Heart failure accounts for a substantial proportion of hospitalizations and mortality, particularly in patients over 65 years of age (1). The incidence of the heart failure syndrome continues to increase because of the expansion of the aging population and therapeutic advances in the management of cardiovascular diseases. Recent estimates indicate that one out of five persons will be at risk of developing heart failure over the course of his or her lifetime (Fig. 92.1) (2). As more drugs become available, our attention has been directed toward the escalation of various “salvage therapies” to reduce morbidity and mortality in patients with advanced heart failure (such as destination left ventricular [LV] assist device therapy, internal cardioverter defibrillator, and cardiac resynchronization therapy; see Chapter 86). In the grand scheme of heart failure management, it has become more and more apparent that this costly strategy is providing only modest incremental benefits and is not geared to reduce disease burden or improve public health.

The concept of “heart failure prevention” generally has been lumped into the category of primary prevention of cardiovascular risk factors. Because of the segregation of specialty “silos,” patients with early heart failure (especially following an acute myocardial infarction or chemotherapeutic insult) frequently escape detection until they develop signs and symptoms of heart failure. It is conceivable that multiple factors may contribute to the pathogenesis of symptomatic heart failure; early initiation of pharmacologic therapy may help to prevent disease progression. There are certain known risk factors and structural prerequisites that lead to the development of LV systolic and/or diastolic dysfunction and the clinical syndrome of heart failure. To emphasize that “heart failure” represents a continuum of disease, the latest guidelines from the American College of Cardiology and American Heart Association categorize patients with chronic heart failure into four stages (3) (Table 92.1):

These “stages” are largely descriptive. In fact, our understanding of the pace at which the signs and symptoms of heart failure
progress is rudimentary. The prevention of heart failure exacerbations in patients with stages C and D were discussed in Chapter 86. This chapter focuses our current knowledge in detecting and preventing heart failure in patients at stages A and B.