By 2040, heart failure in Malta will almost double from 2017 should prevention and treatment trends remain the same, the first nationwide analysis of patients has warned.

Inappropriate treatment for heart failure and lack of follow-up have emerged from the study, showing the effects of excluding life-saving medication on survival rates.

Heart failure will go up to 5.2 per 1,000 of those aged 50 years and over unless there are mitigation measures, the research concludes.

Conducted by Dr Anthony Cutajar for his PhD thesis, the research describes “for the first time” the speed at which heart disease is progressing locally and presents statistical predictions of its burden over the next 15 years by age group and sex.

It set out to understand whether older heart failure patients were getting the same benefits from medication, in terms of mortality reduction, as established by international landmark clinical trials in the 1980s.

Inappropriate follow-up

The study presents evidence of significant survival extension from treatment of patients over 70 years old with required medication, which is equal to younger patients, said Cutajar, an advanced pharmacist practitioner with the Health Ministry.

“Unfortunately, however, it also uncovers suboptimal management in this elderly group of patients that is associated with increased mortality from this disease.

“The real problem was the follow-up, as evidenced by the extensive lack of baseline blood tests,” Cutajar said.

Inappropriate treatment was more common with increasing age and women experienced this bias earlier than men, the findings show.

The majority of patients not on guideline-directed treatment were under the care of non-cardiologists.

The study looks at the use of Angiotensin receptor blockers, used to treat high blood pressure and heart failure, and also ACE inhibitors, medications for treating and managing hypertension, which is a significant risk factor for coronary disease, heart failure, stroke and other cardiovascular conditions.

These reduce mortality by 16 per cent in cases of heart failure and for this reason, they are considered “mainstay” early treatment, excluding contra-indications, Cutajar said.

But in the decade between 2007 and 2017, the period of first diagnosis the study looks at, 51 per cent of these patients failed to receive this treatment either for most of the time or it was completely absent during a three-year follow-up.

The study showed that other heart failure treatment – life-saving medications including beta blockers and spironolactone – was also missing for a high percentage of up to 73 per cent of patients.

“The research did not delve into the reason why. But if you read between the lines and see the level of follow-up involved, around 80 per cent of patients over 70 years old did not have the initial baseline blood tests required before starting treatment and to understand any contraindications.

“This meant inappropriate patient follow-up, which could lead to increased morbidity and mortality, and it is possibly why they failed to receive the therapy,” Cutajar explained.

Failing to undergo critical lab tests during their first diagnostic year meant “the presence of any contraindications could not be a complete explanation to exclude life-saving treatment,” Cutajar argued. “The blood tests were simply not done.”

From 2017 to 2020, the percentage of patients who failed to receive the treatment went down to one in four. But it still meant that 25 per cent were not in line with treatment guidelines, the study maintained.

Encouraging signs

This “major drop” coincided with the opening of the heart failure clinic at Mater Dei Hospital, which meant closer follow-up, Cutajar pointed out.

“It is encouraging to note that the Health Department is planning to expand this service to the newly built Paola health hub and shows the realisation of how important it could be,” he said.

Additional therapy – another two classes of drugs – from the last two years should also be the standard treatment regime but are not on offer, Cutajar insisted, adding they were unaffordable for a large group of heart failure patients.

The government stood to gain as not only would patients live longer but there would also be a reduction in hospitalisations related to heart failure, he continued, noting that cardiologists were requesting these treatments.

Dr Anthony Cutajar (centre) with his research supervisors at Aston University, Birmingham, UK.

At three years post-diagnosis, heart failure patients over 70 years old, who were not on ACE inhibitors and Angiotensin receptor blockers, had a 20 per cent higher probability of death.

“This can also partly explain why Malta has the sixth highest rate of avoidable hospitalisations from heart failure in the EU,” Cutajar said.

“The incidence of disease is three per 1,000 over 50 years old for heart failure with reduced ejection fraction (HFrEF) – a subset of the disease – ranking Malta second highest as of 2023 EU published data.”

Under status-quo heart failure prevention and treatment trends, by 2040, HFrEF incidence will increase by almost 50 per cent, up to 5.2 per 1,000 population aged 50 years and over, the study warned.

This will be driven to a greater extent by males and mostly by the 80 to 89 age group, Cutajar’s research predicted, giving an idea of the impact of a fast-ageing population.

He proposed a three-pronged approach, including ensuring that all patients had access to guideline-directed medical therapy not yet on the government formulary, as well as the improvement of follow-up for patients seen by non-cardiologists.

The country also needed to act on diabetes and obesity, which ranked high on a global level.

Cutajar’s PhD at Aston University, Birmingham, was last year successfully defended in the presence of a UK expert on heart failure from the National Institute for Health and Care Excellence.

The research was made possible thanks to a scholarship awarded through the Endeavour Scholarships Scheme B, aimed at supporting part-time doctoral students whose research has potential of valid contribution to society.