Fig. 6.1
Percentage of population with the diagnosis of heart failure according to age group (From the Heart Disease and Stroke Statistics – 2016 Update)
With the aging of 78 million baby boomers, 1 in 5 Americans is expected to be older than 65 years by 2050, and at risk for HF. This is projected to impact health care and health care economics [5]. It is clear that the burden of heart failure is already increasing. Projections show that by 2030, the total cost of HF will increase almost 127 to $69.7 billion from 2012. This equals ≈ $244 for every US adult [6], and prevalence will increase 46 % from 2012 to 2030, resulting in >8 million people ≥18 years of age with HF [6].
In earlier studies from Framingham, the incidence of HF diagnosed with standardized criteria was between 1.4 and 2.3 per 1000 patients annually, among people 29–79 years old [7]. Data from the Kaiser Permanent system comparing the incidence of HF in 1970–1974 and 1990–1994 in persons 65 years old or greater indicated that the age-adjusted incidence increased by 14 % over this time and was greater for older persons and for men [8]. Conversely, reports from the Framingham Heart study [9] and the Olmsted County Study [10], including outpatient heart failure data, indicate that over time the incidence remained stable [10] or even declined in women [9]. Overall, the Framingham and Olmsted County studies have shown trends of increasing HF incidence among older persons; this pattern is important given the aging of the population.
Health care Burden
Hospitalization/Ambulatory Care
In 2012, there were 1774000 physician office visits with a primary diagnosis of HF (NAMCS, NHLBI tabulation) [11]. There are nearly 658 000 annual emergency department (ED) encounters primarily for acute HF in the USA; almost 20 % of the total HF-specific ambulatory care delivered each year [12]. Ultimately, nearly 80 % of patients treated in the ER are admitted to the hospital [13]. Heart failure is the single most frequent cause of hospitalization in persons 65 years of age or older, and hospital discharges for heart failure increased 175 % between 1979 and 2004 [3]. The annual hospitalization rate for these patients now exceeds 1 million in the United States, 80 % of whom are older than 65 years, and readmission rate as high as 50 % within 6 months of discharge has been reported [14].
National Hospital Discharge Survey data from 1979 to 2004 showed the number of hospitalizations with any mention of heart failure tripled from 1,274,000 in 1979, to 3,860,000 in 2004, and that heart failure was the first-listed diagnosis for 30–35 % of hospitalizations [15]. From 2000 to 2010, it was the first-listed discharge diagnosis of 1008000 and 1023000 patients, respectively [11]. Unfortunately, incidence cannot be obtained from these data, as the statistics were event-based (allowing multiple hospitalizations for the same individual). However, despite the large impact of HF, its burden may be inadequately assessed. In a random sample of all incident HF in Olmsted County from 1987 to 2006, hospitalizations were common after HF diagnosis, with 83 % of patients hospitalized at least once, and 43 % at least 4 times [16]. Global hospitalized heart failure (HHF) registries show that the median length of stay (LOS) ranges from 4 to 20 days and in-hospital mortality from 4 to 30 %. The data based on the American Heart Association’s ongoing Get with the Guidelines – heart failure (GWTG-HF) registry revealed a median LOS of approximately 4 days and in-hospital mortality of <3 % [17]. In the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure) study follow-up cohort representing about 10 % of the overall registry, the postdischarge readmission rate was approximately 30 % within 60–90 days postdischarge, and mortality ranged from 5.4 to 14.0 % based on admission systolic blood pressure. Similarly, the ESC-HF (European Society of Cardiology-Heart Failure) Pilot survey reported 1-year mortality and readmission rates of 17.4 % and 31.9 %, respectively, at representative centers from 12 European countries [18].
Hospitalizations for HF are likely to increase due to an aging population, improved survival after myocardial infarction, and more effective therapies to prevent sudden death, such as b-blockers and implantable cardioverter-defibrillators (ICD). Despite current management options, postdischarge mortality and rehospitalization at 60–90 days are as high as 15 % and 30 %, respectively [19]. This suggests that interventions to avoid readmissions are necessary. It has been shown that patients who have a 1-week follow-up after hospital discharge are less likely to be readmitted within 30 days than those that did not [20].
Mortality
In 2013, 1 in 9 death certificates (284388 deaths) in the United States mentioned heart failure [20]. The number of any-mention deaths attributable to heart failure was approximately as high in 1995 (287000) as it was in 2013 (284000) [11]. Heart failure prognosis is poor, with a survival rate estimated at 50 % and 10 % over 5 and 10 years [21–23]. After age adjustment, 5-year mortality was 59 % in men and 45 % in women during 1990–1999 in the Framingham data [9], and 50 % in men and 46 % in women during 1996–2000 in Olmsted County [10]. Survival improvement in the elderly population was shown in data from the Kaiser Permanent system [8]; survival after diagnosis of HF improved by 33 % in men and 24 % in women and was primarily associated with beta blocker therapy. Data suggest a relative improvement in survival after development of HF [9, 10], but others challenge this, especially in the elderly [24]. Among Medicare beneficiaries, the overall 1-year HF mortality rate declined slightly from 1998 to 2008 but remained high at 29.6 % [25].
Overall, the absolute survival rate after a heart failure diagnosis remains low, and death has increased by 20.5 % in the past decade. In patients older than 67 years old, median survival is less than 3 years after hospitalization for HF [26].
Overall, improvement in survival of the hospitalized HF population is unclear but has been reported by some [27]. In one study, the median survival increase was associated with the effectiveness of angiotensin-converting enzyme inhibitors (ACEI) therapy, increasing from 1.2 to 1.6 years in a sample size of 66,547 patients. These results have been criticized because they were measured in hospitalized patients, without validation; thus, improvement outcomes may be biased by coding trends. Administrative data from the Henry Ford Health system that included outpatient encounters reported a median survival of 4.2 years without discernible improvement over time [26]. Finally, the mortality rate after hospitalization for HF in the Health ABC (health, aging, and body composition study) was 18.0 %, similar to other studies [5, 10, 28].
Diagnosis
Clinically, the ESC guidelines define HF as a “syndrome in which patients have typical symptoms and signs resulting from an abnormality of cardiac structure of function” [29]. The ACCF/AHA Heart failure guidelines [1] described the three most common presentations of patients that healthcare providers usually encounter:
- 1.
With a syndrome of decreased exercise tolerance: Patients that seek medical attention with complaints of reduced effort tolerance, dyspnea and/or fatigue. These symptoms that may occur at rest may be inappropriately attributed by the patients and/or healthcare provider to aging, deconditioning, or other medical disorders (e.g., pulmonary disease)
- 2.
With a syndrome of fluid retention: patients may present complaining of leg or abdominal swelling as their primary, or only, symptom.
- 3.
With no symptoms or symptoms of another cardiac or noncardiac disorder: during the assessment for a disorder other than HF, patients may be found to have evidence of cardiac enlargement or dysfunction
Several diagnostic criteria exist, including the Framingham criteria [7] (Table 6.1), the Boston criteria [30] (Table 6.2), the Gothenburg criteria [31], and the European Society of Cardiology criteria [32]. When the Boston and Framingham criteria were compared blindly [33], their sensitivity was 100 %; however, the specificity and positive predictive value of the Framingham criteria were lower than the Boston criteria for definite heart failure. Some authors recommend use of the Boston criteria in older adults as it has been shown to improve adverse outcome predictability [34]. The comparison of the Cardiovascular Health Study criteria and the Framingham criteria offered similar results [35]. The Framingham criteria offer good performance and are well suited for secular trends as the criteria are unaffected by time and usage of diagnostic test. In earlier Framingham and Olmstead County studies, no survival improvement was reported when heart failure was validated using the Framingham criteria [36].
Table 6.1
Framingham criteria
Major criteria | Minor criteria |
|---|---|
Paroxysmal nocturnal dyspnea | Bilateral ankle edema |
Neck vein distention | Nocturnal cough |
Rales | Dyspnea on ordinary exertion |
Hepatojugular reflex | Hepatomegaly |
Acute pulmonary edema | Pleural effusion |
Third sound gallop | Tachycardia (≥120 beats/min) |
Increased central venous pressure (>16 cm water at the right atrium) | Decrease in vital capacity by 33 % from maximal value recorded |
Radiographic cardiomegaly (increasing heart size on chest X-ray film) | |
Pulmonary edema, visceral congestion or cardiomegaly at autopsy | |
Weight loss ≥4.5 kg in 5 days in response to treatment of CHF |
Table 6.2
Boston criteria
History | |
Rest dyspnea | 4 |
Orthopnea | 4 |
Paroxysmal nocturnal dyspnea | 3 |
Dyspnea on walking on level | 2 |
Dyspnea on climbing | 1 |
Physical examination | |
Heart rate (91–110 min, 1; >110/min, 2) | 1–2 |
Elevated jugular venous pressure (>6 cm H2O 2; >6 cm H2O, plus hepatomegaly or edema 3) | 2–3 |
Rales (basilar 1; > basilar 2) | 1–2 |
Wheezing | 3 |
S3 gallop | 3 |
Chest X-ray | |
Alveolar pulmonary edema | 4 |
Interstitial pulmonary edema | 3 |
Bilateral pleural effusion | 3 |
Cardiothoracic ratio > 0.5 | 3 |
Upper-zone flow redistribution | 2 |
Once the HF diagnosis is established, further classification is determined by the presence of preserved or reduced ejection fraction (EF). A cut-off of 50 % is recommended by the AHA and ACC, and 55 % is recommended by the American Society of Echocardiography guidelines [37]. Heart failure with an EF of 50 % or greater in the absence of major valve disease is defined as heart failure with preserved systolic function [38]. With this threshold, ejection fraction is preserved in more than half of heart failure cases in the community [39, 40]. Assessment of diastolic function, done with two-dimensional echocardiography-Doppler, is a class I indication in the heart failure guidelines [41]. Further, left ventricular function assessment is considered a performance measure for heart failure under the Joint Commission on Accreditation of Health Care Organizations (JCAHO) [42] as left ventricular dysfunction is associated with an increase in risk of sudden death [43].
Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure” [1]. The ACC/AHA guidelines adopted the term “heart failure with preserved ejection fraction” rather than “diastolic heart failure” [1, 41]. It was found that the prevalence of heart failure with preserved ejection fraction in patients discharged between 1987 and 2001 increased. Prevalence increased from 38 to 47 % and then to 54 % in three consecutive 5-year periods. This was more common in community patients versus referral patients (55 % vs. 45 %). Prevalence of preserved ejection fraction in patients with a discharge diagnosis of heart failure was 49 % in patients 65 years or older and 40 % among those under the age of 65 [44]. There raises concern regarding potential misdiagnosis of heart failure in patients with preserved ejection fraction and mild symptoms not requiring hospital admission [45].
Risk Factors
The risk factor profile for cardiovascular disease is changing with increasing prevalence of obesity, metabolic syndrome, and diabetes mellitus [39]. In the Health ABC study (Table 6.3), nine variables were associated with heart failure and included (1) age, (2) left ventricular hypertrophy (LVH), (3) a history of smoking (4) coronary heart disease (CHD), (5) systolic blood pressure (SBP), (6) heart rate, (7) serum glucose, (8) albumin, and (9) creatinine. SBP was dichotomized as controlled vs. uncontrolled at 140 mmHg, fasting glucose level at 125 mg/dL, resting heart rate at 75 beats/min [46] and albumin level at 3.8 g/dL [47]. Smoking and CHD status were collapsed into binary predictors. Independent risk factors were classified as modifiable (CHD, LVH, smoking, glucose level, and SBP) and potentially modifiable (heart rate, albumin level, and renal function). In this study, most modifiable risk factors were significantly more prevalent among black participants (when compared with white participants). Numeric values have been assigned to each variable (Fig. 6.2), and it has showed value in predicting 5-year risk of incident heart failure in the elderly population. It has also showed promise aiding in the identification of subclinical cardiac structural changes and elevated natriuretic peptide levels in the 30–65 years of age population, suggesting it may potentially be a tool for identifying young individuals at increased risk for HF [48].
Table 6.3
Health ABC study risk factors
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