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Improving patient outcomes in heart failure: evidence and barriers
  1. John G F Cleland
  1. Academic Unit, Department of Cardiology, University of Hull, Castle Hill Hospital, Kingston Upon Hull, HU16 5JQ, UK
  1. Professor Cleland email: j.g.cleland{at}

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Heart failure affects up to 2% of the adult population.1Interestingly, this rate is remarkably consistent in different populations throughout the world. It does not matter how affluent a society is, the rate of heart failure does not seem to change. In fact, it may be that more affluent societies have more heart failure. It is a disease of the elderly and, in an affluent society, where average life expectancy is increasing, levels of heart failure will also increase. In societies that are not affluent and cardiovascular risk factors are not controlled, the prevalence of heart failure will also be high.

Approximately 50% of patients with the most severe heart failure (New York Heart Association (NYHA) class IV) die within one year of diagnosis.2 In fact, patients diagnosed with heart failure have a three times higher chance of dying within three years than patients diagnosed with breast cancer. If heart failure was a cancer, it would be treated much more effectively. There is a huge fear culture surrounding cancer which demands attention and sucks in resources, but few cardiologists discuss, and few patients with heart failure know, that the prognosis is worse than for most cancers and thus heart failure is not considered a deadly disease in the same way.

Barriers to management


One of the barriers to the management of heart failure is the sheer size of the problem. In addition to those patients with left ventricular systolic dysfunction and signs of heart failure, there are an equal number of patients who have badly damaged hearts, with major left ventricular systolic dysfunction, but without symptoms. It is also thought that there are many patients with all the features of heart failure but who have well preserved systolic function—so called diastolic heart failure. Patients with suspected, but unconfirmed, heart failure probably …

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