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Epidemiology and general pathophysiological classification of heart failure 

Epidemiology and general pathophysiological classification of heart failure
Epidemiology and general pathophysiological classification of heart failure

Theresa A McDonagh

and Kaushik Guha


This chapter and the others in this section are expansions of the conversation that was previously contained in chapter 16.5.1: Clinical features and medical treatments. Older versions of all of the content in this section can be seen in the version history of this chapter.

Updated on 25 February 2016. The previous version of this content can be found here.
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Definition and classification—heart failure is a clinical syndrome caused by cardiac dysfunction, most commonly left ventricular systolic dysfunction (LVSD). Many epidemiological studies focus on characterizing the incidence and/or prevalence of LVSD, using cut off points ranging from less than 30% to less than 50%. Patients with heart failure symptoms or signs and normal or near normal LV function are often classified as having heart failure with preserved ejection fraction (HF-PEF), but there is no clear and generally accepted definition of this condition.

Epidemiology—estimates of incidence and prevalence are heavily influenced by definition. An echocardiographic study of a random sample of the general population aged 25–74 years in Glasgow (Scotland) estimated a prevalence of heart failure of 1.5%, with a further 1.4% having asymptomatic LVSD. Prevalence rises significantly with age, with a median age of first presentation in the mid seventies. Longitudinal data suggests that the incidence of heart failure has remained fairly stable over the last few decades, but prevalence is increasing as more people survive cardiovascular disease earlier in life.

Aetiology—determining the aetiology of heart failure in epidemiological studies is difficult: the commonest cause in the developed world is coronary artery disease, followed by hypertension, which predominates in those with a diagnosis of HF-PEF.

Prognosis and morbidity—data from the United States of America and the United Kingdom show the death rates of those admitted to hospital with a diagnosis of heart failure have a mortality of over 30% at one year. The outcome has improved in recent years, perhaps linked to the increased usage of angiotensin inhibitors and β‎-blockers. Heart failure accounts for around 5% of all adult general medical admissions, and in developed countries the condition consumes 1 to 2% of health care budgets.


Over the last 30 years we have gone from famine to feast for heart failure epidemiological data. The first seminal publication on the natural history of heart failure was from the Framingham Heart Study in 1971, showing a prevalence of heart failure of 0.8% in those aged between 50 and 59 rising to 9.1% in those over 80 years with incidence rates of 0.2% at age 54 and 0.4% at age 85 (Fig. This was followed by a large European study, ‘The Men Born in 1913’, which gave similar figures of a prevalence of 2.1% at age 50 and 13% at age 67 and incidence rates of 0.15% and 1% respectively at ages 50 and 67. These landmark studies relied on a clinical diagnosis of heart failure, based on symptoms, signs, and scoring systems to identify cases. More modern epidemiological studies have used definitions of heart failure which include objective measures of cardiac function in their definition, in keeping with the ever-changing definitions of heart failure as we have developed more insight into its pathophysiology and treatment. Initially studies focused on systolic dysfunction as they reported at much the same time as the heart failure treatment trials which also enrolled patients with systolic heart failure. More recently attention has turned to describing the epidemiology of heart failure with preserved systolic function. This chapter outlines the contemporary epidemiology of heart failure by describing its prevalence, incidence, aetiology, mortality, and trends.

Fig Incidence of heart failure within the Framingham cohort.

Incidence of heart failure within the Framingham cohort.

The natural history of congestive heart failure: the Framingham study. N Engl J Med;1971;285;26;1441–6. McKee PA, Castelli WP, McNamara PM & Kannel WB.

Current pathophysiological description of heart failure

Most clinical practice guidelines produced by the major international cardiology and heart failure societies have very similar definitions of heart failure. All agree that it is not a diagnosis, per se, but a clinical syndrome: a constellation of symptoms and signs that are ultimately due to cardiac dysfunction. That cardiac dysfunction can be epicardial, myocardial, or endocardial in origin. Most commonly heart failure is attributable to myocardial dysfunction. Of particular importance, due to its main causes being coronary artery disease and hypertension, is the occurrence of left ventricular systolic dysfunction (LVSD). This has added significance, as the main heart failure treatment trials which sealed the place of the neurohormonal antagonists in the therapeutics of heart failure were conducted in those with left ventricular ejection fractions (LVEF) which were less than 40%. Many epidemiology studies therefore focused on characterizing the incidence and prevalence of LVSD, using varying cut points of the normally distributed variable, LVEF, ranging from less than 30% to 50%. This difference in the cut points chosen affects the incidence and prevalence rates which are quoted (see Tables and Often studies have classified those with heart failure symptoms and signs with a normal or only mildly reduced left ventricular function to have heart failure with preserved ejection fraction (HF-PEF). In the absence of any convincingly positive drugs trials for this end of the spectrum of heart failure, no unifying definition of HF-PEF has emerged and been applied to community-based studies. The latest definitions of HF-PEF, in addition to symptoms and or signs of heart failure and a relatively preserved ejection fraction, also require evidence of structural heart disease (usually left ventricular hypertrophy, increased left atrial size/volume and Doppler or tissue Doppler evidence of diastolic dysfunction). Rigorous population-based studies with these more modern definitions have yet to appear.

Table Prevalence of symptomatic and asymptomatic LVSD in populations with a calculated prevalence of manifest heart failure where applicable


Name of Study

Number of patients (no of cases of heart failure)


Age Range

Percentage Symptomatic Left Ventricular Systolic Dysfunction (LVSD)

Percentage Asymptomatic Left Ventricular Systolic Dysfunction (ASLVD)

Prevalence of heart failure < 65 yrs of age

Prevalence of heart failure >65 yrs of age

Parameshwar J et al, 1992

Prevalence of heart failure in 3 GP practices

30,204 (117)

North-West London, UK


28% had echoes

0.6 per 1000

27.7 per 1000

Murphy NF et al, 2004

National survey of heart failure

307,741 (2186)

Scotland, UK


7.1 per 1000 (though not <65)

>85–90.1 per 1000

Rutten FH et al, 2003

A questionnaire based survey of heart failure


Utrecht, Netherlands


53 % had echoes 97% -LVSD

McDonagh TA et al, 1997


1640 (43)

North Glasgow, UK


2.9% LVSD

1.4% ALVSD

15 per 1000

Davies M et al, 2001


3960 (72)

West Midlands, UK

1.8% LVSD 3.5% Preserved EF

0.9% ALVSD

31 per 1000 (>45 yrs of age)

Kupari M et al, 1997

Helsinki Ageing Study

501 (41)

Helsinki, Finland


4.1 % HEFPEF 3.9 % LVSD


(75–86)–82 per 1000

Mosterd A et al, 1999

Rotterdam Heart Study

2267 (88)

Rotterdam, Netherlands


3.7% LSVD

1.4% ASLVD


7 per 1000 (55–64)


6 per 1000 (55-64)


37 per 1000 (65–74)

144 per 1000 (75–84)

59 per 1000 (85–94)


16 per 1000 (65–74)

121 per 1000 (75–84)

140 per 1000 (85-94)

Morgan S et al, 1999

Poole Heart Study

817 (61)

Poole, Dorset, UK


7.5 % LVSD

3.9 % ASLVD

Table Studies demonstrating incident rates of heart failure within different populations


Name of study

Number of patients


Age range

Mean/Median age of diagnosis

Incidence of heart failure < 65 yrs of age

Incidence of heart failure>65 yrs of age

McKee PA et al, 1971


Framingham, US


2 per 1000 (45–54 years)

40 per 1000 (85–94 years)

Erikkson H et al, 1989

The men born in 1913


Gothenburg, Sweden


10 per 1000

Cowie MR et al, 1999

Hillingdon Heart Study


Hillingdon, North West London, UK


76 years

0.02 per 1000 (25–34 years)

0.2 per 1000 (35–44 years)

0.2 per 1000 (45–54 years)

1.2 per 1000 (55–64 years)

3 per 1000 (65–74 years)

7.4 per 1000 (75–84 years)

11.6 per 1000 (85–94 years)

Murphy NF et al, 2004

GP database, Continuous morbidity recording scheme

307,741 (2186 cases)

Scotland, UK


1.3 per 1000 (45–64 years)

6.1 per 1000 (65–74)

16 per 1000 (75–84 years)

De Giuli F et al, 2005

GP Research Database

696,884 (6478 cases)

United Kingdom


77 years

3.4 per 1000 (55–64 years)

25.5 per 1000 (75–84 years)

Kalogeropoulos A et al, 2009

ABC Study

2934 (258)

Pittsburgh, & Memphis, Tennesee US


73.6 years

13.6 per 1000

Bibbins-Domingo K et al


5115 (27)

Birmingham, Alabama, Chicago, Illinois, Minneapolis, Oakland, California, US


39.1 years

African American Male (Cumulative Incidence) -0.9%

African American Female (Cumulative Incidence) -1.1%

Caucasian Male (Cumulative Incidence)-0%

Cacuasain Female (Cumulative Incidence) –0.08%


Prevalence studies

Community-based studies

Many studies have been conducted in primary care or across geographical healthcare communities. One of the first was in north-west London where 30 204 case records were reviewed, yielding a crude prevalence of 3.8/100 cases in the general population with a marked rise from those under 65 to those above 65 years of age, where the rate rose from 0.6 per 1000 to 28.0 per 1000.

More recent data is available from the Scottish Continuous Morbidity scheme, which covers 57 general practices in Scotland and uses GP Read codes for heart failure in 307 741 patients. This results in a calculated prevalence of heart failure within the general population in Scotland of 7.1 per 1000, increasing to 90.1 per 1000 in the population above 85 years old. The population identified in the primary care setting were more elderly and had more comorbidities than in population-based studies or clinical trial populations. These findings have been corroborated in a European study based in Utrecht, Netherlands where patients with heart failure who were under the supervision of a cardiologist were more likely to be male, in their sixties, and have an ischaemic aetiology. When considering such data it should be remembered that the signs and symptoms of heart failure are neither sensitive nor specific. Studies evaluating referrals from primary care, when compared to expert cardiology assessment, have revealed only approximately 30% of patients actually have heart failure.

Population-based studies using echocardiography

Systolic dysfunction

The North Glasgow MONICA study was the first to report on the prevalence of left ventricular dysfunction (LVD) in a random sample of the general population of 2000 men and women aged 25–74 years. In this cohort 2.9% had significant systolic dysfunction, and of these just over half had symptoms of breathlessness or were taking a loop diuretic. The estimated prevalence of heart failure in this population was therefore 1.5% with 1.4% having the important precursor of heart failure, asymptomatic systolic dysfunction (ASLVD). The prevalence rose with age and was higher in men than in women (Fig.

Fig. Prevalence of left ventricular systolic dysfunction in the North Glasgow MONICA cohort.

Prevalence of left ventricular systolic dysfunction in the North Glasgow MONICA cohort.

Reprinted from The Lancet, 350, McDonagh TA, Morrison CE, Lawrence A, Ford I, Tunstall-Pedoe H, McMurray JJ, Dargie HJ. Symptomatic and Asymptomatic left ventricular systolic dysfunction in an urban population. Lancet; 829–833; 1997, with permission from Elsevier.

Many studies have reported since both in Europe and in the United States of America. Data from these cohorts is fairly consistent for the general population. Prevalence rates for LVSD were 1.8–3.5% in the ECHOES study from the English Midlands, with 50% of the left ventricular dysfunction being asymptomatic, and in the US Olmsted county study 2.2% had heart failure validated using the Framingham criteria and of these 56% had systolic dysfunction.

When we look at population-based studies which have included much older subjects the prevalence rates increase markedly. In the Helsinki Ageing Study of 501 subjects aged 75–86 years, clinical heart failure was found to be 8.2% overall, 2.3% had systolic dysfunction, and 9% had ASLVD. In the Rotterdam Study of 2267 men and women aged 55–95, 3.7% had fractional shortening of 25% or less (5.5% men and 2.2% women) and 2.2% had asymptomatic left ventricular dysfunction (Fig. Similar findings were reported in a UK study of 817 subjects aged 70–84 years from Poole (southern England) which demonstrated that 7.5% had LVSD (12.2% of men and 2.9% of women) and 52% were undiagnosed.

Fig. Prevalence of left ventricular systolic dysfunction within the Rotterdam Study.

Prevalence of left ventricular systolic dysfunction within the Rotterdam Study.

Mosterd A, Hoes AW, de Brunye MC, Deckers JW, Linker DT, Hofman A, Grobbee DE. Prevalence of heart failure and left ventricular dysfunction in the general population; the Rotterdam study. Eur Heart J;1999;20;6;447–455.

Heart failure with preserved systolic function

Many of the population-based studies them have also by default or design been able to comment on the prevalence of HF-PEF. Hogg et al. reviewed the epidemiological data for HF-PEF and found that the prevalence ranged from 1.5% to 4.8% depending on the study. There was a definite increase in the proportion of heart failure due to this in cohorts which studied more elderly subjects. In the ECHOES study of the general population, 1.1% had definite heart failure and a LVEF greater than 50%, whereas in the Helsinki Ageing Study, 72% of all the heart failure identified occurred with a normal LVEF. In the United States of America, the Rochester Epidemiology Project in a random sample of 2042 subjects over 45 years of age reported similar findings with 44% of subjects having heart failure with a LVEF greater than 50%.

Even higher prevalence rates have been found in a recent large cross-sectional study from Portugal: 16.1% in the population above 80 years old had heart failure. The prevalence was split roughly equally between preserved and reduced ejection fraction. These studies all confirm one thing, that heart failure is common and increases exponentially with age (Fig. It is unsurprising, therefore, that heart failure affects 15 million Europeans and more than 5 million Americans.


Contemporary studies of incidence are far fewer than those for prevalence. In the west London district of Hillingdon all incident cases of heart failure were identified via either a specialist referral clinic or emergency hospital admission (Fig. The population served was 151 000, and 220 new cases were identified. Participants had a full clinical assessment, standard investigations including a chest radiograph, electrocardiogram, and echocardiography; 99% of the study population had an echocardiogram. The gold standard diagnosis was made by a panel of three cardiologists. The incidence rose from 0.02/1000 per year in the 25–34 age group to 11.6/1000 in those aged over 85. Most had LVSD. This study confirmed that heart failure is predominantly a disease of the elderly with a median age of first presentation of 76 years.

Fig. Incidence of heart failure by sex and age group in Hillingdon Heart Failure Study.

Incidence of heart failure by sex and age group in Hillingdon Heart Failure Study.

Cowie MR, Wood DA, Coats AJC, Thompson SG, Poole-Wilson PA, Suresh V & Sutton GC. Eur Heart J;1999;20;421–428.

Incidence data for the United States of America are also reported from the Cardiovascular Health Study, showing a rate of 19.3/1000 person-years in 5.5 years of follow-up. In the United Kingdom data are also available for incidence from general practice from the General Practice Research Database (GPRD): 696 884 potential patients aged above 45 years old were identified. The records were interrogated and categorized on the basis of clinical data and medication prescription patterns. Using this approach, 6478 patients had definite heart failure, 14 050 possible heart failure and 6076 were treated with diuretics but a non-heart-failure diagnosis was assigned. The overall incidence of definite heart failure was 9.3/1000 per year but when possible heart failure was included the figure increased to 20.2/1000 per year. The mean age of the definite heart failure population was 77 years.

More recently data from the Scottish Continuous Morbidity Recording (CMR) data set showed an overall incidence of 2/1000 population per year; it was 25/1000 per year in men over the age of 85 years.

Trends in incidence and prevalence

Data from the Framingham Heart Study have not shown any increase in incidence since the 1970s, dispelling the theory that we are experiencing an epidemic of heart failure. Similarly, data from Medicare records show a slight reduction in incidence from 57.5/1000 to 48.4/1000 person-years in the 80–84 year age group in the period 1994–2003. However, despite the slight reduction in incidence, the prevalence rate rose markedly from 90/1000 to 120/1000. These trends will continue with the changing demography of most Western populations, with more elderly people and a greater number of survivors from cardiovascular disease earlier in life.


Determining the exact aetiology of patients with heart failure in epidemiological studies is difficult. The commonest cause within the Western world currently is coronary artery disease. This represents a change in aetiology over time. When the Framingham study first reported, the main factor was hypertension. Over time in this study the influence of coronary heart disease has increased by 40% in men and 20% in women.

In the North Glasgow MONICA study over 95% of patients with symptomatic LVSD had some evidence of prior ischaemic heart disease (IHD), although hypertension was also prevalent in this group, occurring in 68%. Other data from prevalence studies show similar results. In the ECHOES study, 53% of those with systolic dysfunction had evidence of IHD and 42% had hypertension, and in the Helsinki Ageing Study it was 54% for hypertension and for IHD. In the United States of America data from the Cardiovascular Health Study confirm similar results, with the population attributable risk for heart failure for coronary heart disease being 13.1% and for hypertension 12.8%. Both are clearly important aetiological factors.

In the original Hillingdon study of incident heart failure, 41% of the heart failure cohort was due to coronary artery disease and a much smaller number, 6%, had hypertension. A subsequent study carried out in Bromley (south London) looked into putative ischaemic aetiologies in more depth. All incident cases of heart failure were identified and referred to a specialist dedicated clinic or identified by tracking the patient during their hospitalization. Using the diagnostic criteria, 332 patients had been identified and 99 of the 136 cases under 75 years of age also underwent coronary angiography. An ischaemic aetiology was eventually attributed to 52% of the 136 cases.

Hypertension as a cause of heart failure still seems to predominate in those HF-PEF patients where ischaemic heart disease seems less prominent. These patients tend to be older and there is a higher proportion of women than men. Both diseases are still common: a recent study by Zile showed a prevalence rate of 82% for hypertension and 45% for coronary heart disease in patients with HF-PEF.


Heart failure is predominantly a disease of elderly people and is therefore associated with multiple comorbidities, which include renal impairment, anaemia, diabetes mellitus, obstructive sleep apnoea, and chronic obstructive pulmonary disease. These all have an adverse impact on survival when associated with heart failure.

Anaemia was present in 51% of patients with heart failure in the Rochester Epidemiology Project. Severely impaired renal function was present in 10%. These rates are increased in patients presenting with acute heart failure syndromes: renal dysfunction occurred in 20% of those admitted with decompensated heart failure in the Euroheart Failure Survey II.


The 32-year follow-up of the Framingham study highlighted the substantial mortality rate of heart failure: 62% for men and 42% for women at 5 years of follow-up from incident diagnosis. However, data from the Framingham study have shown consistent improvements in survival over time for both men and women. In Europe, the mortality of incident heart failure also seems to be falling. In the initial Hillingdon study, 25% of patients were dead at 6 months, but in the more recent cohort of this study from 2004–5 this figure had dropped to 14%. This was independent of confounding variables and linked to the increased usage of angiotensin inhibitors and β‎-blockers.

Although mortality is higher in studies of incident heart failure, it is also poor in prevalent cases (Fig. In the ECHOES study, the 5-year survival rate was 53% for those with heart failure due to systolic function. Survival for those with HF-PEF was a little better, at 62%. This is in contrast to the Mayo Clinic data which showed that survival in the community with heart failure was similar for those with systolic and nonsystolic heart failure. However, more recently the Mayo Clinic group reported on 4596 patients of whom 47% had preserved left ventricular function between 1987 and 2001. The survival rate was slightly better within the population with preserved systolic function. However, rates of mortality declined in the population with systolic dysfunction over the study period, whereas patients with normal ventricular function had no change in mortality rates throughout the study period.

Fig. Overall annual mortality from the Echocardiographic Heart of England Screening Study (ECHOES).

Overall annual mortality from the Echocardiographic Heart of England Screening Study (ECHOES).

Hobbs FD, Roalfe AK, Davis RC, Davies MK et al. Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). Eur Heart J;2007;28;9;1128–1134.

The mortality rates for left ventricular dysfunction in the population are also high—21% dead at 4 years in the North Glasgow MONICA cohort—with no significant difference between those with symptoms of heart failure and those with ALVD. This underscores the need for early detection and treatment of this precursor phase of heart failure.

Data from hospitalized patients in Scotland also show a trend to towards improved survival (Fig. Between 1986 and 2003 median survival after a first admission to hospital with heart failure improved in men from 1.3 to 2.3 years and in women from 1.3 to 1.8 years. Overall survival remains poor, with 50% of men dead at 2.3 years and 50% of women dead at 1.7 years after a first admission for heart failure.

Fig. Trends in median survival in Scotland from 1986 until 2003.

Trends in median survival in Scotland from 1986 until 2003.

Jhund PS, McIntyre K, Simpson CR, Lewsey JD, Stewart S, Redpath A, Chalmers JT, Capewell S, McMurray JJV. Long term trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: A study of 5.1 million people. Circulation;2009;119;515–523.

This poorer survival between those with acute heart failure syndromes requiring admission, compared to population-based surveys of prevalence, is now well described. Data from large European and US registries show consistent findings. In the Euro Heart Failure II survey, in-hospital mortality was 6.6%. This varied with presentation but was nearly 40% in those presenting with cardiogenic shock. In-hospital mortality in the United States of America is better, running at 4% in the OPTIMISE heart failure registry.

However, the picture is probably bleaker when we look to data sources that try to capture consecutive admissions to hospital with heart failure. One of the world’s largest single-country audits of acute hospital admissions has been running in the United Kingdom since 2008. Inpatient case fatality rates for those admitted to hospital with a primary diagnosis of heart failure are high; they were 11.1% in 2011/12 and fell slightly to 9.8% in 2012/13. Worryingly, US and UK data show concordant death rates of those admitted to hospital with heart failure of over 30% at 1 year.

Morbidity and hospitalizations

Part of the enormous morbidity incurred by heart failure patients relates to frequent hospitalizations. In advanced heart failure, patients who have been hospitalized experience rehospitalization rates at 6 months of 36–45%. In the 1990s studies in the Netherlands, Scotland, the United States of America, and Sweden documented increasing trends of admissions relating to heart failure. The rise in hospital admissions was accompanied with increasing expenditure. In Scotland, 0.2% of the population were hospitalized per annum and heart-failure-related admissions accounted for more than 5% of all adult general medical admissions. Some evidence has now emerged that heart failure admissions may have peaked in certain European countries during the mid-1990s. Data from Scotland on 116 556 patients identified from hospital discharge records during the period 1986–2003 showed that rates of admission rose and peaked in the mid-1990s and subsequently fell by 2003 (Fig. This is also the case in the Netherlands (Fig.

Fig. Heart failure hospitalization rate in the Netherlands from 1980 to 1999.

Heart failure hospitalization rate in the Netherlands from 1980 to 1999.

Reproduced from Heart, Mosterd A & Hoes AW. 2007;93;9;1137–1146 with permission from BMG Publishing Group.

The most recent American data, however, initially seems to contradict this finding. Using the period between 1979 and 2004, heart failure admissions were recorded using the National Hospital Discharge Survey. The rate of admission tripled from 1 274 000 in 1979 to 3 860 000 in 2004. However, lengths of stay and mortality have reduced in the United States of America according to data from the ADHERE registry.

Health economics

The high prevalence and frequent and recurrent hospitalizations place a large economic burden on healthcare budgets. In the United States of America, total expenditure on heart failure in 2007 was more than $33 billion (£21 billion, €24 billion). The statistics are mirrored in European settings. Within the United Kingdom heart failure consumes 1–2% of the National Health Service budget, which is approximately £1.2 billion (€1.3 billion, $1.8 million). It is the leading cause of hospitalization within the elderly population in the United Kingdom. Approximately 60% of the total expenditure on heart failure in the United Kingdom is spent on hospital admissions. Figures are similar in continental Europe, with heart failure consuming approximately 1% of healthcare budgets. The length of stay also contributes to the expense, with median stay in Europe of 9 days. These estimates of cost are likely to be underestimates as true costs should include all primary care consultations, secondary care referrals, diagnostics, prescribing habits, further therapies including devices and care networks, and surgical intervention including transplantation.


Despite the advances which have been made in its treatment over the course of the last 20 years, which have seen mortality rates for those in clinical trials of heart failure therapies fall to less than 10% per annum, epidemiological studies still indicate that heart failure remains a common, lethal, disabling, and expensive condition. This is hardly surprising as most of the reduction in mortality is due to advances in treatment for a subset of heart failure patients, those with chronic heart failure due to LVSD. We still have much to do. The increasing prevalence of heart failure, and the lack of advances to date for patients presenting acutely to hospital or those with HF-PEF, mean that heart failure still remains a ‘malignant’ condition.

Further reading

Cleland JG, et al. on behalf of the National Heart Failure Audit Team for England and Wales (2011). The national heart failure audit for England and Wales 2008–2009. Heart, 97, 876–86.Find this resource:

Cowie MR, Wood DA, Coats AJC, et al. (1999). Incidence and aetiology of heart failure: a population-based study. Eur Heart J, 20, 421–8.Find this resource:

Davies M, Hobbs F, Davis R, et al. (2001). Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study. Lancet, 358, 439–44.Find this resource:

Fonarow GC, Heywood JT, Heidenreich PA, et al. (2007). Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations in 2002–2004: findings from the ADHERE registry. Am Heart J, 153, 1021–8.Find this resource:

Gottdiener JS, Arnold AM, Aurigemma GP, et al. (2000). Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study. J Am Coll Cardiol, 35, 1628–37.Find this resource:

Ho KKL, Anderson KM, Kannel WB, Grossman W, Levy D. (1993). Survival after the onset of congestive heart failure in Framingham Study subjects. Circulation, 88, 107–15.Find this resource:

Hogg K, Swedberg K, McMurray J. (2004). Heart failure with preserved left ventricular systolic function: epidemiology, clinical characteristics and prognosis. J Am Coll Cardiol, 43, 317–27.Find this resource:

McDonagh TA, Morrison CE, Lawrence A, et al. (1997). Symptomatic and asymptomatic left ventricular systolic dysfunction in an urban population. Lancet, 350, 829–33.Find this resource:

McDonagh TA, Cunningham AD, Morrison CE, et al. (2001). Left ventricular dysfunction, natriuretic peptides, and mortality in an urban population. Heart, 86, 21–6.Find this resource:

McKee PA, Castelli WP, McNamara PM, Kannel WB (1971). The natural history of congestive heart failure: the Framingham study. N Engl J Med, 285, 1441–6.Find this resource:

McMurray JJ, Adamopoulos S, et al. (2012). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail, 14, 803–69.Find this resource:

Mehta PA, Dubrey SW, McIntyre HF, et al. (2009). Improving survival in the 6 months after diagnosis of heart failure in the past decade: population based data from the UK. Heart, 95, 1851–6.Find this resource:

Nieminen MS, Brutsaert D, Dickstein K, et al. (2006). EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J, 27, 2725–36.Find this resource:

Senni M, Tribouilloy CM, Rodeheffer RJ, et al. (1998). Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation, 98, 2282–9.Find this resource:

The National Heart Failure Audit 2011/12 and 12/13.