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Best practice: evidence from the clinical trials
  1. M R Cowie
  1. Correspondence to:
    Professor Martin Cowie, Cardiac Medicine, National Heart & Lung Institute, Faculty of Medicine, Imperial College, Dovehouse Street, London SW3 6LY, UK;

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`What is heart failure?’ is a question that can be addressed from the point of view of the doctor, the health service, and of the patient.

From the medical viewpoint, heart failure is where the heart is damaged to the extent that it is no longer an effective pump. There is a pronounced neurohormonal activation, and the affected patient is breathless, tired, and retains fluid and has a poor quality of life. Furthermore, as has been shown in several population based studies, patients have a reduced life expectancy, irrespective of the age at which they present. The Hillingdon heart failure study looked at incident heart failure in a west London population of 151 000 individuals. A total of 220 incident cases were identified and during a median follow up of 42 months there were 126 deaths. The survival curve dropped rapidly, such that by three months a quarter of these patients had died. At six months only 70% survived and at 12 months this was down to 63% (fig 1).1 Survival among those patients who developed heart failure in the Framingham heart study between 1948 and 1988 was remarkably similar: two years after diagnosis half of the men had died.2

Figure 1

Survival of incident cases of heart failure from the Hillingdon heart failure study (95% confidence intervals also shown). Modified from Cowie et al.1

From the point of view of the health service, heart failure represents a serious problem in that it poses a steadily rising burden on the secondary care sector: it accounts for 5% of acute medical admissions and around 10% of all medical bed days. These patients tend to have prolonged admissions and it is often difficult to discharge them home. Hospital discharge data from Scotland show that from 1983 to 1996 there was …

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