Preventing clinical heart failure: the rationale and scientific evidence

The contemporary epidemiology of heart failure shows it is a common clinical problem, at least for the elderly and very elderly, and largely a consequence of coronary artery disease and hypertension.1,2 Patients presenting for the first time with clinical heart failure have a median age of 76 years, and for many life expectancy is poor. A quarter die within three months, over a third by one year, and nearly one in two patients are dead by two years. Most deaths within the first three months occur during initial hospitalisation, and this depressing case fatality is despite appropriate use of modern medical and other therapies. So in contrast to clinical trials of pharmacological treatments in selected patients with heart failure, survival in unselected patients from the general population is, for the most part, much poorer. Although heart failure is the final common pathway for many and diverse cardiac pathologies, the most common is coronary artery disease. At this stage of the disease’s clinical course the benefits of coronary artery interventions, both medical and mechanical, are necessarily limited by the extent of myocardial damage which explains much of the early case fatality. Therefore, preventing or postponing the development of heart failure caused by coronary artery disease is a more appropriate strategy, by addressing the determinants of atherosclerosis and its complications. The London heart failure studies have described the contemporary incidence, aetiology, and survival of patients with heart failure in the population. The first epidemiological study was in Hillingdon in northwest London, where 220 incident cases of heart failure were identified from a population of 151 000 over a 20 month period.1 Incident cases were identified through general practitioners agreeing to refer all suspected cases of new heart failure to a rapid access heart failure clinic held at Hillingdon Hospital. …