No abstract

Within the general population, new cases of heart failure largely occur in the elderly, and the incidence is higher in men than women. The single most common aetiology is coronary heart disease, but in a third of cases the aetiology cannot be determined on the basis of non-invasive investigation alone. To be relevant to clinical practice, future clinical trials in heart failure should not exclude the elderly.

Objective-To describe the survival of a population based cohort of patients with incident (new) heart failure and the clinical features associated with mortality. Design-A population based observational study. Setting-Population of 151 000 served by 82 general practitioners in west London. Patients-New cases of heart failure were identified by daily surveillance of acute hospital admissions to the local district general hospital, and by general practitioner referral of all suspected new cases of heart failure to a rapid access clinic. Interventions-All patients with suspected heart failure underwent clinical assessment, and chest radiography, ECG, and echocardiogram were performed. A panel of three cardiologists reviewed all the data and determined whether the definition of heart failure had been met. Patients were subsequently managed by the general practitioner in consultation with the local cardiologist or admitting physician. Main outcome measures-Death, overall and from cardiovascular causes. Results-There were 90 deaths (83 cardiovascular deaths) in the cohort of 220 patients with incident heart failure over a median follow up of 16 months. Survival was 81% at one month, 75% at three months, 70% at six months, 62% at 12 months, and 57% at 18 months. Lower systolic blood pressure, higher serum creatinine concentration, and greater extent of crackles on auscultation of the lungs were independently predictive of cardiovascular mortality (all p < 0.001). Conclusions-In patients with new heart failure, mortality is high in the first few weeks after diagnosis. Simple clinical features can identify a group of patients at especially high risk of death. (Heart 2000;83:505-510)

Gap junctions in normal adult human working ventricular myocardium occupy an area of 0.0051 micron2/micron3 myocyte volume. This surface area is reduced in ventricular myocardium from hearts subject to chronic hypertrophy and ischemia, despite a normal number of intercellular abutments, and this alteration may contribute to abnormal impulse propagation in these hearts.

Coronary artery disease is the cause of 52% (95% CI 43-61%) of incident heart failure in the general population under 75 years. Clinical assessment without angiography under-estimates the proportion of patients with coronary artery disease, and fails to identify those patients who may benefit from revascularization.