROSPERO registration CRD42023456390. The protocol is available from: https://www.crd.york.ac.uk/prospero/#recordDetails.ID= CRD42023456390 Eligibility criteria Population Our study included patients who were diagnosed with HF (as defined by ESC guidelines) and aged 15 years or older. The search will be limited to only studies published in English. However, there will be no restrictions based on the geographical location. Studies that discuss heart failure but do not report survival rates, studies with insufficient data or inaccessible full texts, or studies with under 1 year of follow-up will be excluded given the lack of information on long-term prognosis. Intervention In this study, no intervention was conducted, and we focused on investigating the survival time of patients with heart failure. Information sources A systematic literature search was carried out using the PubMed, Scopus, and Web of Science databases. Three authors (SN, AM, SA) will independently perform two rounds of screening. The initial screening will be based on titles and abstracts, followed by a comprehensive review of the full text. In the case of disagreements, a third reviewer was consulted. Additionally, three authors will separately carry out duplicate data extraction. If needed, study investigators will be contacted for unreported data or additional details. The means of the recorded data were recorded in an Excel spreadsheet. Search strategy Our study included patients who were diagnosed with HF (as defined by ESC guidelines) and aged 15 years or older. The search will be limited to only studies published in English. However, there will be no restrictions based on the geographical location. Studies that discuss heart failure but do not report survival rates, studies with insufficient data or inaccessible full texts, or studies with under 1 year of follow-up will be excluded given the lack of information on long-term prognosis. We aim to identify studies that are representative of the real world and furnish data that can be generalized to community populations. Consequently, we will eliminate interventional studies and instead focus on observational studies or studies that incorporate both interventional and observational phases. We will exclude studies that focus on novel biomarkers, case reports, studies that involve selective subpopulations, and case series because they are not generalizable to community populations. Conference abstracts were excluded from our analysis due to their limited provision of methodological details, hindering a thorough critical appraisal. Studies lacking original data, including review articles, were also excluded. However, we will conduct a thorough examination of their reference lists to identify original research studies that align with our inclusion criteria. For a list of terms that have been searched, see Supplementary File 1. Data items and data collection process The data to be extracted included the following: the first author's name, country of origin, year, study design, and methodology. study setting, sample size, mean duration of follow-up, and study dates. The participants’ age, sex, comorbidities, and echocardiography findings, including left ventricular ejection fraction. The outcome data included mortality rate, hospital admission cause of death, and summary statistics of any measure of morbidity, e.g., hazard ratio (HR). Number of person-years at risk and number of deaths by duration of follow-up, mean survival time, and other necessary information. Outcome Survival time was the primary outcome. Whenever feasible, the survival time was considered from the point of diagnosis. In cases where this information is unavailable, the survival time will be calculated from the time of enrollment in the study as a substitute. Methodological appraisal and risk of bias Two authors independently evaluated the risk of bias and methodological quality of each study using the Quality in Prognosis Studies (QUIPS) tool. This tool is specifically designed for prognostic studies and provides insights into the quality of each study. Additionally, the methodology of individual observational studies will be assessed against the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria to further evaluate the reporting and methodological aspects of the included studies. Data synthesis We will utilize STATA version 17.0 (STATA Corp., College Station, TX) for all the statistical analyses. We plan to calculate effect sizes (hazard ratios) and 95% confidence intervals (CIs) for analysis using survival data for HF patients at various time points and Kaplan‒Meier plots. To assess heterogeneity among studies, we will employ the Q² and I² statistics and explore potential sources of heterogeneity via subgroup analysis. The findings will be discussed accordingly. In cases of low heterogeneity (I 2 < 50%), we used the fixed-effects model for the analysis. Conversely, the random-effects model was utilized when the heterogeneity was high (I 2 ≥ 50%). Additionally, we will conduct exploratory subgroup analyses based on age, sex (male and female), and study setting. Subsequently, sensitivity analysis will be used to identify outlier effect sizes and missing data. We will employ statistical methods, such as the Begg test and Egger test, in the meta-analysis to assess publication bias and evaluate publication bias in the corresponding graphs. Forest plots were used to visualize the results of the meta-analysis, aiding in the identification of factors that may influence prognosis. Discussion Predicting the survival of patients with heart failure (HF) is critical for improving the management of heart disease and increasing awareness . Heart disease has high morbidity and mortality rates, which impairs patient survival. Recent studies have shown that approximately 64.34 million individuals have HF globally, and this number has increased over the past several years. Improving the survival of these patients requires up-to-date knowledge and precise information about this type of disease(18). This systematic study was conducted from August 2018 to August 2023, and according to the studies and research that are being conducted annually in this field, it is necessary to update the information and awareness in the field of HF. Creating awareness and up-to-date information in the field of HF makes it possible for affected individuals and their families, as well as the healthcare system, to better manage and propose solutions in the future. These studies provide information about influential factors such as age, treatment, and left ventricular ejection fraction. To our knowledge, this study is the second meta-analysis investigating the survival of patients with HF, and in recent years, there have been few improvements in the survival rates of individuals with chronic HF. However, the 5-year survival rate is close to 50%, and many patients still die directly from HF or from CVD. Older people are at the highest risk of death and pose a major challenge to healthcare systems in light of changing global demographics. Greater awareness of chronic HF survival can facilitate advanced care planning between patients and healthcare professionals(4). However, updating such information can further provide a basis for increasing awareness of public health. This knowledge base enables healthcare providers to develop more accurate and specific survival strategies. Comparing the changes before and after the provision of awareness over time provides insight into the effectiveness of interventions, and if such awareness does not culminate in improvement over time, handling such outcomes may increase awareness about this disease between policymakers and the medical community. This approach provides new ideas for patients with chronic HF to maximize their benefit from the healthcare system. The strengths of this study include the use of a protocol and search strategy before data extraction. The search strategy was carried out by experts and again reviewed by two members of the research team. Moreover, these methods are based on Prisma guidelines. The observed and international findings of this study make it generalizable to patients with HF in healthcare systems. The limitations of observational studies on communication but not on outcomes could be attributed to the limitations of the current investigation. Ultimately, HF is a complex condition, and its classifications may change over time, which causes variability and consequently heterogeneity in studies. The aim of this meta-analysis was to consolidate existing data concerning the survival rates of patients with heart failure and identify risk factors. We hope to offer a valuable reference for the development of comprehensive treatment strategies for patients with heart failure. Declarations Authors’ contributions SN initiated and conceptualized the study, and reviewed previous systematic reviews. SN, AM, and SA wrote the manuscript. MAJ advised on the background and methodology section and revised the manuscript for important intellectual content. NN and SM provided insight on epidemiological aspects of the review and helped draft the manuscript. All authors read and approved the final manuscript. Acknowledgments The authors express their sincere gratitude to the Research Deputy of Rajaie Cardiovascular, Medical, and the specialized cardiologist for HF for their invaluable collaboration. Ethics approval and consent to participate This work was approved by the ethics committee of the School of Medical Sciences Tarbiat Modares University under the approval ID IR.MODARES.REC.1402.012. informed consent will be obtained from participants. Consent for publication Not applicable. Availability of data and materials Not applicable. Funding there is no funding available to support the publication of the research. References Hajouli S, Ludhwani D. Heart failure and ejection fraction. In: StatPearls [Internet]. StatPearls Publishing; 2022. Rosano GMC, Seferovic P, Savarese G, Spoletini I, Lopatin Y, Gustafsson F, et al. Impact analysis of heart failure across European countries: an ESC‐HFA position paper. ESC Hear Fail. 2022;9(5):2767–78. Alotaibi FS. Implementation of a machine learning model to predict heart failure disease. Int J Adv Comput Sci Appl. 2019;10(6). Jones NR, Roalfe AK, Adoki I, Richard Hobbs FD, Taylor CJ. Survival of patients with chronic heart failure in the community: a systematic review and meta-analysis protocol. Syst Rev. 2018;7:1–7. Riehle C, Bauersachs J. Key inflammatory mechanisms underlying heart failure. Herz. 2019;44(2):96. Pellicori P, Khan MJI, Graham FJ, Cleland JGF. New perspectives and future directions in the treatment of heart failure. Heart Fail Rev. 2020;25:147–59. Groenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. Eur J Heart Fail. 2020;22(8):1342–56. Kingery JR, Roberts NL, Lookens Pierre J, Sufra R, Dade E, Rouzier V, et al. Population-Based Epidemiology of Heart Failure in a Low-Income Country: The Haiti Cardiovascular Disease Cohort. Circ Cardiovasc Qual Outcomes. 2023;16(2):e009093. Urbich M, Globe G, Pantiri K, Heisen M, Bennison C, Wirtz HS, et al. A systematic review of medical costs associated with heart failure in the USA (2014–2020). Pharmacoeconomics. 2020;38:1219–36. Lecoeur E, Domengé O, Fayol A, Jannot AS, Hulot JS. Epidemiology of heart failure in young adults: a French nationwide cohort study. Eur Heart J. 2023;44(5):383–92. Jain V, Minhas AMK, Khan SU, Greene SJ, Pandey A, Van Spall HGC, et al. Trends in HF hospitalizations among young adults in the United States from 2004 to 2018. Heart Fail. 2022;10(5):350–62. MERAL SMDG. HEART FAILURE IN ELDERLY. Geriatr EMERGENCIES. 2022;51. Díez-Villanueva P, Jiménez-Méndez C, Alfonso F. Heart failure in the elderly. J Geriatr Cardiol JGC. 2021;18(3):219. Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: a comprehensive and updated review of epidemiology. Cardiovasc Res. 2022;118(17):3272–87. Shahim B, Kapelios CJ, Savarese G, Lund LH. Global public health burden of heart failure: an updated review. Card Fail Rev. 2023;9. Bragazzi NL, Zhong W, Shu J, Abu Much A, Lotan D, Grupper A, et al. Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017. Eur J Prev Cardiol. 2021;28(15):1682–90. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Kardiol Pol (Polish Hear Journal). 2016;74(10):1037–147. Guo S, Zhang H, Gao Y, Wang H, Xu L, Gao Z, et al. Survival prediction of heart failure patients using motion-based analysis method. Comput Methods Programs Biomed. 2023;236:107547. Additional Declarations No competing interests reported. Supplementary Files PRISMAPchecklist.pdf Searchstrategy.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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people globally, with survival rates varying from 95.7% to 50%, and physical performance strongly influences prognosis.\u003c/li\u003e\n \u003cli\u003eOne-year survival in acute HF is between 55-65%, compared to 80-90% in chronic HF.\u003c/li\u003e\n \u003cli\u003eThis is the second meta-analysis on HF survival, which spans August 2018 to August 2023, seeking to update information and awareness in the field of HF. By assessing survival rates and prognostic indicators, the study aimed to enhance the understanding of public health and healthcare provider strategies.\u003c/li\u003e\n \u003cli\u003eThe study\u0026apos;s findings can benefit stakeholders such as patient advocacy groups, the medical community, policymakers, and researchers by enhancing patient management, raising awareness, and proposing future solutions. It facilitates advanced care planning, especially for older populations, and aids in developing comprehensive treatment strategies.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eHeart failure (HF) is a complicated clinical syndrome arising from either functional or structural deficiencies in the ventricles, leading to symptomatic dysfunction in the left ventricle (LV). Despite advancements in therapies and prevention, it remains a primary cause of cardiovascular morbidity and mortality globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), affects approximately 63\u0026nbsp;million people worldwide, and is becoming more prevalent as the population ages(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). HF is a major health concern with a high incidence and prevalence rate, resulting in significant morbidity, mortality, and financial burden. Heart failure imposes greater burdens of morbidity and mortality in low- and middle-income countries than in higher-income countries. This is attributed to challenges such as limited diagnostic capacity, restricted access to therapeutics and advanced care, and deficiencies in provider awareness and prescribing patterns(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTraditionally, heart failure has been classified into two types: acute and chronic HF. Acute HF is a condition marked by a sudden deterioration of symptoms, which can also be evident at the time of initial diagnosis. On the other hand, chronic HF refers to a situation in which patients have been dealing with HF for a significant duration and their symptoms have remained stable for at least a month(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, heart failure can be classified into different categories based on measurements of the left ventricular ejection fraction (LVEF)(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The increase in HF incidence can be attributed to the growing incidence of conditions such as renal failure, arterial hypertension, chronic obstructive pulmonary disease (COPD), diabetes mellitus, and metabolic syndrome(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to previous research, unhealthy eating habits, tobacco use, excessive sugar consumption, and overweight or excess body fat are among the common causes of heart disease. The prevalent symptoms may include discomfort in the arms and chest (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Today, many patients live for extended periods after being diagnosed with CVD. Treatment of conditions such as hypertension, diabetes, chronic kidney disease, atrial fibrillation, and ischemic heart disease can delay heart failure but is not considered preventive(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Hospitalization is an event with clear prognostic value. However, hospital records may not encompass all instances of heart failure, especially because patients with chronic heart failure are receiving increasing amounts of care on an outpatient basis and may not always be referred(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The economic strain of heart failure on healthcare systems is substantial and is expected to escalate with the growing prevalence of this condition (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile HF is commonly perceived as a condition impacting elderly individuals, recent studies have highlighted an escalating burden of HF among the younger population (those\u0026thinsp;\u0026lt;\u0026thinsp;50 years old)(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Younger patients with HF are more likely to have nonischemic causes, tend to adhere less to medical and dietary guidelines, and have higher readmission rates than older patients are(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn developed countries, it is generally estimated that heart failure, which is recognized by the medical community, affects approximately 1\u0026ndash;2% of the overall adult population(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). As comprehension of its pathophysiology improves each day, notable progress is evident in the treatment of heart failure. Over the last decade, substantial advancements have been made in both technological approaches and drug treatments for HF(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The incidence of HF notably increases with advancing age, impacting approximately 20% of individuals aged 75 years and older (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The incidence of HF varies significantly across countries and regions, even when standardized for age(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A study that included 4\u0026nbsp;million people from the UK revealed that the incidence of HF, adjusted for age and sex, was 1.6% between 2002 and 2014(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The INTER-CHF study revealed varied 1-year mortality rates globally for HF, with the highest occurring in Africa (34%) and India (23%), the intermediate occurring in Southeast Asia (15%), and the lowest occurring in China (7%). Recognizing these differences emphasizes the importance of tailoring HF-related public health policies and strategies to local conditions(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Among these factors, it is crucial to comprehend the disease trajectory, mean survival time, and distinctive prognostic indicators for heart failure(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe aim to identify, evaluate, and summarize pertinent existing studies on survival in patients with heart failure who are treated in either primary or secondary care. We believe that the obtained information can provide better insight into and awareness of heart failure. Additionally, these findings are expected to be useful for improving the health of heart failure patients and others in care settings. We also hope to take a step toward future studies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe objective of this systematic review was to identify risk factors and evaluate survival in patients with HF according to the 2016 ESC guidelines(17). Patient survival after being diagnosed with HF was the main focus of this study (primary outcome). Secondary outcomes included hospital admissions and factors that contribute to an elevated risk of mortality, such as age, left ventricular systolic dysfunction, treatment, and comorbidities.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eProtocol and registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was developed in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols) recommendations(17). The protocol was submitted for registration on the International Prospective Register of Systematic Reviews (PROSPERO) website on 21 August 2023 ahead of any data extraction. PROSPERO registration\u0026nbsp;CRD42023456390. The protocol is available from:\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003ehttps://www.crd.york.ac.uk/prospero/#recordDetails.ID= CRD42023456390\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eEligibility criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study included patients who were diagnosed with HF (as defined by ESC guidelines) and aged 15 years or older. The search will be limited to only studies published in English. However, there will be no restrictions based on the geographical location. Studies that discuss heart failure but do not report survival rates, studies with insufficient data or inaccessible full texts, or studies with under 1 year of follow-up will be excluded given the lack of information on long-term prognosis.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, no intervention was conducted, and we focused on investigating the survival time of patients with heart failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformation sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systematic literature search was carried out using the PubMed, Scopus, and Web of\u003cbr\u003e\u0026nbsp;Science databases. Three authors (SN, AM, SA) will independently perform two rounds of screening. The initial screening will be based on titles and abstracts, followed by a comprehensive review of the full text. In the case of disagreements, a third reviewer was consulted. Additionally, three authors will separately carry out duplicate data extraction. If needed, study investigators will be contacted for unreported data or additional details. The means of the recorded data were recorded in an Excel spreadsheet.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eSearch strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study included patients who were diagnosed with HF (as defined by ESC guidelines) and aged 15 years or older. The search will be limited to only studies published in English. However, there will be no restrictions based on the geographical location. Studies that discuss heart failure but do not report survival rates, studies with insufficient data or inaccessible full texts, or studies with under 1 year of follow-up will be excluded given the lack of information on long-term prognosis.\u003c/p\u003e\n\u003cp\u003eWe aim to identify studies that are representative of the real world and furnish data that can be generalized to community populations. Consequently, we will eliminate interventional studies and instead focus on observational studies or studies that incorporate both interventional and observational phases.\u003c/p\u003e\n\u003cp\u003eWe will exclude studies that focus on novel biomarkers, case reports, studies that involve selective subpopulations, and case series because they are not generalizable to community populations.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eConference abstracts were excluded from our analysis due to their limited provision of methodological details, hindering a thorough critical appraisal. Studies lacking original data, including review articles, were also excluded. However, we will conduct a thorough examination of their reference lists to identify original research studies that align with our inclusion criteria. For a list of terms that have been searched, see Supplementary File 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData items and data collection process\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The data to be extracted included the following:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ethe first author\u0026apos;s name, country of origin, year, study design, and methodology.\u003c/li\u003e\n \u003cli\u003estudy setting, sample size, mean duration of follow-up, and study dates.\u003c/li\u003e\n \u003cli\u003eThe participants\u0026rsquo; age, sex, comorbidities, and echocardiography findings, including left ventricular ejection fraction.\u003c/li\u003e\n \u003cli\u003eThe outcome data included mortality rate, hospital admission cause of death, and summary statistics of any measure of morbidity, e.g., hazard ratio (HR).\u003c/li\u003e\n \u003cli\u003eNumber of person-years at risk and number of deaths by duration of follow-up, mean survival time, and other necessary information.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurvival time was the primary outcome. Whenever feasible, the survival time was considered from the point of diagnosis. In cases where this information is unavailable, the survival time will be calculated from the time of enrollment in the study as a substitute.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eMethodological appraisal and risk of bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo authors independently evaluated the risk of bias and methodological quality of each study using the Quality in Prognosis Studies (QUIPS) tool. This tool is specifically designed for prognostic studies and provides insights into the quality of each study. Additionally, the methodology of individual observational studies will be assessed against the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria to further evaluate the reporting and methodological aspects of the included studies.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eData synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will utilize STATA version 17.0 (STATA Corp., College Station, TX) for all the statistical analyses. We plan to calculate effect sizes (hazard ratios) and 95% confidence intervals (CIs) for analysis using survival data for HF patients at various time points and Kaplan‒Meier plots. To assess heterogeneity among studies, we will employ the Q\u0026sup2; and I\u0026sup2; statistics and explore potential sources of heterogeneity via subgroup analysis. The findings will be discussed accordingly. In cases of low heterogeneity (I\u003csup\u003e2\u003c/sup\u003e\u0026lt; 50%), we used the fixed-effects model for the analysis. Conversely, the random-effects model was utilized when the heterogeneity was high (I\u003csup\u003e2\u003c/sup\u003e \u0026ge; 50%). Additionally, we will conduct exploratory subgroup analyses based on age, sex (male and female), and study setting. Subsequently, sensitivity analysis will be used to identify outlier effect sizes and missing data. We will employ statistical methods, such as the Begg test and Egger test, in the meta-analysis to assess publication bias and evaluate publication bias in the corresponding graphs. Forest plots were used to visualize the results of the meta-analysis, aiding in the identification of factors that may influence prognosis.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePredicting the survival of patients with heart failure (HF) is critical for improving the management of heart disease and increasing awareness\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e Heart disease has high morbidity and mortality rates, which impairs patient survival. Recent studies have shown that approximately 64.34 million individuals have HF globally, and this number has increased over the past several years. Improving the survival of these patients requires up-to-date knowledge and precise information about this type of disease(18).\u003c/p\u003e\n\u003cp\u003eThis systematic study was conducted from August 2018 to August 2023, and according to the studies and research that are being conducted annually in this field, it is necessary to update the information and awareness in the field of HF. Creating awareness and up-to-date information in the field of HF makes it possible for affected individuals and their families, as well as the healthcare system, to better manage and propose solutions in the future. These studies provide information about influential factors such as age, treatment, and left ventricular ejection fraction.\u003c/p\u003e\n\u003cp\u003eTo our knowledge, this study is the second meta-analysis investigating the survival of patients with HF, and in recent years, there have been few improvements in the survival rates of individuals with chronic HF. However, the 5-year survival rate is close to 50%, and many patients still die directly from HF or from CVD. Older people are at the highest risk of death and pose a major challenge to healthcare systems in light of changing global demographics. Greater awareness of chronic HF survival can facilitate advanced care planning between patients and healthcare professionals(4). However, updating such information can further provide a basis for increasing awareness of public health. This knowledge base enables healthcare providers to develop more accurate and specific survival strategies.\u003c/p\u003e\n\u003cp\u003eComparing the changes before and after the provision of awareness over time provides insight into the effectiveness of interventions, and if such awareness does not culminate in improvement over time, handling such outcomes may increase awareness about this disease between policymakers and the medical community. This approach provides new ideas for patients with chronic HF to maximize their benefit from the healthcare system.\u003c/p\u003e\n\u003cp\u003eThe strengths of this study include the use of a protocol and search strategy before data extraction. The search strategy was carried out by experts and again reviewed by two members of the research team. Moreover, these methods are based on Prisma guidelines. The observed and international findings of this study make it generalizable to patients with HF in healthcare systems.\u003c/p\u003e\n\u003cp\u003eThe limitations of observational studies on communication but not on outcomes could be attributed to the limitations of the current investigation. Ultimately, HF is a complex condition, and its classifications may change over time, which causes variability and consequently heterogeneity in studies.\u003c/p\u003e\n\u003cp\u003eThe aim of this meta-analysis was to consolidate existing data concerning the survival rates of patients with heart failure and identify risk factors. We hope to offer a valuable reference for the development of comprehensive treatment strategies for patients with heart failure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSN initiated and conceptualized the study, and reviewed previous systematic reviews. SN, AM, and SA wrote the manuscript. MAJ advised on the background and methodology section and revised the manuscript for important intellectual content. NN and SM provided insight on epidemiological aspects of the review and helped draft the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their sincere gratitude to the Research Deputy of Rajaie Cardiovascular, Medical, and the specialized cardiologist for HF for their invaluable collaboration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was approved by the ethics committee of the School of Medical Sciences Tarbiat Modares University under the approval ID IR.MODARES.REC.1402.012. informed consent will be obtained from participants.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;there is no funding available to support the publication of the research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHajouli S, Ludhwani D. Heart failure and ejection fraction. In: StatPearls [Internet]. StatPearls Publishing; 2022.\u003c/li\u003e\n \u003cli\u003eRosano GMC, Seferovic P, Savarese G, Spoletini I, Lopatin Y, Gustafsson F, et al. Impact analysis of heart failure across European countries: an ESC‐HFA position paper. ESC Hear Fail. 2022;9(5):2767\u0026ndash;78.\u003c/li\u003e\n \u003cli\u003eAlotaibi FS. Implementation of a machine learning model to predict heart failure disease. Int J Adv Comput Sci Appl. 2019;10(6).\u003c/li\u003e\n \u003cli\u003eJones NR, Roalfe AK, Adoki I, Richard Hobbs FD, Taylor CJ. Survival of patients with chronic heart failure in the community: a systematic review and meta-analysis protocol. Syst Rev. 2018;7:1\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eRiehle C, Bauersachs J. Key inflammatory mechanisms underlying heart failure. Herz. 2019;44(2):96.\u003c/li\u003e\n \u003cli\u003ePellicori P, Khan MJI, Graham FJ, Cleland JGF. New perspectives and future directions in the treatment of heart failure. Heart Fail Rev. 2020;25:147\u0026ndash;59.\u003c/li\u003e\n \u003cli\u003eGroenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. Eur J Heart Fail. 2020;22(8):1342\u0026ndash;56.\u003c/li\u003e\n \u003cli\u003eKingery JR, Roberts NL, Lookens Pierre J, Sufra R, Dade E, Rouzier V, et al. Population-Based Epidemiology of Heart Failure in a Low-Income Country: The Haiti Cardiovascular Disease Cohort. Circ Cardiovasc Qual Outcomes. 2023;16(2):e009093.\u003c/li\u003e\n \u003cli\u003eUrbich M, Globe G, Pantiri K, Heisen M, Bennison C, Wirtz HS, et al. A systematic review of medical costs associated with heart failure in the USA (2014\u0026ndash;2020). Pharmacoeconomics. 2020;38:1219\u0026ndash;36.\u003c/li\u003e\n \u003cli\u003eLecoeur E, Domeng\u0026eacute; O, Fayol A, Jannot AS, Hulot JS. Epidemiology of heart failure in young adults: a French nationwide cohort study. Eur Heart J. 2023;44(5):383\u0026ndash;92.\u003c/li\u003e\n \u003cli\u003eJain V, Minhas AMK, Khan SU, Greene SJ, Pandey A, Van Spall HGC, et al. Trends in HF hospitalizations among young adults in the United States from 2004 to 2018. Heart Fail. 2022;10(5):350\u0026ndash;62.\u003c/li\u003e\n \u003cli\u003eMERAL SMDG. HEART FAILURE IN ELDERLY. Geriatr EMERGENCIES. 2022;51.\u003c/li\u003e\n \u003cli\u003eD\u0026iacute;ez-Villanueva P, Jim\u0026eacute;nez-M\u0026eacute;ndez C, Alfonso F. Heart failure in the elderly. J Geriatr Cardiol JGC. 2021;18(3):219.\u003c/li\u003e\n \u003cli\u003eSavarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: a comprehensive and updated review of epidemiology. Cardiovasc Res. 2022;118(17):3272\u0026ndash;87.\u003c/li\u003e\n \u003cli\u003eShahim B, Kapelios CJ, Savarese G, Lund LH. Global public health burden of heart failure: an updated review. Card Fail Rev. 2023;9.\u003c/li\u003e\n \u003cli\u003eBragazzi NL, Zhong W, Shu J, Abu Much A, Lotan D, Grupper A, et al. Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017. Eur J Prev Cardiol. 2021;28(15):1682\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003ePonikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Kardiol Pol (Polish Hear Journal). 2016;74(10):1037\u0026ndash;147.\u003c/li\u003e\n \u003cli\u003eGuo S, Zhang H, Gao Y, Wang H, Xu L, Gao Z, et al. Survival prediction of heart failure patients using motion-based analysis method. Comput Methods Programs Biomed. 2023;236:107547.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Heart failure, Prognosis, Protocol, Survival, Systematic review, Meta-analysis.","lastPublishedDoi":"10.21203/rs.3.rs-3950855/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3950855/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eHeart failure (HF) is a chronic syndrome that necessitates patients' active management of symptoms and adherence to a complex medication regimen. Identifying and treating symptoms early are crucial components of heart failure care, aiming to enhance quality of life and reduce the risk of hospitalization and mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods and analysis:\u003c/strong\u003e This review included observational studies or studies that incorporated both interventional and observational phases. Three independent reviewers will search multiple databases, including PubMed, Web of Science, and Scopus. There was no geographical restriction, and the languages of the studies were written in English. The studies were published from August 2018 to August 2023. Three independent reviewers will carry out the literature screening, research selection, and data extraction. Stata 17.0 software was used to construct a funnel map, assess heterogeneity, perform subgroup analysis, and complete sensitivity analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and dissemination: \u003c/strong\u003eThis systematic review aimed to present the most recent findings regarding the survival rates and prognostic indicators of individuals with HF. By comparing outcomes over time, we seek to gain insights into the influence of evidence-based treatment advancements on the average survival of patients. The outcomes of this review are expected to be advantageous for various stakeholders, such as patient advocacy groups, the medical community, policymakers, and researchers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePROSPERO registration number: \u003c/strong\u003eCRD42023456390\u003c/p\u003e","manuscriptTitle":"Survival of patients with heart failure: a systematic review and meta-analysis protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-23 10:50:48","doi":"10.21203/rs.3.rs-3950855/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"33184efe-80ea-4cbc-a399-389163ed2a7c","owner":[],"postedDate":"February 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-26T14:58:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-23 10:50:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3950855","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3950855","identity":"rs-3950855","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}