Manual of Heart Failure Kanu Chatterjee
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Heart Failure: EpidemiologyCHAPTER 1

Kanu Chatterjee
Chapter Outline
  • • Epidemiology
  • • Prevalence
  • • Incidence
    • – Racial Differences
    • – Geographic Differences
    • – Gender Differences
  • • Secular Trends
 
INTRODUCTION
The incidence, prevalence, and etiology of heart failure are variable and influenced by the definition of heart failure used and the relevant causes unique to the individual countries. For example, rheumatic heart disease as a cause of heart failure is more common in developing countries than in developed countries. However, irrespective of countries and the socioeconomic status, there are some common epidemiologic factors.
Aging, hypertension, diabetes, obesity, and increased body mass index are the major risk factors of heart failure.
Heart failure can result from primary valvular, pericardial, or myocardial diseases. It can be acute or chronic. Heart failure complicating acute coronary syndromes or myocarditis are examples of acute heart failure. Heart failure complicating acute coronary syndromes, valvular, pericardial, and myocardial diseases is discussed in different chapters. Decompensated heart failure is discussed in Chapter 8: Acute Heart Failure Syndromes.
Presently chronic heart failure is classified into two major clinical subtypes: (i) heart failure with reduced ejection fraction (HFREF) [also termed systolic heart failure (SHF)] and (ii) heart failure with preserved ejection fraction (HFPEF) [also called diastolic heart failure (DHF)].
In this chapter, the epidemiology of HFREF and HFPEF has been discussed. In subsequent chapters, diagnosis, pathophysiology and management of HFREF and HFPEF have been discussed.
 
EPIDEMIOLOGY
The definition of HFREF is based on measurement of left ventricular ejection fraction. If the ejection fraction is 45% or less, HFREF is diagnosed. In HFPEF, left ventricular ejection fraction should be higher than 45%. For the diagnosis of heart failure based on signs and symptoms, a number of scoring 2systems have been proposed.1 However, in practice and also in clinical trials, the Framingham system is most frequently used.
 
PREVALENCE
Prevalence is calculated by determining the number of total cases occurring in the population at risk. The 2011 American Heart Association update has reported that the prevalence of heart failure is approximately 2.4% of the adult population of the United States of America. In 2011, it was estimated that in the United States of America there were about 5.7 million people had an established diagnosis of heart failure.2 By 2040, it is expected that approximately 10 million people will have heart failure (Tables 1 and 2).2a The worldwide prevalence of heart failure was estimated to be 23 millions.
The prevalence of heart failure increases sharply with age. The Framingham heart study reported the prevalence in men of 8/1,000 at age of 50–59 years which increased to 66/1,000 at ages 80–89 years.3 In women, it was also 8/1,000 at age of 50–59 years and 79/1,000 at ages 80–89 years. In patients younger than 40 years, the prevalence is only 1%; in patients 80 years or older, it is 20%. The 2011 AHA update,2 reported that in the American males the prevalence was 3%, in females 2%. In non-Hispanic males, it was 2.7% and in non-Hispanic females 1.8%. The prevalence is much higher in non-Hispanic Black males, 4.5% and in females, 3.8%. In Mexican-American males the prevalence of heart failure is 2.3% and in females 1.3%.2
TABLE 1   Epidemiology of heart failure in the United States of America
• Estimated 5,50,000 new cases occur/year
• Estimated to rise to 7,72,000/year by year 2040
• More than 5 million Americans have heart failure
• Estimated to increase to 10 million by year 2040
• Among medicare beneficiaries, heart failure is the leading cause of hospitalization
• Cost of HF treatment is >35 billion $ in 2007
TABLE 2   Prevalence of heart failure in the United States of America
• Heart failure is the third most prevalent cardiovascular disease
• Prevalence and age:
  • 20–39—less than 1%
  • 80 or older—about 20%
• Lifetime risk of developing heart failure
  • 20% for both women and men
• Lifetime risk of developing heart failure without coronary artery disease:
  • Age 40—men—11.4%, women—15.4%
3
In Glasgow, Scotland, the estimated prevalence was 1.5% at ages 25–75 years.4 The Rotterdam study reported a prevalence of HFREF of 0.7% in people at ages 55–64 years, 2.7% at 65–74 years and 13% at 75–84 years.5 The similar rates of prevalence have been reported in other studies.68 Redfield and colleagues reported a prevalence of 2.2% in the population at the age of 45 years or older. In this study, patients with both SHFand DHF were included.9
The lifetime risk for developing heart failure has been estimated, and it is about 20% for both men and women. In absence of coronary artery disease at age 40 years, it is 11.4% in men and 15.4% in women.10
It is estimated that the prevalence of heart failure in the United States will increase during next three decades. Currently, approximately 570,000 patients are diagnosed with heart failure per year, and it is estimated that the number will increase to 770,000 per year by the year 2040.3
There appears to be several reasons for this increase in prevalence of heart failure. The aging of the population, improvement in longevity due to salvage of a greater proportion of patients with acute coronary syndrome with the modern therapy and the increase in diabetes and obesity in the population are likely causes for the epidemic of heart failure. Along with the increase in prevalence of heart failure, the hospital admission and readmission rates have increased (Fig. 1). The increased hospital admission rates are not only due to increased frequency of advanced heart failure but also due to comorbidities (such as renal failure), electrolyte abnormalities and multiorgan systems failure.
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FIGURE 1: The increasing rates of hospital admission in women and men with discharge diagnosis of heart failure are illustrated(Source: Modified from American Heart Association)
4
TABLE 3   Rate of hospitalizations, mortality, and morbidity of heart failure in the United States of America
Prevalence
• Increasing rate of hospitalizations:
  • 1979—1,274,000
  • 2004—3,860,000
• More than 80% of patients were among 65 years or older
Prevalence and etiology
• Mortality: Nearly 50,000 annually
• Morbidity: 6.5 million days of hospital stay/year
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FIGURE 2: The readmission rates in heart failure and the prognosis of patients requiring readmission are illustrated(Source: Modified from Jong P, et al. Arch Intern Med. 2002;162:1689–94)
Heart failure is the most common cause of hospital admissions in patients older than 65 years.10 Heart failure is also the most common discharge diagnosis and has increased by over 170% between 1979 and 2003 (Table 3).10 The 2011 AHA update reported that in 2007, there were 990,000 patients were discharged with a diagnosis of heart failure.2 In 1979, just over 1 million patients were admitted to hospital for heart failure; in 2004, it was close to 4 million. More than 80% of patients were 65 years of age or older.11,12 The hospital readmission rates are also high. Approximately 20% of patients are readmitted within 30 days, and 50% within 6 months. The readmissions are also associated with high mortality (Fig. 2). The mortality of patients requiring readmissions is about 12% at 30 days, 33% at 12 months and 50% at 5 years.13
The costs of management of heart failure also increase with number of hospitalizations. The total direct costs of heart failure are primarily related to number of hospitalizations and the length of hospital stay. In many developed countries, the cost of heart failure management is between 1% and 2% of the total health care budget.14 In the United States, the costs of care for heart failure exceeded 35 billion dollars in 2007.
The prevalence of HFPEF (diastolic heart failure) appears to be similar to that of HFREF (systolic heart failure).5
Approximately 50% of patients with overt heart failure have preserved left ventricular ejection fraction. However, there is a considerable variability in the reported prevalence of heart failure with preserved left ventricular ejection fraction, and it ranges between 13% and 74%.15 Similar to HFREF, the prevalence of HFPEF increases with age. It has been estimated that the prevalence in patients younger than 50 years of age is approximately 15%, between 50 and 70 years 33% and older than 70 years 50%.16 In Medicare-eligible patients hospitalized with the diagnosis of heart failure, 34% had preserved left ventricular ejection fraction.17 The HFPEF is more common in women than in men. A multivariate analysis has reported that the prevalence of HFPEF in women twofold higher than that in men (odds ratio 2.07, 95% Confidence Interval 1.93–2.34).
 
INCIDENCE
Incidence is calculated with the number of patients with new onset of heart failure divided by the number of people at risk of developing heart failure.
The incidence of heart failure increases with increasing age. Over each successive decade of life the incidence almost doubles. In the Framingham study, the annual incidence of heart failure in men increased from 2/1,000 at the age 35–64 years to 12/1,000 at the age 65–94 years.3 The lifetime risk (incidence) of developing heart failure is about 20% at all ages older than 40 years.18
There is controversy regarding the incidence of heart failure in relation to time. The Framingham study reported that there has been no change in the age-adjusted incidence of heart failure in men between the time periods 1950–1969 and 1990–1999. In women, there was a decline in the incidence of heart failure.19 In another retrospective study, no change in the age-adjusted incidence of heart failure was found either in men or women between the time period of 1979 and 2000.20 In another study, however, an increase in the age-adjusted incidence of heart failure was reported between the periods 1970–1974 and 1990–1994.21 Among medicare beneficiaries, 65 years of age or older, the incidence of heart failure declined between 1994 and 2003. The decline was largest in people aged 80–84 years.22
The incidence of heart failure is lower in people of younger age. A five-year risk of developing heart failure in people 40 years of age is 0.1–0.2%.18 In another study, a similar lower incidence of heart failure was observed in people younger than 50 years of age.22 The 2011 AHA update reported that the incidence of heart failure in patients 45 years or older was 670,000, in males 350,000, and in females 320,000.26
The risk factors for developing heart failure are summarized in Table 4 and Figure 3. The conventional risk factors are age, gender, hypertension, diabetes, obesity, and coronary artery disease. Insulin resistance, genetic factors and use of cardiotoxins are other risk factors that have been recognized. In patients with diabetes, the risk of developing heart failure in 10 years after the diagnosis is approximately 10% in men and 18% in women. In patients with hypertension, it is 12% in men and 8% in women. In patients having a myocardial infarction approximately of 30% of men and women develop heart failure in 10 years.23 Hypertension as a risk factor is now less common than coronary artery disease for developing heart failure (Table 5).24,25
In the studies of left ventricular dysfunction (SOLVD) registry, approximately 70% of patients had coronary artery disease and only 7% of patients had hypertension who developed SHF (Fig. 3).24 The population attributable risk has been assessed to determine the relative contribution of the various risk factors for developing heart failure.26
TABLE 4   Risk factors for heart failure
Heart failure in the United States of America: Epidemiology
• Increasing age
• Hypertension
• Coronary artery disease
• Diabetes
• Obesity
• Insulin resistance
• Genetic factors
• Use of cardiotoxins
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FIGURE 3: The etiology of systolic heart failure in the SOLVD registry is illustrated. The most common cause was ischemic heart disease.(Source: Modified from Bourassa, et al. J Am Coll Cardiol. 1993;22: 14A-19A)
7
TABLE 5   Risk of heart failure due to diabetes, hypertension, or myocardial infarction
Over 10 years, heart failure develops in
• 10% of men
• 18% of women with diabetes
• 12% of men
• 8% of women with hypertension
• 30% of men
• 30% of women with myocardial infarction
TABLE 6   Racial differences in the incidence of congestive heart failure
Over all incidence
  • African-American
  • Hispanic
  • White
  • Chinese-American
3.1/1000 person-years
4.6/1000 person-years
3.5/1000 person-years
2.4/1000 person-years
1.0/1000 person-years
For coronary artery disease, the overall population attributable risk was 62%. It was 68% in men and 56% in women. For hypertension it was 10%, for cigarette smoking it was 17%, and for diabetes it was 3%. The overweight was associated with the population attributable risk for developing heart failure of 8%. It is of interest that in patients with established heart failure the traditional risk factors appear to be associated with reduced risk of mortality which is called reverse epidemiology.27 Newer risk factors for developing heart failure have been identified. Obesity and central adiposity,28 high-normal albuminuria,29 leukocytosis, particularly granulocytosis and increased levels of C-reactive protein30 are associated with increased risk of heart failure.
 
RACIAL DIFFERENCES
Racial differences in the incidence of heart failure have been investigated (Table 6).31 In the multioethnic study of atherosclerosis, the overall incidence rate of developing heart failure during a median follow-up of 4.0 years was 3.1/1,000 person-years. The incidence rate among African Americans, Hispanic, White and Chinese Americans were 4.6, 3.5, 2.4 and 1.0/1,000 person-years respectively. However, when hypertension and/or diabetes were included, the incidence of congestive heart failure in African Americans were not statistically different compared to other ethnic population. The socioeconomic status also contributed to the higher incidence of congestive heart failure 8in the African Americans. The relative proportion of DHF was also higher in African Americans.
 
GEOGRAPHIC DIFFERENCES
The information about the prevalence or incidence of heart failure in the Asians or Southeast Asians is scarce. However as the incidence of coronary artery disease in these countries are increasing, it is very likely that the prevalence and incidence of heart failure resulting from coronary artery disease are also high. Furthermore, hypertension is very common in these countries and, therefore, hypertension-related heart failure is likely to be common as well.
It has been reported that in Chinese in China, hypertension is the predominant risk factor for developing heart failure.32
In Japan, the characteristics and outcomes of HFPEF and HFREF were compared by using the national registry database. This was a prospective observational study and 2,675 patients were enrolled. The average duration of follow-up was 2.4 years. The patients with HFPEF were more likely to be older female with a higher frequency of hypertension than coronary artery disease. The patients with HFREF were more likely to be male, younger and with a higher frequency of coronary artery disease than hypertension. The risk of mortality and rehospitalization rates were similar in patients with HFPEF and HFREF.33
In Pakistan, the prognosis of new or recent onset of HFREF was evaluated in a relatively small number (196) of patients. These patients were younger and had higher frequency of prior ischemic heart disease. During a follow-up period of 379 days, 27.5% of patients died and 52% had combined event of death or rehospitalization.34
In Singapore, the prognosis of patients with HFREF was evaluated in 225 patients hospitalized for heart failure. Malay and Indian patients had higher incidence of heart failure compared to Chinese. Ischemic heart disease was the most common cause. During 5 years of follow-up, the mortality was 67.5% and female gender, older age, renal failure and severe heart failure were important risk factors.33
In Malaysia, the prevalence and the risk factors of heart failure were assessed from acute medical hospital admissions of 1,435 patients in a busy hospital in Kuala Lumpur. The prevalence of heart failure was 6.7%, and coronary artery disease was the major risk factor. In Malaysian Indians, diabetes was very prevalent.34
In Harrow, United Kingdom, the prevalence and the etiology of left ventricular systolic dysfunction among 1,392 patients who were 45 years of age or older were assessed. The incidence of probable and definite left ventricular systolic dysfunction was 95.5% and 3.5%, respectively. The prevalence was similar in white Caucasians and South Asians.35
In Leicester, United Kingdom, the prognosis and predictive factors were studied among 176 South Asians and 352 age- and sex-matched white Caucasians with new onset of heart failure. The South Asians and white Caucasians had similar rates of coronary heart disease, but the South Asians had more hypertension, diabetes and preserved left ventricular ejection fraction. During follow-up, the mortality in South Asians was 41.2% and in white Caucasians 47.4%. At the time of first hospital admission, heart failure was less severe in South Asians compared to that in white Caucasians.36
Geographic variation in heart failure hospitalization has been recognized.37 Number of primary care physicians per population, regional income level have been associated with rate of hospitalization for the treatment of heart failure.38
 
GENDER DIFFERENCES
The gender differences in the incidence of heart failure have been studied.39 The age-adjusted incidence/1,000 person-years was highest in African Americans men, 9.1, followed by African women, 8.1 (Table 7). The incidence in Caucasian men was 6.0, and 3.4 in Caucasian women. Thus, the lowest incidence was in the Caucasian women in this study.40
In the Malmö preventive project study, 33,342 heart failure subjects were enrolled between 1974 and 1992 to assess the gender differences in the incidence of heart failure.41 In this community-based study, women had lower risk of developing heart failure than men. The incidence of all-cause mortality and heart failure-related death was also lower in women than in men during follow-up of over 20 years.
In patients hospitalized with heart failure, in general women receive less appropriate hospital discharge instructions about follow-up management plans. The length of hospital stay is also longer in women than in men. Older patients, however, are less likely to receive guideline-recommended therapies irrespective of gender, and have higher risks of adverse outcomes.42
TABLE 7   Gender differences in the incidence of congestive heart failure
Heart failure in the United States of America—Epidemiology
Age adjusted incidence rate 1/1000 person-years:
• Caucasian men: 6.0
• African-American men: 9.1
• Caucasian women: 3.4
• African women: 8.1
Lowest incidence is in Caucasian women
10
In patients hospitalized with decompensated heart failure, the incidence of HFPEF and reduced ejection fraction are very similar. The patient with HFPEF is more common in elderly women, and hypertension is more common etiology. Coronary artery disease is more common in HFREF. The incidence of diabetes and atrial fibrillation was slightly higher in HFPEF (Table 8).43
 
SECULAR TRENDS
Very limited information is available regarding the secular trends in the incidence of heart failure. The mortality in men after the diagnosis of heart failure was approximately 70% between 1979 and 1984, 60% between 1985 and 1990 and 50% between 1991 and 1995, and 40% between 1996 and 2000 (Fig. 4).44 In women, it was 60% between 1979 and 1981, 55% between 1985 and 1990, 50% between 1991 and 1995, and 40% between 1996 and 2000.
TABLE 8   Demographic differences between systolic (HFREF) and diastolic (HFPEF) from the ADHERE registry
ADHERE—All enrolled discharges
Profile
SHF
DHF
(59,523)
(50,497)
EF
<40%
>40%
Age
69.9
74.2*
Female
39%
62.2%*
CAD
63%
54%*
Diabetes
42%
46%*
AF
29%
33%*
*<0.0001
(Abbreviations: EF: Ejection fraction; CAD: Coronary artery disease; AF: Atrial fibrillation)
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FIGURE 4: The mortality in men and women in relation to time(Source: Published with permission from Roger, et al. JAMA. 2004;292:344–50)
11
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FIGURES 5A AND B: The mortality in patients with (A) reduced ejection fraction and (B) preserved ejection fraction.(Source: Modified from Owan, et al. N Engl J Med. 2006;355:251–9).
In patients with HFREF, the 5-years mortality between 1987 and 1991 was approximately 70%, between 1992 and 1996 and between 1997 and 2001, 60% (Fig. 5A).45 In patients with preserved ejection fraction, the mortality was approximately 60% during the same periods (Fig. 5B).46
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