Epidemiología de la insuficiencia cardiaca en España en los últimos 20 años

Heart failure is a major health care problem in Spain, although its precise impact is unknown due to the lack of data from appropriately designed studies. In contrast with the 2% prevalence of heart failure elsewhere in Europe and in the United States, studies in Spain report figures of 5%, probably because of methodological limitations. Heart failure consumes enormous quantities of health care resources; it is the first cause of hospitalization in persons aged 65 years or older and represents 3% of all hospital admissions and 2.5% of health care costs. There are two patterns of heart failure: one with preserved systolic function, more often associated with high blood pressure, and another with depressed systolic function, more often associated with ischemic heart disease. In 2010, heart failure accounted for 3% of all deaths in men and for 10% of all deaths in women. In recent years, the mortality rate from heart failure has gradually fallen. The rise in hospital admissions for heart failure and the decrease in mortality from this cause could partly be explained by temporary changes in diagnostic coding, but there is evidence that the reduced mortality could also be due to adherence to clinical practice guidelines.     

Heart failure mortality in Spain, 1977-1998

INTRODUCTION AND OBJECTIVES: Heart failure is now the third leading cause of cardiovascular death in developed countries and is also an important cause of morbidity and hospitalization that now represents the main cause of admissions among the elderly. In this study we present heart failure mortality trends in Spain developing over the last 20 years. METHODS: Data on deaths due to heart failure were obtained from files supplied by the Spanish National Institute for Statistics. We present age-adjusted specific mortality rates over time analyzed by sex and geographic area. Poisson regression models were used to estimate trends. RESULTS: Heart failure is responsible for 4 to 8% of all-cause mortality in men and women, and for 12 to 20% of cardiovascular mortality overall, the the highest rates seen among the elderly and in Andalusia. The lowest rates are found in the Basque Country and some provinces of Castilla-Leon. Rates have tended to decrease over the last 20 years, but the rate of decrease has been slower in women, such that their mortality began to exceeded that of men from 1990 onwards. Mortality among the elderly has not changed significantly but the total number of deaths and morbidity are both increasing. CONCLUSIONS: Because the Spanish population is aging, we can foresee that chronic heart failure will require greater attention in the future.     

Geographic variation in hospitalizations and mortality related to congestive heart failure in Spain, 1980-1993

BACKGROUND AND OBJECTIVES: Geographical differences in hospitalizations and mortality for heart failure serve to estimate the potential for reducing the associated hospital and demographic burden on the population. Accordingly, the objective of this paper is to analyze the geographic variation in heart failure hospitalizations and mortality in Spain during the period of 1980-1993, and to examine their potential determinants. METHODS: Data on the primary diagnosis of heart failure were taken from the National Hospital Morbidity Survey and National Vital Statistics. Information on determinants of heart failure were obtained from large-scale nationally representative surveys conducted by the National Statistics Office. RESULTS: The period of 1980-1993 witnessed a decrease in geographical differences in heart failure hospitalizations and mortality. Theoretically, however, heart failure hospitalizations and mortality among persons aged > or = 45 years could still be further reduced by 60% and 30% respectively. In the period of 1989-1993 heart failure hospitalizations were correlated (p < 0.05) with ischaemic heart disease hospitalizations and the number of beds/1,000 inhabitants. Heart failure mortality showed a statistically significant correlation (p < 0.05) with ischaemic heart disease mortality, illiteracy and unemployed status. CONCLUSIONS: There is a great potential for a reduction in the hospital and demographic burden of heart failure in Spain. Control of ischaemic heart disease and a reduction in the geographical differences in socio-economic status would probably contribute to lessening the healthcare burden of heart failure in Spain.     

Drug therapy of heart failure in the elderly

Heart failure is a disorder that predominantly affects older adults, with more than 50% of heart failure hospitalizations occurring in persons over 75 years of age. Unfortunately, most of the major heart failure clinical trials have targeted middle-aged patients with systolic heart failure, and the applicability of these studies to elderly patients, particularly those with preserved left ventricular systolic function, remains uncertain. In this paper, current data on the pharmacotherapy of heart failure in older adults are reviewed, recommended approaches to managing systolic and diastolic heart failure are outlined, and the importance of preventive measures is emphasized.     

Epidemiology, clinical features, and prognosis of acute myocardial infarction in the elderly

The incidence and prevalence of acute myocardial infarction (MI) increase progressively with age. In the United States, over 60% of acute MIs occur in patients 65 years of age or older, and approximately one third occur in persons over age 75. In addition, mortality rates following acute MI increase exponentially with age, such that approximately 60% of all MI deaths in the United States occur in the 6% of the population 75 years of age or older. The clinical features of acute MI vary by age. In particular, very elderly patients are less likely than younger patients to report chest pain. Conversely, confusion or altered mental status may be the presenting manifestation of acute MI in up to 20% of patients over 85 years of age. Older patients are also more likely to have "silent" or unrecognized MIs, as well as MIs without ST-segment elevation, compared with younger patients. Elderly patients with acute MI are more likely than younger patients to experience heart failure, atrial fibrillation, cardiac rupture, and shock, all of which are associated with increased mortality. Other factors contributing to the poor prognosis following acute MI in elderly individuals include a marked decline in cardiovascular reserve in the elderly, increased prevalence of comorbid conditions, underutilization of evidence-based therapies, and increased risk of iatrogenic complications.     

Hypertension and heart failure: Diagnosis and management

Heart failure continues to be a significant problem faced by today’s health care professional. Heart failure remains one of the principal causes of cardiovascular morbidity and mortality. The prevalence of heart failure continues to increase, largely due to an aging population and to modern technologic innovations that have led to prolonged survival of the cardiac patient. Hypertension increases the risk for heart failure in all age groups. In those individuals aged 40 years or older whose blood pressure is > 140/90 mm Hg, the lifetime risk for developing heart failure may be twice as high as that of their aged-matched counterparts. Therefore, it is imperative that the clinician be aware of the current diagnostic and therapeutic advancements for the early detection and aggressive treatment of hypertension and heart failure, to prevent patients from developing symptoms of heart failure and to decrease the need for hospitalizations once the diagnosis is confirmed.     

Heart failure in the elderly: strategies to optimize outpatient control and reduce hospitalizations

Heart failure is a disorder that disproportionately affects the elderly, and over 50% of heart failure hospitalizations in the United States occur in persons over 75 years of age. Moreover, despite recent advances in heart failure therapy, optimal treatment of elderly patients remains undefined. In addition, heart failure management in older persons is often complicated by the presence of multiple comorbid conditions, polypharmacy, psychosocial and behavioral concerns, dietary issues, and economic considerations. As a result, management of heart failure in the elderly requires a coordinated, multidisciplinary approach, and a series of recent studies have documented the efficacy of heart failure disease management programs in reducing readmissions, enhancing medication and dietary compliance, and lowering cost of care. Ongoing studies will provide insights into the feasibility and effectiveness of implementing heart failure disease management programs on a population-wide basis, and on the effects of such programs on long-term clinical outcomes and costs.     

Non-cardiovascular co-morbidity in elderly patients with heart failure outnumbers cardiovascular co-morbidity

BACKGROUND: Patients with heart failure often suffer from multiple co-morbid conditions. However, until now only cardiovascular co-morbidity has been well described. AIMS: To understand heart failure in the context of multi-morbidity, by describing the age and sex specific patterns of non-cardiovascular co-morbidity in elderly patients with heart failure in general practice. METHODS: All patients aged 65 years and over, diagnosed with heart failure in four practices of the Nijmegen Academic Practice-based Research Network (NPBRN) between January 1999 and December 2003 were selected, and the prevalence of 27 cardio- and non-cardiovascular co-morbidities determined. RESULTS: Of the 269 patients identified (mean age 79 years; 57% women), 80.2% had four or more co-morbidities. With increasing age, a significant increase in the prevalence of non-cardiovascular conditions like visual and hearing impairments, osteoarthritis, dementia and urine incontinence; and a decrease in cardiovascular conditions like myocardial infarction and in women, hypertension, was observed. In patients aged 85 years and over, non-cardiovascular disorders predominated over cardiovascular disorders. CONCLUSIONS: In elderly patients with heart failure, the prevalence of non-cardiovascular co-morbidity is very high and exceeds the prevalence of cardiovascular conditions. Diseases such as dementia and osteoarthritis must be taken into account in the management of elderly patients with heart failure.     

Effects of losartan versus captopril on mortality in patients with symptomatic heart failure: rationale, design, and baseline characteristics of patients in the Losartan Heart Failure Survival Study--ELITE II.

BACKGROUND: In the Evaluation of Losartan in the Elderly (ELITE) heart failure study, a survival benefit (primarily because of a reduction in sudden deaths) was observed in symptomatic patients treated with losartan compared with captopril. METHODS AND RESULTS: The Losartan Heart Failure Survival Study--ELITE II (currently ongoing) is a double-blind, randomized clinical trial being conducted in 45 countries at 288 sites. ELITE II formally tests the hypotheses that losartan, compared with captopril, will reduce all-cause mortality (primary end point) and sudden cardiac death and/or resuscitated cardiac arrest (secondary end point). In addition, all-cause mortality and/or hospitalizations and cardiovascular mortality and/or hospitalizations will be evaluated. The trial has 90% power to detect a 25% treatment difference in all-cause mortality (event driven, 510 deaths). Substudies are examining quality of life, health care resource utilization, and mechanisms related to the reduction in sudden death. During recruitment (June 1997 to May 1998), 3,152 patients aged 60 years or older (mean age, 71.6 years), with New York Heart Association classes II (51%), III (44%), and IV (5%), and left ventricular ejection fraction of 40% or less (mean, 31%) were randomized to receive either 12.5 mg of losartan, titrated as tolerated to 50 mg once daily, or 12.5 mg of captopril, titrated as tolerated to 50 mg thrice daily. Randomization was stratified by clinical site and for baseline beta-blocker use. CONCLUSION: The ELITE II study will further define the role of losartan in the treatment of patients with symptomatic heart failure relative to the angiotensin-converting enzyme inhibitor captopril, an agent from a class currently considered standard treatment for this disease.     

Long-term cardiovascular consequences of obesity: 20-year follow-up of more than 15 000 middle-aged men and women (the Renfrew-Paisley study).

AIMS: To examine the long-term cardiovascular consequences of obesity and project the cardiovascular consequences of the recent increase in prevalence of obesity. METHODS AND RESULTS: Between 1972 and 1976, 15 402 individuals aged 45-64, living in two towns in the west of Scotland underwent comprehensive cardiovascular screening. We analysed all deaths and hospitalizations for cardiovascular reasons occurring over the subsequent 20 years according to baseline body mass index (BMI) category. Compared with normal weight individuals (BMI 18.5-24.9), obesity (BMI > or =30) was associated with an increased adjusted risk of coronary heart disease (hazard ratio for death or hospital admission: 1.60, 95% CI 1.45-1.78), heart failure (2.09, 1.68-2.59), stroke (1.41, 1.21-1.65), venous thrombo-embolism (2.29, 1.60-3.30), and atrial fibrillation (1.75, 1.17-2.65). Obesity was associated with nine additional cardiovascular deaths and 36 additional cardiovascular hospital admissions for every 100 affected middle-aged men over the subsequent 20 years (seven deaths and 28 admissions in women). Assuming no change in cardiovascular risk profile and outcomes related to obesity, the increase in prevalence in 1998, when compared with 1972, is projected to lead to an additional four cardiovascular deaths and 14 admissions per 100 middle-aged men and women over the next 20 years. CONCLUSION: Obesity is associated with an increase in a broad range of fatal and non-fatal cardiovascular events. Consideration of only coronary, only fatal, and only first events greatly underestimates the cardiovascular consequences of obesity.     

Cardiovascular disease in the Netherlands, 1975 to 1995: decline in mortality, but increasing numbers of patients with chronic conditions

OBJECTIVE: To examine the relation between trends over time in mortality and hospital morbidity caused by various cardiovascular diseases in the Netherlands. DESIGN: Trend analysis by Poisson regression of national data on mortality and hospital admissions from 1975 to 1995. SUBJECTS: The Dutch population. RESULTS: All cardiovascular diseases combined were responsible for 39% of all deaths and 16% of all hospital admissions in 1995. From 1975 to 1995, age adjusted cardiovascular mortality declined by an annual change of -2.0% (95% confidence intervals (CI) -2.1% to -1.9%), while in the same period age adjusted discharge rates increased annually by 1. 3% (95% CI 1.1% to 1.5%). Around 60% of the gain in life expectancy in this period was related to lower cardiovascular mortality. For mortality, major reductions were seen in coronary heart disease (annual change -2.9%) and in stroke (-2.1%), whereas the increase in hospital admissions was mainly caused by chronic manifestations of coronary heart disease (5.1%), heart failure (2.1%), and diseases of the arteries (1.8%). In recent years, the gap between men and women at risk of dying from coronary heart disease became smaller for those aged 相似文献   

Evolution and Current Circumstances of Heart Transplants: Global and Mexican Perspective

A cardiac transplant is an irreplaceable alternative for patients with terminal chronic heart failure refractive to treatment. Heart failure results from an imbalance between cardiac output and organic demand, the prominent etiology is ischemic heart disease and arterial hypertension. In developed countries, it has a prevalence of 4.2%, reaching over 11.8% in adults over 65. It affects around 64.3 million people worldwide, with 9 cases for every 1000 people. This syndrome has a death rate of 56% in 5 years, making heart transplants relevant. The procedure has dramatically evolved from the beginning of animal experimentation in the early 20th century to now, where significant advances are still being made. The purpose of this review is to compile the central aspects of international and Mexico's local heart transplant history and current status, as well as a general view of what this procedure entails and possible prospective outcomes for this practice.     

Trends In Heart Failure Hospitalizations

Heart failure (HF) requiring hospitalization can be defined as an admission to the hospital resulting in a calendar date change. According to the National Hospital Discharge Survey, the number of HF hospitalizations, either as a primary or secondary diagnosis, tripled between 1979 and 2004, and individuals over the age of 65 make 80?% of the prevalent cases of heart failure in the developed countries. HF is the most expensive Diagnosis Related Groups (DRG) diagnosis for hospitalizations in general, and the most frequent diagnosis for 30-day readmissions, incurring 15 billion in cost. To better understand and capture information, registries and trials have started to examine hospitalization rates and HF mortality, in addition to characterizing the hospitalized population. Registries exist worldwide. The role of emergency departments and HF clinics has become paramount in recognizing the preventable hospitalizations and 30-day readmissions, and cost containment.     

Age-associated Cardiovascular Changes in Health: Impact on Cardiovascular Disease in Older Persons

In the United States, cardiovascular disease, e.g., atherosclerosis and hypertension, that lead to heart failure and stroke, is the leading cause of mortality, accounting for over 40 percent of deaths in those aged 65 years and above. Over 80 percent of all cardio-vascular deaths occur in the same age group. Thus, age, per se, is the major risk factor for cardiovascular disease. Clinical manifestations and prognosis of these cardiovascular diseases likely become altered in older persons with advanced age because interactions occur between age-associated cardiovascular changes in health and specific pathophysiologic mechanisms that underlie a disease. A fundamental understanding of age-associated changes in cardiovascular structure and function ranging in scope from humans to molecules is required for effective and efficient prevention and treatment of cardiovascular disease in older persons. A sustained effort over the past two decades has been applied to characterize the multiple effects of aging in health on cardiovascular structure and function in a single study population, the Baltimore Longitudinal Study on Aging. In these studies, community dwelling, volunteer participants are rigorously screened to detect both clinical and occult cardiovascular disease and characterized with respect to lifestyle, e.g. exercise habits, in an attempt to deconvolute interactions among lifestyle, cardiovascular disease and the aging process in health. This review highlights some specific changes in resting cardiovascular structure and function and cardiovascular reserve capacity that occur with advancing age in healthy humans. Observations from relevant experiments in animal models have been integrated with those in humans to provide possible mechanistic insight.     

Epidemiology of sudden coronary death: population at risk

Sudden coronary death is a major manifestation of clinical coronary artery disease which doubles in incidence with each decade of life after age 45, with women lagging behind men in incidence by 20 years. Some 14% of heart attacks present as sudden death, and 41% of deaths from coronary disease are sudden deaths. Half of all sudden coronary deaths occur in persons without prior overt coronary artery disease. Persons with established coronary disease are at a three- to fourfold increased risk of sudden death, but the proportion of coronary deaths due to sudden death is no higher. This report examines how sudden death evolves over the long term in the general population and in persons with overt coronary artery disease, and attempts to delineate prime candidates and modifiable predisposing factors using the Framingham Heart Study. In asymptomatic persons the risk of sudden death varies over a wide range in relation to risk factors such as systolic blood pressure, serum cholesterol, cigarette smoking, heart rate, electrocardiographic abnormality and relative weight. Multivariate combination of these risk factors identifies 38.6% of sudden deaths in men and 43.8% of sudden deaths in women in the upper quintile of multivariate risk, which are, respectively, 6.0 and 5.8 times greater than the proportion of sudden deaths in the lowest quintile. When overt coronary artery disease is manifest, the major risk factors have less influence on sudden death risk, which becomes determined chiefly by indicators of intrinsic myocardial damage. With cardiac failure there is an eightfold increased risk of sudden death in men, and cardiac failure without concomitant coronary artery disease imposes a 2.7-fold increased risk.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prevalence, morbidity, and mortality of heart failure-related hospitalizations in children in the United States: a population-based study

BackgroundFew data exist on prevalence, morbidity, and mortality of pediatric heart failure hospitalizations. We tested the hypotheses that pediatric heart failure–related hospitalizations increased over time but that mortality decreased. Factors associated with mortality and length of stay were also assessed.Methods and ResultsA retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed for pediatric (age ≤18 years) heart failure–related hospitalizations for the years 1997, 2000, 2003, and 2006. Hospitalizations did not significantly increase over time, ranging from 11,153 (95% confidence interval [CI] 8,898–13,409) in 2003 to 13,892 (95% CI 11,528–16,256) in 2006. Hospital length of stay increased from 1997 (mean 13.8 days, 95% CI 12.5–15.2) to 2006 (mean 19.4 days, 95% CI 18.2 to 20.6). Hospital mortality was 7.3% (95% CI 6.9–8.0) and did not vary significantly between years; however, risk-adjusted mortality was less in 2006 (odds ratio 0.70, 95% CI 0.61 to 0.80). The greatest risk of mortality occurred with extracorporeal membrane oxygenation, acute renal failure, and sepsis.ConclusionsHeart failure–related hospitalizations occur in 11,000–14,000 children annually in the United States, with an overall mortality of 7%. Many comorbid conditions influenced hospital mortality.     

Trends in hospitalization for heart failure in Scotland 1980-1990

Heart failure is a growing public health problem in industrializedcountries with ageing populations. Scotland has a relativelystable population of approximately 5 million and a well describedsystem for recording details of hospitalizations (Scottish HospitalIn-Patients Statistics-SHIPS). We have examined SHIPS data forhospitalizations for heart failure in Scotland 1980–1990.Discharges for heart failure as the primary diagnosis increasedby almost 60%, from 1.30 to 2.12/1000 population in this period(as either primary or secondary diagnosis the rate increasedfrom 2.51 to 4.24/1000). Seventy-eight percent of dischargeswere in persons aged 65 years and 48% of discharges were male.Heart failure (primary diagnosis) accounted for almost 4% ofall general (internal) medicine discharges. In-patient casefatality was 18% in 1990. Mean duration of in-patient stay onInternal Medicine wards was approximately 11 days. The number of hospitalizations for heart failure is now almostidentical to those for myocardial infarction. These trends mirrorthose recently reported from the United States. Heart failureis an increasingly common and costly cause of hospitalizationin Scotland. Approaches which can reduce this burden on thehospital service require urgent attention.     

Diagnosis of heart failure in elderly patients in primary care

BACKGROUND: Heart failure is difficult to diagnose in a primary care setting with a reported false positive diagnosis in up to 70% of cases. Aims: To use echocardiography in a large rural practice to evaluate the accuracy of diagnosis of heart failure in patients over 65 years of age. METHODS: Sixty patients with a previous diagnosis of heart failure were selected at random from the practice records and were invited to attend for an echocardiogram at the practice premises. RESULTS: Fifty-eight patients attended, the age was 81+/-7 years, 29% had impaired left ventricular (LV) systolic function of whom 65% were in atrial fibrillation. A further 7% had isolated diastolic LV dysfunction. The prevalence of heart failure by clinical assessment was 29 per 1000 in this patient group and 9 per 1000 when echocardiography was used to confirm the diagnosis. CONCLUSION: True heart failure in this population is less prevalent than has been estimated from practice records.