epidemiology of heart failure

Prof. Ahmed Yahya Hegab M.DProf. Ahmed Yahya Hegab M.D..

National Heart InstituteNational Heart Institute..

Epidemiology of HFEpidemiology of HF

Heart Failure DefinitionHeart Failure Definition A complex clinical syndrome that can result from any A complex clinical syndrome that can result from any

structural or functional cardiac disorder that impairs the structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.ability of the ventricle to fill with or eject blood.

Both abnormalities can impair the functional capacity Both abnormalities can impair the functional capacity and quality of life of affected individuals, but they do not and quality of life of affected individuals, but they do not necessarily dominate the clinical picture at the same necessarily dominate the clinical picture at the same time.time.

Hunt SA et al. J Am Coll Cardiol. 2005; 46: e1-e86.

Some patients have exercise intolerance but little Some patients have exercise intolerance but little evidence of fluid retention, whereas others complain evidence of fluid retention, whereas others complain primarily of edema and report few symptoms of dyspnea primarily of edema and report few symptoms of dyspnea or fatigue.or fatigue.

Because not all patients have volume overload at the Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive failure” is preferred over the older term “congestive heart failure.”heart failure.”


Classification of HF: Comparison Classification of HF: Comparison Between ACC/AHA HF Stage and Between ACC/AHA HF Stage and

NYHA Functional ClassNYHA Functional Class

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.

ACC/AHA HF Stage1 NYHA Functional Class2

A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)

B Structural heart disease but withoutsymptoms of heart failure

C Structural heart disease with prior orcurrent symptoms of heart failure

D Refractory heart failure requiringspecialized interventions

I Asymptomatic

II Symptomatic with moderate exertion

IV Symptomatic at rest

III Symptomatic with minimal exertion

None

HF stagesHF stages


• Marked symptoms at rest despite maximal medical therapy (eg, those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)

Refractory end-stage HFD

• Known structural heart disease• Shortness of breath and fatigue• Reduced exercise tolerance

Symptomatic HFC

• Previous MI• LV systolic dysfunction• Asymptomatic valvular disease

Asymptomatic HFB

• Hypertension• CAD • Diabetes mellitus• Family history of cardiomyopathy

High risk for developing heart failure (HF)A

Patient DescriptionStage

Heart Failure Clinical Stages

Symptoms not controlled with treatment

NORMAL

Asymptomatic LV Dysfunction

Compensated

Decompensated

No symptomsNormal exerciseNormal LV fxn

No symptomsNormal exerciseAbnormal LV fxn

No symptoms ExerciseAbnormal LV fxn

Symptoms ExerciseAbnormal LV fxn

Refractory

EpidemiologyEpidemiology

Epidemiology of Heart FailureEpidemiology of Heart Failure

Approximately 5 million patients in the USA have HF, Approximately 5 million patients in the USA have HF, with a yearly incidence of close to 500,000. with a yearly incidence of close to 500,000.

It is primarily a disease of the elderly, with 6-10% It is primarily a disease of the elderly, with 6-10% patients over 65 years old being diagnosed with HF. patients over 65 years old being diagnosed with HF.

80% of hospitalized patients with HF are > 65yo. 80% of hospitalized patients with HF are > 65yo. Heart failure is the most common Medicare DRG. Heart failure is the most common Medicare DRG.


“…“…one-year mortality of approximately 45 one-year mortality of approximately 45 percent.percent.”” 22

““Survival ranges from 80% at 2 years for patients Survival ranges from 80% at 2 years for patients rendered free of congestion to less than 50% at rendered free of congestion to less than 50% at 6 months for patients with refractory 6 months for patients with refractory symptoms.symptoms.”” 33

2 Jessup M, Brozena S, Medical Progress: Heart Failure, NEJM, 348(20): 2007-18, 2003.3 Nohria A, et al, Medical Management of Advanced Heart Failure, JAMA, 287(5): 628-40, 2002.


““Heart failure admission rates are rising, and the Heart failure admission rates are rising, and the prognosis of heart failure has been compared prognosis of heart failure has been compared with that of malignancy, with a 6-year mortality with that of malignancy, with a 6-year mortality rate of 84% in men and 77% in women.rate of 84% in men and 77% in women.”” 44

Heart failure kills people much more surely than Heart failure kills people much more surely than most cancers!most cancers!

Coronary artery disease is the cause of two Coronary artery disease is the cause of two thirds of left ventricular systolic dysfunctionthirds of left ventricular systolic dysfunction

4 Mair F, et al, Evaluation of suspected left ventricular systolic dysfunction, JFP, 51(5): 466-71, 2002.

Epidemiology of Heart Failure Epidemiology of Heart Failure in the USin the US

More deaths from heart failure More deaths from heart failure than from all forms of cancer than from all forms of cancer

combinedcombined

550,000550,000 new cases/yearnew cases/year

4.74.7 million symptomatic patients; million symptomatic patients; estimated 10 million in 2037estimated 10 million in 2037

*Rich M. J Am Geriatric Soc. 1997;45:968–974.American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.

3.5

4.7

10

0

2

4

6

8

10

12

1991 2000 2037*

Hea

rt F

ailu

re P

atie

nts

in U

S(M

illio

ns)

The ESC represents countries with a population The ESC represents countries with a population of >900 million, and thereof >900 million, and there

are at least 15 million patients with HF in those 51 are at least 15 million patients with HF in those 51 countriescountries

prevalence of asymptomatic ventricular prevalence of asymptomatic ventricular dysfunction is similar, that HF or asymptomatic dysfunction is similar, that HF or asymptomatic ventricular dysfunction is evident in 4% of the ventricular dysfunction is evident in 4% of the populatiopopulatio

The prevalence of HF is between 2 andThe prevalence of HF is between 2 and

3%3% and rises sharply at 75 years of age, so the prevalenceand rises sharply at 75 years of age, so the prevalencein 70- to 80-year-old people is between 10 and 20%in 70- to 80-year-old people is between 10 and 20%..

in younger age groups HF is more common in men because thein younger age groups HF is more common in men because the

most common cause, coronary heart disease, occurs in earliermost common cause, coronary heart disease, occurs in earlierdecadesdecades..

In the elderly, the prevalence is equal between the sexesIn the elderly, the prevalence is equal between the sexes..The overall prevalence of HF is increasing because of the ageing ofThe overall prevalence of HF is increasing because of the ageing ofthe population, the success in prolonging survival in patients sufferingthe population, the success in prolonging survival in patients sufferingcoronary events, and the success in postponing coronary events bycoronary events, and the success in postponing coronary events byeffective prevention in those at high risk or those who have already . effective prevention in those at high risk or those who have already . survived a first event (secondary preventionsurvived a first event (secondary prevention

The mean age of patients with HF in theThe mean age of patients with HF in the

community in developed countries is 75 yearscommunity in developed countries is 75 years.. ( HF with Preserved EF )HFPEF is more( HF with Preserved EF )HFPEF is more

common in the elderly, women, and those with common in the elderly, women, and those with hypertension or diabeteshypertension or diabetes..

HF is the cause of 5% of acute hospital admissions, is HF is the cause of 5% of acute hospital admissions, is present in 10% of patients in hospital beds, and present in 10% of patients in hospital beds, and accounts for 2% of national expenditure on accounts for 2% of national expenditure on health,mostly due to the cost of hospital admissionshealth,mostly due to the cost of hospital admissions

The outlook is, in general, gloomy, although some The outlook is, in general, gloomy, although some patients can live for many yearspatients can live for many years..

Overall 50% of patients are dead atOverall 50% of patients are dead at

44 years. Forty per cent of patients admitted to years. Forty per cent of patients admitted to hospital with HFhospital with HF

are dead or readmitted within 1 yearare dead or readmitted within 1 year..

Studies show that the accuracy of diagnosis of Studies show that the accuracy of diagnosis of HF by clinical means alone is often inadequate, HF by clinical means alone is often inadequate, particularly in women, the elderly, and the obese particularly in women, the elderly, and the obese

HFPEF (EF .45HFPEF (EF .45––50%) is present in50%) is present in

half the patients with HF. The prognosis in more half the patients with HF. The prognosis in more recent studies has been shown to be essentially recent studies has been shown to be essentially similar to that of systolic HFsimilar to that of systolic HF

Heart Failure Heart Failure PathophysiologyPathophysiology

NecrosisApoptosis

Cell death

Altered gene expression

Growth and remodeling

Ischemia and energy depletion

Activation of RAS, SNS, and cytokines

Increased loadReduced systemic perfusion

Direct toxicity

Cardiac injury

Progression of Heart Progression of Heart FailureFailure

Coronary artery disease

Hypertension Diabetes

Atrial Fibrillation

Death

PathologicRemodeling

Low ejectionfraction

Left ventricularinjury

Cardiomyopathic factors

Valvular disease

Prevalence of Heart Failure

Source: CDC/NCHS and NHLBI.

Absolute Numbers)millions patients(

Rate)per thousand(

Western Europe 5.3 14

Eastern Europe 1.3 13

Former Soviet Union 5.6 19

North America 5.2 18

Japan 2.4 19

South America ? ?

Asia ? ?

Prevalence of Heart FailurePrevalence of Heart Failure

Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Geneva: World Health Organization; 1996.

Sys/Diastolic Dysfunction Prevalence

Redfield MM et al. JAMA. 2003; 289: 194-202.

Systolic Dysfunction Prevalence

Wang TJ et al. Ann Intern Med. 2003; 138: 907-916. 4%

Temporal Changes in Incidence

Roger VL et al. JAMA. 2004; 292: 344-351.

Cardiovascular Deaths

300,000 death/yr

Survival according to Survival according to NYHA ClassNYHA Class

NYHA Class I–II(SOLVD Prevention Trial)

0 6 12 18 24 30 36 42 480

102030405060708090

100

Mor

talit

y (%

)

Placebo

Months

NYHA Class IV (CONSENSUS)

Conventional therapies (diuretics, digoxin)

NYHA Class II–III(SOLVD Treatment Trial)

CONSENUS Trial Study Group. N Engl J Med. 1987; 316: 1429-1435.The SOLVD Investigators. N Engl J Med. 1991; 325: 293-298.The SOLVD Investigators. N Engl J Med. 1992; 327: 685-690.

Trends in Heart Failure Mortality

Roger VL et al. JAMA. 2004; 292: 344-351.

Mode of Death by NYHA Mode of Death by NYHA ClassClass

NYHA II NYHA III NYHA IV

HF26%

Other 15%

SD59% HF

56%

Other 11%

SD33%

MERIT-HF Study Group. Lancet. 1999; 353: 2001-2007.

HF12%

SD64%

Other 24%

Source: CDC/NCHS.

Heart Failure Hospitalizations

Heart Failure Hospitalizations

Rosamond W et al. Circulation. 2008; 115: e2-e122.

Hos

pita

lizat

ions

/100

,000

Pop

ulat

ion

19700

50

100

150

200

250

1975 1980 1985 1990 1995

Year

65+ years

45-64 years

1 mil hospitalizations/ year

Estimated Direct and Indirect Costs

254.8

142.1

56.8 59.727.9

393.5

050

100150200250300350400450

Hea

rtD

isea

se

Cor

onar

yH

eart

Dis

ease

Str

oke

Hyp

erte

nsiv

eD

isea

se

Con

gest

ive

Hea

rt F

ailu

re

Tot

al C

VD

*

Bill

ions

of D

olla

rs


Heart Failure Direct CostsHeart Failure Direct Costs

Home Health ($3.0 billion) 10%

Drugs/Medical Durables

($3 billion) 10%

Physicians/Other Providers

($2 billion) 7%

Hospital/Nursing Home ($21 billion) 73%

Total Expenditure (direct costs) = $29 billion


epidemiology of heart failure

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