The Journal of International Medical Research 1995; 23: 139 - 153

Identifying the Patient with Heart Failure HIKRAM Christchurch Hospital, Christchurch, New Zealand

Heart failure is becoming an increasing concern to healthcare worldwide, and of particular concern in the Western world where the age of the population continues to rise. Furthermore, it has now become clear that, if heart failure is identified and treated in the earliest stages of ventricular dysfunction, the possibility of recovery from or substantial delay in progression to complete heart failure is extremely good and will give the patient a considerably improved quality of life. Certain signs and symptoms found on routine examination, coupled with knowledge of patient history, can indicate early heart failure. Patients will normally present to their family practitioner, who is likely to have long term, firsthand knowledge ofthe patient's medical and family history. Consequently, the general practitioner has a key role in identifying individuals with early heart failure. It is essential that the general practitioner is aware of the signs and symptoms of early heart failure, can interpret them correctly and knows what follow-up tests are necessary to confirm the diagnosis. Guidelines are presented here to assist the general practitioner in this task. KEY WORDS:

HEART

FAILURE

DIAGNOSIS;

PATHOPHYSIOLOGY;

CLINICAL SIGNS

INTRODUCTION Heart failure is of major concern to healthcare worldwide, especially since the rates of mortality and hospitalization are

increasing considerably each year.' Data from the USA indicate that the overall number of deaths connected with heart failure

139

Hlkrum Identifying the patient with heart failure

increased from 11 425 in 1970 2 to 33227 in 1983 and 39206 in 1991. In parallel with these deaths, the rate of hospitalization attributable to heart failure has also shown a marked increase from 155000 in 1970 to 585000 by 1985 and 772 000 by 1990. 3 Heart failure is now the only cardiovascular disease still increasing in incidence, about 400 000 new cases occurring each year in the USA. Evidence suggests that hypertension is now a less widespread, although still important, cause of heart failure, due to its early identification and treatment." The major underlying causes of heart failure, as shown by the Studies of Left Ventricular Dysfunction (SOLVD) Treatment Triap,6 and by Sutton/ are now ischaemic heart disease and myocardial infarction. In the. UK, chronic heart failure is quite prevalent. A typical UK district general hospital, with a catchment of 250000 patients, is likely to have approximately 20 000 patients with cardiovascular disease, 2500 with chronic heart failure and 10000 heart failure patient consultations per year

(approximately 200 per week). Heart failure is equally prevalent in the USA where it is the most common discharge diagnosis in patients over 65 years of age. A major reason for the growing incidence of heart failure is the increasing age of the population (Fig. 1).8 By the year 2001 it is estimated that 22% of the UK population will be over 75 years old, and there will be a 69% increase in those aged over 85 years. Another major reason for the increase in heart failure is enhanced survival rate following myocardial infarction. Increased sophistication of diagnostic techniques, such as echocardiography, also contributes to an increased detection and, hence, increased apparent incidence of the condition. Heart failure has profound socio-economic implications and these are likely to increase substantially over the next few years. Late-stage heart failure has a very poor prognosis, many patients having a shorter life expectancy than individuals with most forms of cancer: 62% of males die within 5 years of a diagnosis of heart failure (Fig. 2),9

FIGURE 1

•

80 70 c:

0 60 ~ :; a. 50 0 a. 0 40 0 0

-e--

Q;

30

a.

Ql

Cil

a:

20 10 0

45-54 55-64 65-74 75-84 85-94 Age (years)

The incidence of heart failure with increasing age (from Kanne/and Be/angerS).

140

Hlkrom

Identifying the patient with heart failure

FIGURE 2

Ol

Total population sample

Men

1.0

c

'S: .~

0.8

.~

0.8

Women rT ,o - -.••-••.•-••'O.-

o.

:::J

(J)

(J)

0 0.6 ~ 0.4

0

0.6

~ 0.4

is

e

1.0

c "5

:::J

ell .0

Ol

ell .0

0.2

e

o,

CHF

.•....•.•.....• 0.

is

"