• heart failure
• management of heart failure
• clinical practice
• angiotensin converting enzyme inhibitors
• β blockers

Heart failure is common. It affects, depending on definition, between 1–5% of the population or between 0.5 and 3 million people in the UK.¹ Prospective follow up of a large cohort of non-institutionalised elderly patients (aged >70 years) over six years showed that 15% developed heart failure before they died and that 24% of all deaths over this period were preceded by heart failure.² Heart failure is the most common reason for admission to hospital in people aged over 60 years and complicates many more admissions.^3–5 Using narrowly defined criteria, about 5% of medical beds are occupied by patients with heart failure,^4,6 but broader definitions of heart failure suggest it may be 2–4 times this figure. A survey of elective, non-cardiovascular, surgical admissions suggested that 14% of patients also suffered from heart failure.⁷

Heart failure is disabling. As reported above, heart failure is sufficiently debilitating to cause a large number of hospital admissions. It is also the most common reason for early readmission of patients.⁸ Studies conducted in non-hospitalised patients suggest that heart failure continues to cause gross impairment of the quality of life after discharge.^9,10 A recent large European survey of heart failure in primary care suggested that half of patients remained moderately or severely symptomatic on therapy, perhaps because treatment was suboptimal for most patients.¹¹ Heart failure is also an important risk factor for stroke and renal failure.^12,13

Heart failure is deadly. The three year mortality of patients with new onset heart failure is about 60%, with evidence of a small improvement over the last 15 years.^3,14,15 Mortality is biphasic, with a six month mortality of 35–40% and a 7–10% annual mortality for the entire population thereafter.^3,14 If only six …