Heart 2000;83:596–602

+ Comprehensive clinical registries collected

HEART FAILURE in conjunction with clinical trials. These
include a large proportion of individuals
who were identified on the basis of having
Epidemiology, aetiology, and prognosis both impaired left ventricular systolic dys-
of heart failure function and signs and symptoms of heart
failure.
596 Within the context of the specific limitations
John J McMurray, Simon Stewart of the type of data available from these studies,
Clinical Research Initiative in Heart Failure, Wolfson Building, the current understanding of the aetiology, epi-
University of Glasgow, Glasgow, UK demiology, and prognostic implications of
chronic heart failure are discussed here.

H
eart failure is now recognised as a
major and escalating public health Epidemiology of heart failure
problem in industrialised countries
with ageing populations. Any attempt to Prevalence
describe the epidemiology, aetiology, and Table 1 summarises the reported prevalence of
prognosis of heart failure, however, must take heart failure according to whether this was
account of the diYculty in defining exactly estimated from a survey of individuals requir-
what heart failure is. Though the focus of this ing medical treatment from a general prac-
article is the symptomatic syndrome it must be titioner or from population screening. Despite
remembered that as many patients again may the wide variation in the reported prevalence of
have asymptomatic disease that might be heart failure (undoubtedly caused by diVering
legitimately labelled “heart failure”—for exam- research methods, in addition to inherent
ple, asymptomatic left ventricular systolic dys- diVerences in the sociodemographic and risk
function. More comprehensive reviews of the factor profiles of study cohorts), overall these
epidemiology and associated burden of heart data demonstrate that the prevalence of
failure have been published by McMurray and clinically overt heart failure increases consider-
colleagues1 and more recently by Cowie and ably with age. These data also suggest that the
colleagues.2 prevalence of heart failure has increased over
Data relating to the aetiology, epidemiology the past few decades.
and prognostic implications of heart failure are
principally available from five types of studies: Studies of patients visiting a general practitioner
+ Cross sectional and longitudinal follow up There have been several large studies examin-
surveys of well defined populations. These ing the number of patients being treated for
have almost exclusively focused on those signs and symptoms of chronic heart failure by
individuals with clinical signs and symptoms a general practitioner, undertaken in the UK
indicative of chronic heart failure. over the past 40 years. Only some of the more
+ Cross sectional surveys of individuals who recent of these can be reviewed here. For
have been medically treated for signs and example, Paramshwar and colleaguesw1 exam-
symptoms of heart failure within a well ined the clinical records of diuretic treated
defined region. patients in three general practices in northwest
+ Echocardiographic surveys of individuals London in 1992 to identify possible cases of
within a well defined population to deter- heart failure. From a total of 30 204 patients, a
mine the presence of left ventricular systolic clinical diagnosis of heart failure was made in
dysfunction. 117 cases (46 male and 71 female), giving an
+ Nation wide studies of annual trends in overall prevalence of 3.9 cases/1000. Preva-
heart failure related hospitalisation identi- lence of heart failure increased considerably
fied on the basis of diagnostic coding at dis- with age—in those aged under 65 years the
charge. prevalence rate was 0.6 cases/1000 compared

Table 1 Reported prevalence of heart failure1 2

Prevalence rate in older age

Study Location Overall prevalence rate group

Surveys of treated patients

RCGP (1958) UK national data 3/1000 –
Gibson et al (1966) Rural cohort, USA 9-10/1000 65/1000 (>65 years)
RCGP (1986) UK national data 11/1000 –
Parameshwar et al (1992) London, UK 4/1000 28/1000 (> 65 years)
Correspondence to: RodeheVer (1993) Rochester, UK 3/1000 (< 75 years) –
Professor John J Mair et al (1994) Liverpool, UK 15/1000 80/1000 (> 65 years)
RCGP (1995) UK national data 9/1000 74/1000 (65–74 years)
McMurray, The Clarke et al (1995) Nottinghamshire, UK 8-16/1000 40–60/1000 (> 70 years)
Clinical Research Population screening
Initiative in Heart Droller and Pemberton (1953) SheYeld, UK – 30-50/1000 (> 62 years)
Failure, Wolfson Garrison et al (1966) Georgia, USA 21/1000 (45–74 years) 35/1000 (65–74 years)
Building, University of Framingham (1971) Framingham, USA 3/1000 (< 63 years) 23/1000 (60-79 years)
Glasgow, Glasgow, Landahl et al (1984) Sweden (males only) 3/1000 (< 75 years) 80–170/1000 (> 67 years)
Eriksson et al (1989) Gothenburg, Sweden – 130/1000 (> 67 years)
United Kingdom, NHANES (1992) USA national data 20/1000 80/1000 (> 65 years)
G12 8QQ, UK Cardiovascular health study (1993) USA national data 20/1000 80/1000 (> 65 years)
email: RCGP (1995) UK national data 9/1000 (25–74 years) 74/1000 (65–74 years)
J.McMurray@bio.gla.ac.uk
Education in Heart

to 28 cases/1000 in those aged over 65 years. selected 1640 (83%) underwent a detailed
However, objective investigation of left ven- assessment of their cardiovascular status and
tricular function had been undertaken in less underwent echocardiography. Left ventricular
than one third of these patients. Using similar systolic dysfunction was defined as a left
methods, Mair and colleaguesw2 identified a ventricular ejection fraction (LVEF) < 30%.
total of 266 cases of heart failure from 17 400 The overall prevalence of left ventricular systo-
patients within two general practices in Liver- lic dysfunction using this criterion was 2.9%.
pool. Undertaken in 1994, the overall preva- Concurrent symptoms of heart failure were 597
lence rate was 15 cases/1000 patients with 80 found in 1.5% of the cohort, while the remain-
cases/1000 in those aged > 65 years. ing 1.4% were asymptomatic. Prevalence was
More recently, Clarke and colleaguesw3 both greater in men and increased with age: in
reported an even larger survey of heart failure men aged 65–74 years it was 6.4% and in age
based on similar methods and including analy- matched women 4.9%.
sis of prescription of loop diuretics for all resi- The Rotterdam study in the Netherlands,
dents of the English county of Nottingham- though examining individuals aged 55–74
shire. They estimated that between 13 017 and years, reported similar findings. Overall the
26 214 patients had been prescribed frusemide
prevalence of left ventricular systolic dysfunc-
(furosemide) in this region of central England.
tion, defined in this case as fractional shorten-
Case note review of a random sample of those
ing of < 25%, was 5.5% in men and 2.2% in
patients receiving such treatment found that
women.w7
56% were being treated for heart failure. On
this basis they calculated an overall prevalence The Helsinki ageing study describes clinical
rate of 8–16 cases/1000. Once again, heart fail- and echocardiographic findings in 501 subjects
ure prevalence increased with advancing age (367 female) aged 75-86 years.w8 The preva-
with the rate increasing to between 40–60 lence of heart failure, based on clinical criteria,
cases/1000 among those aged > 70 years. was 8.2% overall (41 of 501) and 6.8%, 10%,
and 8.1% in those aged 75, 80, and 85 years,
Population studies based on clinical criteria. respectively. These individuals had a high
There are now many population studies of prevalence of moderate or severe mitral or aor-
heart failure and only some can be reviewed tic valve disease (51%), ischaemic heart disease
here. At entry into the Framingham study, 17 (54%), and hypertension (54%). However, of
of 5209 persons (3 cases/1000) screened for the 41 subjects with “heart failure” only 11
heart failure on the basis of clinical criteria (28%) had significant left ventricular systolic
were thought to have heart failure; all were less dysfunction (diagnosed by the combined pres-
that 63 years of age.w4 After 34 years follow up, ence of fractional shortening < 25% and left
prevalence rates increased as the cohort aged. ventricular dilation), and in 20 cases no
The estimated prevalence of heart failure in the echocardiographic abnormality was identified.
age groups 50–59, 60–69, 70–79, and > 80 Of the 460 without symptoms of heart failure
years was 8, 23, 49, and 91 cases/1000 persons 43 (9%) also had left ventricular systolic
respectively.3 NHANES-1 (national health and dysfunction. The overall prevalence of left ven-
nutrition examination survey) reported the tricular systolic dysfunction was therefore
heart failure prevalence rate within the US 10.8% (95% confidence interval (CI) 8.2% to
population. Based on self reporting, and a 13.8%).
clinical scoring system, this study screened More recently, Morgan and colleaguesw9
14 407 persons of both sexes, aged 25–47 studied 817 individuals aged 70–84 years
years, between 1971 and 1975, with detailed selected from two general practices in South-
evaluation of only 6913 subjects and reported a ampton, England. Left ventricular function
prevalence rate of 20 cases/1000.w5 The study was assessed qualitatively as normal, mild,
of men born in 1913 examined the prevalence moderate or severe systolic dysfunction. The
of heart failure in a cohort of 855 Swedish men overall prevalence of all grades of dysfunction
at ages 50, 54, 57, and 67 years.w6 The was 7.5% (95% CI 5.8% to 9.5%). Prevalence
prevalence rate of “manifest” heart failure rose of left ventricular dysfunction doubled between
dramatically from 21 cases/1000 at age 50 the ages of 70–74 years and > 80 years.
years to 130 cases/1000 at age 67 years.

Prevalence of left ventricular systolic dysfunction Preserved left ventricular systolic function
In only a few of the two types of prevalence One of the most controversial issues pertaining
study described above was objective evidence to the subject of heart failure at present is the
of cardiac dysfunction obtained. Consequently, occurrence of the syndrome in patients with
it is unclear whether all patients really had preserved left ventricular systolic function (and
heart failure and, if they did, what the cause of no other obvious cause, such as valve disease).
heart failure was. There have, however, been A full discussion of this topic is beyond the
four recent estimates of the population preva- scope of this article. There are, however, two
lence of left ventricular systolic dysfunction as recent studies of this type of heart failure. The
determined by echocardiography emanating Olmsted county study, Minnesota, found that
from Scotland,4 the Netherlands, England, and 43% of patients with chronic heart failure had
Finland. an LVEF > 50%.5 Similarly, the Framingham
The Scottish study targeted a representative investigators found that 51% of their cohort
cohort of 2000 persons aged 25–74 years living with heart failure had an LVEF of > 50% (see
north of the River Clyde in Glasgow. Of those also Helsinki ageing study above).6
 Education in Heart

Incidence Table 2 Reported incidence of heart failure.1 2

There is much less known about the incidence
Incidence rate Incidence rate in older
than the prevalence of heart failure. Table 2 Study Location (whole population) age groups
shows reported incidence rates from the largest
population based studies. The most detailed Eriksson et al (1989) Sweden (men born in – 10/1000 (61–67 years)
1913)
incidence data emanate from the Framingham Remes et al (1992) Eastern Finland 1–4/1000 (45–74 years) 8/1000 (> 65 years)
heart study.3 Like other population based Ho et al (1993) Framingham, USA 2/1000 –
598 prevalence studies heart failure was defined RodeheVer et al (1993)
Cowie et al (1999)
Rochester, USA
London, UK
1/1000 (< 75 years)
1/1000
16/1000 (> 65 years)
12/1000 (> 85 years)
according to a clinical scoring system. The only
“cardiac” investigation was chest radiography.
At 34 years follow up, the incidence of heart
failure was approximately 2 new cases/1000 in days on acute geriatric wards. Within the UK
persons aged 45–54 years, increasing to 40 new about one third of patients are readmitted
cases/1000 in men aged 85–94 years. Using within 12 months of discharge, while the same
similar criteria, the study of men born in 1913 proportion are reportedly readmitted within six
reported incidence rates of “manifest” heart months in the USA.8 9 Such readmission rates
failure of 1.5, 4.3, and 10.2 new cases/1000 in are usually higher than the other major causes
men aged 50–54, 55–60, and 61–67 years, of hospitalisation, including stroke, hip frac-
respectively.w6 The Rochester epidemiology ture, and respiratory disease. Moreover, al-
project also reported the incidence of heart though there is evidence to suggest that an
failure in a US population during 1981 in per- increasing number of heart failure patients are
sons aged 0–74 years.w10 The annual incidence
surviving a heart failure related hospital admis-
was 1.1 new cases/1000. Once again incidence
sion, there is a parallel decrease in the number
was higher in men compared to women (1.57 v
0.71 cases/1000, respectively). It also increased of patients who are discharged on an independ-
with age, the rate of new cases increasing from ent basis to their own homes. On a sex specific
0.76/1000 in men aged 45–49 years to basis, men tend to be younger than women
1.6/1000 in men aged 65–69 years. when admitted for the first time with heart fail-
The most recent incidence study was re- ure, but because of greater female longevity, the
ported by Cowie and colleagues from the Hil- number of male and female admissions are
lingdon district of London with a population of roughly equal.
approximately 150 000.7 In a 15 month period,
122 patients were referred to a special heart
Cost of heart failure
failure clinic. This represented an annual refer-
In any health care system, hospital admissions
ral rate of 6.5/1000 population. Using a broad
definition of heart failure, only 29% of these represent a disproportionate component of
patients were clearly diagnosed as having heart total health care expenditure. Not surprisingly,
failure (annual incidence 1.85/1000 popula- considering the high rates of hospitalisation for
tion). heart failure and the ongoing treatment and
care it requires, the overall management of
Heart failure admissions heart failure requires a significant amount of
A diVerent type of epidemiological information health care expenditure in industrialised na-
comes from reports of heart failure related tions. Figure 2 shows that heart failure is
hospital admissions on a country to country reported to consume 1–2% of health care
basis; however, these also need to be inter- expenditure in a number of industrialised
preted with some caution because of their ret- countries.1 Moreover, considering the increas-
rospective nature and variations in coding ing rates of hospitalisation it is likely that these
practices and changing admission thresholds reported estimates fall short of the current
over time. Figure 1 shows the reported burden of heart failure.
hospitalisation rates from Scotland,8 Spain, the
USA, Sweden, New Zealand, and the Nether-
lands for the period 1978 to 1993. As such,
hospitalisation for heart failure appears to be a
growing problem on a global scale. For
example, studies undertaken in the UK suggest
that in the early 1990s 0.2% of the population
were hospitalised for heart failure per annum
and that such admissions accounted for more
than 5% of adult general medicine and geriat-
ric hospital admissions—outnumbering those
associated with acute myocardial infarction.8 In
the USA heart failure continues to be the most
common cause of hospitalisation in people over
the age of 65 years.9
An admission for heart failure is frequently
prolonged and in many cases followed by
readmission within a short period of time. For
example, in the UK the mean length of stay for
Figure 1: Comparison of heart failure admissions rates per annum (recorded
a heart failure related admission in 1990 was hospital admissions/10 000 population at risk) in western developed countries
11.4 days on acute medical wards and 28.5 1978 to 1993. Adapted from data in McMurray et al.1
Education in Heart

Common precursors of chronic heart

failure

x Coronary artery disease (for example,

consequent upon acute myocardial
infarction)

x Chronic hypertension
599
x Cardiomyopathy (for example, dilated,
hypertrophic, alcoholic, and idiopathic)

x Valve dysfunction (for example, diseases of

the aortic and mitral valve)

Figure 2: Cost of chronic heart failure compared with the total health expenditure x Cardiac arrhythmias/conduction
in Sweden, the UK, France, the USA, the Netherlands, and New Zealand. The disturbance (for example, heart block and
figures represent the component of hospital costs contributing to total expenditure atrial fibrillation)
quoted in the local currency and (in parentheses) as a proportion of total health
care expenditure for that country. Adapted from data in McMurray et al.1
x Pericardial disease (for example,
constrictive pericarditis)
Aetiology of heart failure x Infection (for example, rheumatic fever,
Chagas disease, viral myocarditis, and
HIV)
In western developed countries, coronary
artery disease, either alone or in combination
with hypertension, seems to be the most com- tricular hypertrophy in the presence of hyper-
mon cause of heart failure. It is, however, very tension carried an approximate 15 fold
diYcult to be certain what is the primary aeti- increased risk of developing heart failure. In the
ology of heart failure in a patient with multiple subsequent years of follow up, however, coron-
potential causes (for example, coronary artery ary heart disease became increasingly prevalent
disease, hypertension, diabetes mellitus, atrial before the development of heart failure and, as
fibrillation, etc). Furthermore, even the ab- the identified cause of new cases of heart
sence of overt hypertension in a patient failure, increased from 22% in the 1950s to
presenting with heart failure does not rule out almost 70% in the 1970s.w11 During this period,
an important aetiological role in the past, with the relative contribution of hypertension and
normalisation of blood pressure as the patient valvar heart disease declined dramatically.
develops pump failure. Even in those with sus- Figure 3 is a summary of the changing
pected coronary artery disease the diagnosis is association of coronary artery disease, hyper-
not always correct and in the absence of coron- tension, diabetes, and valvar heart disease with
ary angiography must remain presumed rather the subsequent development of heart failure
than confirmed. In this context, even coronary over the period 1950 to 1987.10 As such there
angiography has its limitations in identifying was an approximate 5% and 30% decline in the
atherosclerotic disease. prevalence per decade of hypertension during
The initial cohort of the Framingham heart this period among men and women, respec-
study was monitored until 1965; hypertension tively. The declining contribution of hyper-
appeared to be the most common cause of heart tension most probably reflects the introduction
failure, being identified as the primary cause in of antihypertensive treatment; the parallel
30% of men and 20% of women and a cofactor decline in the prevalence of left ventricular
in a further 33% and 25%, respectively. Moreo- hypertrophy supports this supposition. It is also
ver, electrocardiographic evidence of left ven- probable that during this same period, progres-
sively greater accuracy in determining the pres-
ence of coronary heart disease contributed to its
increasing importance in this regard.
As noted above, however, any interpretation
of the Framingham data has to consider the fact
that heart failure was identified on clinical crite-
ria alone and undoubtedly included individuals
without associated left ventricular systolic dys-
function. Conversely, the large scale clinical
trials have largely recruited patients who have
reduced left ventricular ejection fractions and
applied an extensive list of exclusion criteria.
Table 3 is a summary of the most commonly
attributed causes and associates of heart failure
in a number of clinical trials and registries.11–17
As such it demonstrates that coronary artery
disease appears to be the most common under-
Figure 3: Change in causal factors for heart failure in the Framingham heart
study during the period 1950 to 1987. Adapted from data reported by Kannel WB lying cause of heart failure, consistent with the
et al.10 more recent Framingham experience.
 Education in Heart

Table 3 Aetiology of heart failure in clinical trials and registers.11–17

Clinical trials Registers

SOLVD DIG Study MERIT-HF ATLAS RALES SOLVD SPICE

1991 1997 1999 1999 1999 1992 1999

Size of cohort 2569 6800 3991 3192 1663 6273 9580

Mean age 61 64 64 64 65 62 66
600 Male (%) 80 78 78 79 73 74 74
Aetiology of heart failure
Ischaemic 71% 70% 66% 64% 54% 69% 63%
Non-ischaemic – 29% 34% 35% 46% 31% –
Hypertensive – (9%) – (20%) – 7% 4%
IDCM 18% (15%) – (28%) – 13% 17%
Valvar – – – (6%) – – 5%
Other – 6% – – – 11% –
Unknown – – – – – 6%
Comorbidity
Hypertension 42% – 44% 46% – 43% 27%
Diabetes 26% – 25% 29% – 23% –
Atrial fibrillation 10% – 17% – – 14% –
Current angina 37% – – 27% – –
Respiratory disease 26% – – – – 15% –

In the study of left ventricular function in epidemiology project has also described the
North Glasgow,4 95% v 71% of symptomatic prognosis in 107 patients presenting to associ-
and asymptomatic individuals with definite ated hospitals with new onset heart failure in
left ventricular systolic dysfunction had evi- 1981, and 141 patients presenting in 1991.
dence of coronary artery disease (p = 0.04). The median follow up in these cohorts was
Those individuals with symptomatic heart 1061 and 1233 days, respectively. The mean
failure were also more likely to have a past age of the 1981 patients was 75 years rising to
myocardial infarction (50% v 14%; p = 0.01) 77 years in 1991. The one year and five year
and concurrent angina (62% v 43%; mortality was, respectively, 28% and 66% in
p = 0.02). Hypertension (80%) and valvar the 1981 cohort and 23% and 67% in the
heart disease (25%) were also more prevalent 1991 cohort.w12 In other words, though the
in those individuals with both clinical and same diagnostic criteria used in the Framing-
echocardiographically determined heart ham study were used in the Rochester project,
failure compared to the remainder of the the prognosis was somewhat better in the
cohort, including those with asymptomatic latter.
left ventricular dysfunction (67% and The only other large, representative, epide-
0%, respectively).4 One recent study, miological study reporting long term outcome
however, reports an unknown aetiology for in patients with heart failure is the NHANES-
heart failure in a disturbingly high proportion I.w5 The initial programme evaluated 14 407
of cases.7 adults aged 25 and 74 years in the USA
Therefore, the aetiological importance of between 1971 and 1975. Follow up studies
many of the associated causes of heart failure were carried out in 1982-84 and again in 1986
will depend on both the age cohorts examined (for those aged > 55 years and alive during the
and the type of criteria used to determine the 1982-84 review). The estimated 10 year mor-
presence of heart failure. tality in subjects aged 25–74 years with self
reported heart failure was 42.8% (49.8% in
men and 36% in women). Mortality in those
Prognosis aged 65–74 years was 65.4% (71.8% and
59.5% in men and women, respectively).
Heart failure, irrespective of whether it has These mortality rates are considerably lower
been detected on the basis of being actively than those observed in Framingham. The
treated (for example, during a hospital admis- patients in NHANES-I were non-
sion) or in otherwise asymptomatic individuals, institutionalised and their heart failure was self
is a lethal condition. reported. Follow up was incomplete.
There are some data to suggest that NHANES-I was also carried out in a more
heart failure related mortality is comparable recent time period than Framingham when
to that of cancer. For example, in the original prognosis in heart failure patients may have
and subsequent Framingham cohort, the improved. Framingham investigators in 1993
probability of someone with a diagnosis of looked at patients developing heart failure in
heart failure dying within five years was the period 1948 to 1988 and the Rochester
62% and 75% in men and 38% and 42% in investigators in the period 1981 to 1991. In
women, respectively.18 In comparison, five year both of these studies no temporal change in
survival for all cancers among men and women prognosis was identified.
in the US during the same period was All three of these studies describe a
approximately 50%. The general applicability mixed population of patients, some of whom
of these data is, however, limited by the few had systolic left ventricular dysfunction and
events recorded overall, the relative homoge- others who did not. The true contribution of
neity of the Framingham population, and the heart failure to overall mortality or coronary
exclusion of older individuals. The Rochester artery disease related mortality is almost
Education in Heart

certainly underestimated. Although heart

failure is highly prevalent among the elderly, Summary
representing the terminal manifestation of a
number of cardiovascular disease states, and x Heart failure represents a major and
has been shown to be associated with ex- escalating public health problem.
tremely poor survival rates, oYcial statistics
x The overall prevalence of clinically identified
continue to attribute only a small proportion
heart failure is estimated to be 3–20 cases/ 601
of deaths to this syndrome. This reflects a 1000 population, but rises to > 100 cases/
common policy of coding the cause of death as 1000 population in those aged >65 years.
the underlying aetiology (for example, coron-
ary artery disease rather than heart failure x Prevalence of confirmed left ventricular
itself). systolic dysfunction also increases with age
and is more common in men. However,
these rates are far less than reported for the
Future burden of heart failure syndrome of heart failure.

Despite a decline in age adjusted mortality x The overall annual incidence of clinically
from coronary heart disease (CHD) in overt heart failure in middle aged men and
developed countries overall, the number of women is approximately 0.1–0.2%.
However, with each additional decade of
patients with chronic CHD is increasing. This
life there is an approximate doubling of this
is principally the result of two separate trends.
rate and the incidence of heart failure in
Firstly, the proportion of elderly in the those aged > 85 years is approximately
population is increasing rapidly and these 2–3%.
subjects have the highest incidence of CHD
and hypertension. Secondly, survival in those x Although reported incidence rates are higher
with coronary artery disease is improving. In in men than women, greater longevity in
particular, it has been shown that survival after women tends to balance overall prevalence
acute myocardial infarction has increased rates on a sex specific basis.
notably over the past decade, at least in part
because of better medical treatment.19 As cor- x Heart failure admission rates appear to be
onary artery disease is the most powerful risk steadily increasing in all industrialised
factor for heart failure (and its most important countries, especially among older
precursor) it is likely that the aforementioned individuals. Overall, annual admission rates
trends will lead to an increase its future preva- for 1990 ranged from 10–40 admissions/
lence. Chronic heart failure may, therefore, 10 000 population and increased to > 75
admissions/10 000 population in those
become a more common manifestation of
aged > 65 years.
chronic heart disease and contribute to many
more deaths. Two formal projections of x The cost of managing heart failure in the
the future burden of heart failure have early 1990s was estimated to be 1–2% of
been undertaken in respect to the total health care expenditure. Because
Netherlands20 and Australia.w13 For example, hospital care consumes a significant
an analysis of demographic trends in the proportion of this expenditure, and rates of
Netherlands has predicted that the prevalence heart failure related hospitalisation have
of heart failure caused by coronary heart probably risen, this may be an
disease will rise by approximately 70% from underestimate of the current cost of heart
1985 to 2010. failure.

1. McMurray JJ, Petrie MC, Murdoch DR, et al. Clinical x Heart failure is associated with an
epidemiology of heart failure: public and private health approximately 60% mortality rate within
burden. Eur Heart J 1998;19:P9–16. five years of diagnosis.
2. Cowie MR. Annotated references in epidemiology. Eur
J Heart Failure 1999;1:101–7.
+ An update of a comprehensive overview of the x The combination of increasing survival
epidemiology of heart failure published by the same post acute myocardial infarction and
author in 1997. increased longevity in western developed
3. Ho KK, Pinsky JL, Kannel WB, et al. The epidemiology nations is likely to lead to an increase in the
of heart failure: The Framingham study. J Am Coll Cardiol
1993;22:6A-13A. overall prevalence of heart failure.
+ A follow up report of the classic incidence and
natural history study conducted in a community in
northeastern USA, starting in 1946 and continuing to this
day. It describes the long term follow up of a sizeable ventricular ejection fraction: prevalence and mortality in a
cohort of individuals with chronic heart failure. population-based cohort. J Am Coll Cardiol
1999;33:1948–55.
4. McDonagh TA, Morrison CE, Lawrence A, et al.
Symptomatic and asymptomatic left-ventricular systolic 7. Cowie MR, Wood DA, Coats AJ, et al. Incidence and
dysfunction in an urban population. Lancet aetiology of heart failure; a population-based study. Eur
1997;350:829–33. Heart J 1999;20:421–8.
+ The first population survey of men and women to report + A contemporary, London based, population survey of the
the prevalence estimates of left ventricular systolic incidence and new cases of chronic heart failure in men
dysfunction using echocardiography. It was carried out in and women.
north Glasgow, which has a very high prevalence of
coronary artery disease and hypertension. 8. McMurray J, McDonagh T, Morrison CE, et al. Trends
in hospitalization for heart failure in Scotland 1980–1990.
5. Senni M, Tribouilloy CM, Rodeheffer RJ. Congestive Eur Heart J 1993;14:1158–62.
heart failure in the community: a study of all incident cases + A survey of heart failure related hospitalisations in
in Olmsted County, Minnesota, in 1991. Circulation Scotland during the period 1980 to 1990. It represents the
1998;98:2282–9. first European report of its kind.
6. Vasan RS, Larson MG, Benjamin EJ, et al. Congestive 9. Haldeman GA, Croft JB, Giles WH, et al. Hospitalization
heart failure in subjects with normal versus reduced left of patients with heart failure: national hospital discharge
 Education in Heart

survey 1985–1995. Am Heart J 1999;137:352–60. 16. SOLVD Investigators. Natural history and patterns of
+ A survey of heart failure related hospitalisations in the current practice in heart failure. J Am Coll Cardiol
USA during the period 1985 to 1995. It represents the 1993;4A:14A-19A.
most up to date report from an industrialised nation.
17. Bart BA, Ertl G, Held P, et al. Contemporary
10. Kannel WB, Ho KK, Thom T. Changing epidemiological management of patients with left ventricular systolic
features of cardiac failure. Eur Heart J 1994;72:S3–9. dysfunction. Results from the study of patients intolerant of
+ Using data from the long term surveillance of the
Framingham cohorts, an important overview of the converting enzyme inhibitors (SPICE) registry. Eur Heart J
changing epidemiology and aetiology of heart failure. 1999;20:1182–90.
+ A clinical trial based registry that contains data from 105
602 11. The SOLVD Investigators. Effect of enalapril on
survival in patients with reduced left ventricular ejection
study centres in eight countries in North America and
Europe.
fractions and congestive heart failure. N Engl J Med
1991;325:293–302. 18. Ho KKL, Anderson KM, Karmel WB, et al. Survival
after the onset of congestive heart failure in the Framingham
12. Pitt B, Zannad F, Remme WJ, et al. The effect of
spironolactone on morbidity and mortality in patients with heart study subjects. Circulation 1993;88:107–15.
severe heart failure. Randomized aldactone evaluation study + Another follow up report of the Framingham
investigators. N Engl J Med 1999;341:709–17. study describing extremely poor survival rates in
those individuals diagnosed with chronic heart failure.
13. The Digitalis Investigation Group. The effect of
digoxin on mortality and morbidity in patients with heart 19. Rosamund WD, Chambless LE, Folsom AR, et al.
failure. N Engl J Med 1997;336:525–33. Trends in the incidence of myocardial infarction and in
mortality due to coronary artery disease. N Engl J Med
14. MERIT Investigators. Effect of metoprolol CR/XL in
chronic heart failure: metoprolol CR/XL randomised
1998;339:861–7. website
intervention trial in congestive heart failure (Merit-HF). 20. Bonneux L, Barendregt JJ, Meeter K, et al. Estimating extra
Lancet 1999;353:2001–7. clinical morbidity due to ischaemic heart disease and
congestive heart failure: the future rise of heart failure. Am J Additional references
15. Packer M, Poole-Wilson PA, Armstrong PW, et al.
Comparative effects of low and high doses of the Public Health 1994;84:20–8. appear on the
angiotensin converting enzyme inhibitor, lisinopril, on + The first population based modelling exercise of its kind, Heart website
morbidity and mortality in chronic heart failure. Circulation this study estimated the future prevalence and associated
1999;100:2312–18. burden of chronic heart failure in the Netherlands. www.heartjnl.com