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Heart failure 

Heart failure
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date: 23 October 2019

Heart failure is a well recognized and documented disease entity. Over the last four decades developments have been made in its diagnosis, treatment, management, and epidemiology. However despite the transformation in its management and outcomes, it remains a widely prevalent disease with high levels of mortality. Due to the burden of disease it also carries economic consequences for healthcare systems. Heart failure, four decades ago, carried an extremely poor prognosis, with the medical profession as bystanders. Treatment was with mercurial diuretics and digoxin. Forty years on the modern heart failure patient is treated with a sophisticated algorithm of neuro-hormonal and sympathetic antagonists. Device therapy is also established for patients with heart failure; cardiac resynchronization therapy and implantable cardioverting defibrillators are now commonly implanted and have significantly impacted on morbidity and mortality. Complex health management systems are now the norm, including a variety of multi-disciplinary team members to deal with the medical, electrical, psychological, and social issues which challenge the care of patients with heart failure.

The cornerstone of understanding any disease process is its epidemiology. This is defined as the study of patterns of health and associated factors at the population level. Only once the fundamental patterns of disease have been ascertained can developments be made in terms of therapeutics and selective targeting of aetiologies. Whereas once the epidemiology of heart failure was relatively scarce, there has been much work in this area over the last four decades. There is now a more mature literature resource which is able to guide not only therapeutics but also the deployment of care and the best care models.

However, epidemiology, like all other branches of medicine, has to generate scientifically accurate and robust studies. There are some noteworthy problems with epidemiology, including the methodology of ‘case definition’, the methods of obtaining the data, and the temporal setting of the study. Due to the changes in management, one cannot compare contemporaneous data with historical data. Hence the epidemiology of heart failure has and will continue to evolve. Though much is now known with regards to left ventricular systolic dysfunction, there are still areas which lack a depth and breadth of knowledge. In an increasingly globalized community, it is now becoming evident that some of the traditional risk factors identified from previous work in the West are now applicable to cohorts within the developing world. It should also be remembered that with globalization and the ease of movement, aetiologies of heart failure which are long forgotten in the West may well reappear.

This chapter will focus on ten key papers within the field and highlight their importance, but also their contribution. The chapter is not intended to be an up-to-the-minute review and, if interested, readers are urged to delve into the literature. The papers were chosen because in the authors’ beliefs they were landmark papers which transformed previously held concepts. A landmark paper should be considered a seminal piece of work which both increased understanding of the mechanism of disease, but also conclusively proved an alternative hypothesis. This has led to a constant revision of the best models of care. It is meant to be a summary of heart failure epidemiology and not an overview of heart failure. Therefore in terms of subject areas, it will stay focused on the epidemiology.

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