• heart failure
• diagnosis of heart failure
• primary care

• ACE, angiotensin converting enzyme
• BNP, brain natriuretic peptide
• ECHOES, echocardiographic heart of England screening
• LVSD, left ventricular diastolic dysfunction

Heart failure and left ventricular systolic dysfunction (LVSD) are major diseases, with existing high prevalence (around 2% each),^1,2 and prevalence that is on the increase.³ Based on the ECHOES (echocardiographic heart of England screening) study,¹ which probably provides the most precise estimates on heart failure prevalence to date, 2.3% of adults in England over the age of 45 years suffer all cause heart failure, which rises to 3.1% if adults who are symptomatic with borderline abnormal ejection fractions (40–50%) are added. The latter suffer a significantly worse prognosis than people with an ejection fraction above 50%. In addition, 1.8% of adults suffer LVSD, of whom 1% also suffer symptoms and are therefore included within the rates quote for heart failure.

As if this burden of disease was not significant enough, heart failure will get more common, for two main reasons. The first is that despite rates of myocardial infarction declining, infarction remains very common and rates of survival are increasing. Heart failure is an inevitable sequel in a high proportion of survivors (25% over 10 years). Secondly, heart failure is essentially a disease of the elderly with a prevalence of 3% in those aged 65–74 years, 7% in those ages 75–84, and 15% in those over 85.¹ As our populations increasingly age, the consequences in terms of heart failure are self evident.

As well as being very common, both conditions are characterised by very poor prognosis⁴ and quality of life⁵ for patients, and are responsible for among the highest healthcare costs for single conditions.⁶ Prognosis is so poor that heart failure can be effectively considered a malignant disease, with mortality rates equivalent to colorectal cancer and worse than breast or prostate cancer (table 1).⁷