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Congestive Heart Failure: Insights From Epidemiology, Implications for Treatment

1993; Elsevier BV; Volume: 68; Issue: 12 Linguagem: Inglês

10.1016/s0025-6196(12)60078-0

1942-5546

Mohamad H. Yamani, Barry M. Massie,

Cardiovascular Function and Risk Factors

The article by Rodeheffer and colleagues in this issue of the Mayo Clinic Proceedings (pages 1143 to 1150), in which the epidemiologic features of heart failure in Rochester, Minnesota, are examined, provides new insight into trends that have been apparent to health-care practitioners and economists for some time—namely, that congestive heart failure is a common, growing, and fatal condition. Although statistics to confirm this observation abound, several emphasize the importance of this problem. On the basis of data from the current study and other epidemiologic surveys, in the United States more than 3 million adults have evidence of congestive heart failure, and more than 400,000 new cases occur each year.1Smith WM Epidemiology of congestive heart failure.Am J Cardiol. 1985; 55: 3A-8AAbstract Full Text PDF PubMed Scopus (143) Google Scholar, 2Congestive heart failure—a worldwide market study of ACE inhibitors, diuretics and other pharmaceutical products [press release]. New Haven (CT): Technology Management Group, Jun 1992Google Scholar In the United States, Canada, western Europe, and Japan combined, the estimated number of patients with heart failure exceeds 10 million. Heart failure is the most common cardiovascular discharge diagnosis in elderly patients and was the primary diagnosis listed in 770,000 hospital discharge records in 1990, accounting for more than 5 million hospital days and $8 billion in expenditures.3National Center for Health Statistics Graves EJ National Hospital Discharge Survey: Annual Summary, 1990.Vital Health Stat [13]. 1992; 112: 28Google Scholar, 4Munoz E Chalfin D Birnbaum E Mulloy K Johnson H Wise L Hospital costs, resource characteristics, and the dynamics of death for patients with a primary diagnosis of congestive heart failure.N Y State J Med. 1989; 89: 60-63PubMed Google Scholar Aside from hypertension, heart failure is the leading cardiovascular cause for outpatient physician visits as well and results in major additional costs from diagnostic procedures and prescription medications. Despite considerable advances in the diagnosis and treatment of heart failure, associated mortality rates remain high. Perhaps most strikingly, congestive heart failure is the only major cardiovascular disorder that is increasing in incidence, prevalence, and overall mortality. The study by Rodeheffer and coworkers is the latest of several that have examined the epidemiologic characteristics of heart failure in the United States and Europe (Table 1).5McKee PA Castelli WP McNamara PM Kannel WB The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446Crossref PubMed Scopus (2619) Google Scholar, 6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar, 7Eriksson H Svärdsudd K Larsson B Ohlson LO Tibblin G Welin L et al.Risk factors for heart failure in the general population: the study of men born in 1913.Eur Heart J. 1989; 10: 647-656PubMed Google Scholar, 8Remes J Reunanen A Aromaa A Pyörälä K Incidence of heart failure in eastern Finland: a population-based surveillance study.Eur Heart J. 1992; 13: 588-593PubMed Google Scholar, 9Schocken DD Arrieta MI Leaverton PE Ross EA Prevalence and mortality rate of congestive heart failure in the United States.J Am Coll Cardiol. 1992; 20: 301-306Abstract Full Text PDF PubMed Scopus (730) Google Scholar, 10Parameshwar J Shackell MM Richardson A Poole-Wilson PA Sutton GC Prevalence of heart failure in three general practices in north west London.Br J Gen Pract. 1992; 42: 287-289PubMed Google Scholar Several important aspects of these studies differ: sampling methods (population-based versus cohort-based), geography and demographics, case-finding methods (medical record review versus systematic questionnaires and examinations), and diagnostic criteria. Although these differences are likely to be responsible for some of the disparity in findings, they also provide a more robust data base and complementary information. Selected data from each of these studies are shown in Table 2; variation in the format of data presentation, particularly relative to age and gender groupings, makes interstudy comparisons difficult. Despite the diversity of methods, several important points are apparent. Both the incidence and the prevalence of heart failure increase substantially with advancing age and are higher in men than in women. Data are relatively sparse in patients younger than 45 years of age, but the incidence of new cases of heart failure ranges from 1 to 5 per 1,000 patient-years among those younger than age 65 years, approaches 10 per 1,000 patient-years among those older than age 65 years, and substantially exceeds this level beyond age 75 years. The overall prevalence of heart failure is 1 to 2% in middle-aged and older adults, reaches 2 to 3% in patients older than age 65 years, and is 5 to 10% in patients beyond age 75 years. This pronounced increase in incidence and prevalence of heart failure with advancing age, coupled with the aging of the US population, is the primary factor responsible for the growing number of hospitalizations and economic burden related to this condition.Table 1Summary of Recent Epidemiologie Studies of Congestive Heart FailureStudyPopulationCase ascertainmentAssessmentsRochester, MN*See Rodeheffer and associates, pages 1143 to 1150 of this issue.Rochester residents <75 yr of age, 1981-1982113 cases (46 new onset) identified by review of medical recordsIncidence, prevalence, survival, and etiologyFramingham5McKee PA Castelli WP McNamara PM Kannel WB The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446Crossref PubMed Scopus (2619) Google Scholar6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar10,344 patients with longitudinal follow-up, 1948-1988652 cases identified by periodic interviews and examinationsIncidence, prevalence, survival, and etiologyGöteborg7Eriksson H Svärdsudd K Larsson B Ohlson LO Tibblin G Welin L et al.Risk factors for heart failure in the general population: the study of men born in 1913.Eur Heart J. 1989; 10: 647-656PubMed Google ScholarSample of 973 men born in 1913, follow-up 1963-198084 cases identified by interviews and periodic examinationsIncidence, prevalence, and etiologyEastern Finland8Remes J Reunanen A Aromaa A Pyörälä K Incidence of heart failure in eastern Finland: a population-based surveillance study.Eur Heart J. 1992; 13: 588-593PubMed Google Scholar37,600 persons from rural communities in eastern Finland, 1986-198875 cases identified by review of medical and pharmacy recordsIncidenceNHANES9Schocken DD Arrieta MI Leaverton PE Ross EA Prevalence and mortality rate of congestive heart failure in the United States.J Am Coll Cardiol. 1992; 20: 301-306Abstract Full Text PDF PubMed Scopus (730) Google Scholar†NHANES = National Health and Nutrition Examination Survey.14,407 persons 25-74 yr of age, examined 1971-1975,10-15 yr of follow-upCases identified by questionnaire and examinationPrevalence and survivalLondon10Parameshwar J Shackell MM Richardson A Poole-Wilson PA Sutton GC Prevalence of heart failure in three general practices in north west London.Br J Gen Pract. 1992; 42: 287-289PubMed Google Scholar30,204 patients in 3 practices, 1988117 cases identified by review of recordsPrevalence and etiology* See Rodeheffer and associates, pages 1143 to 1150 of this issue.† NHANES = National Health and Nutrition Examination Survey. Open table in a new tab Table 2Incidence and Prevalence of Congestive Heart Failure in Six Epidemiologie StudiesStudy and age subset (yr)Incidence (per 1,000 patient-years)Prevalence (per 1,000 patients)MenWomenTotalMenWomenTotalRochester, MN*See Rodeheffer and associates, pages 1143 to 1150 of this issue. 45-540.8……0.81.5… 55-644.01.3…9.75.2… 65-7413.27.2…26.819.4… 0-740.71.61.13.32.12.7Framingham5McKee PA Castelli WP McNamara PM Kannel WB The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446Crossref PubMed Scopus (2619) Google Scholar6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar 45-542.01.0………8†Prevalence rates are for age-groups 50-59 yr, 60-69 yr, 70-79 yr, and 80-89 yr, respectively. 55-644.03.0………23†Prevalence rates are for age-groups 50-59 yr, 60-69 yr, 70-79 yr, and 80-89 yr, respectively. 65-748.05.0………49†Prevalence rates are for age-groups 50-59 yr, 60-69 yr, 70-79 yr, and 80-89 yr, respectively. 75-8414.013.0………91†Prevalence rates are for age-groups 50-59 yr, 60-69 yr, 70-79 yr, and 80-89 yr, respectively. 45-743.72.5………10Göteborg7Eriksson H Svärdsudd K Larsson B Ohlson LO Tibblin G Welin L et al.Risk factors for heart failure in the general population: the study of men born in 1913.Eur Heart J. 1989; 10: 647-656PubMed Google Scholar 50-541.5……21…… 55-604.3……32…… 61-6710.2……130……Eastern Finland8Remes J Reunanen A Aromaa A Pyörälä K Incidence of heart failure in eastern Finland: a population-based surveillance study.Eur Heart J. 1992; 13: 588-593PubMed Google Scholar 45-541.51.2………… 55-643.82.5………… 65-749.14.2………… 45-744.72.4…………NHANES9Schocken DD Arrieta MI Leaverton PE Ross EA Prevalence and mortality rate of congestive heart failure in the United States.J Am Coll Cardiol. 1992; 20: 301-306Abstract Full Text PDF PubMed Scopus (730) Google Scholar‡NHANES = National Health and Nutrition Examination Survey. 55-64………453037 65-74………484345 25-74………192020London10Parameshwar J Shackell MM Richardson A Poole-Wilson PA Sutton GC Prevalence of heart failure in three general practices in north west London.Br J Gen Pract. 1992; 42: 287-289PubMed Google Scholar 65……………28.0 Total population……………4.0* See Rodeheffer and associates, pages 1143 to 1150 of this issue.† Prevalence rates are for age-groups 50-59 yr, 60-69 yr, 70-79 yr, and 80-89 yr, respectively.‡ NHANES = National Health and Nutrition Examination Survey. Open table in a new tab Of note, the incidence and prevalence of heart failure in the study by Rodeheffer and coworkers are generally lower than those in the other reports. Although these differences may reflect variations in diagnostic criteria for heart failure or in the demographic and disease patterns of the populations studied, similar diagnostic criteria were used in all the studies, and all included primarily Caucasian patients in areas with a relatively high incidence of coronary artery disease. More likely, the differences are related to the case ascertainment approaches. In the Rochester study, cases were identified from medical records, an approach that suggests that most patients would have to have a sufficient degree of symptoms to seek medical care. This presumption is supported by the preponderance of patients with severe symptoms (New York Heart Association class III or IV). In contrast, in the Framingham5McKee PA Castelli WP McNamara PM Kannel WB The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446Crossref PubMed Scopus (2619) Google Scholar, 6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar and Göteborg7Eriksson H Svärdsudd K Larsson B Ohlson LO Tibblin G Welin L et al.Risk factors for heart failure in the general population: the study of men born in 1913.Eur Heart J. 1989; 10: 647-656PubMed Google Scholar studies, previously identified cohorts of patients were systematically and serially interviewed and examined to identify those with heart failure. In the Finnish study,8Remes J Reunanen A Aromaa A Pyörälä K Incidence of heart failure in eastern Finland: a population-based surveillance study.Eur Heart J. 1992; 13: 588-593PubMed Google Scholar which reported an incidence of heart failure most comparable to the Rochester findings, cases were also identified by medical records, but additional cases were found by using prescription records. Thus, the actual incidence of heart failure has most likely been underestimated in the Rochester data—particularly among young persons, who may be less likely than older patients to seek medical attention for mild symptoms or for other medical problems. The same explanation is likely to account for the lower prevalence of heart failure for the entire age range in comparison with the Framingham5McKee PA Castelli WP McNamara PM Kannel WB The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446Crossref PubMed Scopus (2619) Google Scholar, 6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar and National Health and Nutrition Examination Survey (NHANES)9Schocken DD Arrieta MI Leaverton PE Ross EA Prevalence and mortality rate of congestive heart failure in the United States.J Am Coll Cardiol. 1992; 20: 301-306Abstract Full Text PDF PubMed Scopus (730) Google Scholar data. If patients with mild heart failure are underdiagnosed or seek medical attention only after a substantial delay, the consequences could have important clinical ramifications (discussed subsequently herein). The most frequent identifiable cause of heart failure in the Rochester study was ischemic heart disease, which affected 50% of the new cases and was probably responsible for a substantial proportion of the 40% of cases in which no specific etiologic factor was determined. This finding differs somewhat from the original Framingham data,5McKee PA Castelli WP McNamara PM Kannel WB The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446Crossref PubMed Scopus (2619) Google Scholar in which hypertension was thought to be the most common cause. Other more recent studies have also identified coronary artery disease as the most frequent cause,7Eriksson H Svärdsudd K Larsson B Ohlson LO Tibblin G Welin L et al.Risk factors for heart failure in the general population: the study of men born in 1913.Eur Heart J. 1989; 10: 647-656PubMed Google Scholar, 10Parameshwar J Shackell MM Richardson A Poole-Wilson PA Sutton GC Prevalence of heart failure in three general practices in north west London.Br J Gen Pract. 1992; 42: 287-289PubMed Google Scholar and a similar finding emerged from more recent Framingham analyses.6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar Indeed, in large-scale treatment trials of patients with heart failure, coronary artery disease also predominated.11Teerlink JR Goldhaber SZ Pfeffer MA An overview of contemporary etiologies of congestive heart failure [editorial].Am Heart J. 1991; 121: 1852-1853Abstract Full Text PDF PubMed Scopus (116) Google Scholar The declining proportion of cases in which hypertension seems to be the primary cause of heart failure probably reflects the success of diagnosing and treating hypertension. Nonetheless, hypertension, as well as diabetes mellitus, remains an important contributing cause and exacerbating factor in the development of congestive heart failure. The current report also confirms the poor prognosis of patients with congestive heart failure. Among subjects with newly identified cases, 3-month, 1-year, and 8-year survival rates were 78%, 65%, and 30%, respectively. These figures are comparable to the Framingham experience, in which the 3-month, 1-year, and 5-year survival rates were 73%, 57%, and 25%, respectively, in men and 72%, 64%, and 38% in women.6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar In both experiences, the mortality rates were highest during the first few months after the development of heart failure. Thus, in patients who survived the initial 3 months (Framingham) or 12 months (Rochester), 1-year and 5-year survival rates were 80% and 45% in Rochester and approximately 84% and 45% in Framingham. Although these discouraging statistics are tempered somewhat by the advanced age of most of the patients in whom heart failure developed, mortality rates were still 2 to 3 times those in age-matched control subjects. Because major advances have occurred in cardiovascular therapy during the past decade and several trials have shown that the survival of patients with congestive heart failure can be increased with vasodilators and angiotensin-converting enzyme inhibitors,12Cohn JN Archibald DG Ziesche S Franciosa JA Harston WE Tristani FE et al.Effect of vasodilator therapy on mortality in chronic congestive heart failure: result of a Veterans Administration Cooperative Study.N Engl J Med. 1986; 314: 1547-1552Crossref PubMed Scopus (2060) Google Scholar, 13CONSENSUS Trial Study Group Effects of ehalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Survival Study (CONSENSUS).N Engl J Med. 1987; 316: 1429-1435Crossref PubMed Scopus (4692) Google Scholar, 14The SOLVD Investigators Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.N Engl J Med. 1991; 325: 293-302Crossref PubMed Scopus (6673) Google Scholar, 15The SOLVD Investigators Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions.N Engl J Med. 1992; 327: 685-691Crossref PubMed Scopus (3505) Google Scholar, 16Pfeffer MA Braunwald E Moyé LA Basta L Brown Jr, EJ Cuddy TE et al.Effect of Captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival and Ventricular Enlargement trial.N Engl J Med. 1992; 327: 669-677Crossref PubMed Scopus (5462) Google Scholar an important issue is whether the prognosis has improved in the general population. Overall, the findings have been inconsistent. Age-adjusted mortality rates in Canada have shown a progressive decline (by approximately 15% in men and more than 30% in women) since the peak year of 1980.17Brophy JM Epidemiology of congestive heart failure: Canadian data from 1970 to 1989.Can J Cardiol. 1992; 8: 495-498PubMed Google Scholar In a recent report from the Framingham study, however, virtually no improvement was noted in survival rates after the diagnosis of congestive heart failure in cohorts derived from the 1975 to 1988 period in comparison with 1948 to 1974.6Ho KKL Anderson KM Kannel WB Grossman W Levy D Survival after the onset of congestive heart failure in Framingham Heart Study subjects.Circulation. 1993; 88: 107-115Crossref PubMed Scopus (1598) Google Scholar Similarly, the current Rochester survival data are comparable to those from the earlier Framingham experience. Several explanations can be proposed for the lack of substantial improvement in the prognosis for patients with congestive heart failure. As one explanation, the nature of the populations in the reported studies may have changed over time, with an improvement of prognosis in some categories of patients being obscured by a shift from lower to higher risk patients. In that regard, the prevalence5McKee PA Castelli WP McNamara PM Kannel WB The natural history of congestive heart failure: the Framingham study.N Engl J Med. 1971; 285: 1441-1446Crossref PubMed Scopus (2619) Google Scholar of hypertension as the primary etiologic factor in the early Framingham experience and the lack of noninvasive measurements of left ventricular function suggest that a substantial number of patients may have had primarily diastolic dysfunction.18Bonow RO Udelson JE Left ventricular diastolic dysfunction is a cause of congestive heart failure: mechanisms and management.Ann Intern Med. 1992; 117: 502-510Crossref PubMed Scopus (359) Google Scholar Although several studies in the past decade have shown that more than 20% of patients who had signs and symptoms of heart failure had primarily diastolic dysfunction, that proportion may have been larger in the past. Such patients have a considerably better prognosis than do patients with reduced ejection fractions. Thus, if the number of patients with diastolic dysfunction in recent studies has decreased because of better antihypertensive therapy or increased utilization of noninvasive techniques, a survival improvement in the patients with systolic dysfunction may not have been recognized. A more likely explanation for the lack of improvement in prognosis is that during the period covered by these studies, only a minority of patients with congestive heart failure were treated by the agents that have been demonstrated to prolong survival—the angiotensin-converting enzyme inhibitors and vasodilators. Vasodilators were used only rarely in the 1970s and only in a small minority of patients with the most advanced heart failure in the early 1980s.19Hlatky MA Fleg JL Hinton PC Lakatta EG Marcus FI Smith TW et al.Physician practice in the management of congestive heart failure.J Am Coll Cardiol. 1986; 8: 966-970Abstract Full Text PDF PubMed Scopus (60) Google Scholar Even in 1992, after the publication of several studies that showed that these regimens can prolong survival in symptomatic patients with heart failure, less than 25% of patients with the diagnosis of heart failure were receiving an angiotensin-converting enzyme inhibitor.2Congestive heart failure—a worldwide market study of ACE inhibitors, diuretics and other pharmaceutical products [press release]. New Haven (CT): Technology Management Group, Jun 1992Google Scholar Even among the treated patients, most have received much smaller doses than those used in the trials that reported beneficial results.20Medical Marketing Conference Congestive Heart Failure Therapy Study Tabular Report. Market Measures, Inc., Oct 1992Google Scholar Thus, whereas the target dosage of enalapril used in the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS), Studies of Left Ventricular Dysfunction (SOLVD), and Vasodilators in Heart Failure Trial II (V-HeFT II) was 10 mg twice daily, the average patient received more than 15 mg as a total daily dose; in contrast, fewer than 25% of patients in practice are receiving total daily doses of more than 10 mg. Similarly, the target dosage of captopril in major heart failure trials was 50 or 100 mg three times daily, and the mean total daily dose was approximately 100 mg; however, fewer than 15% of patients are receiving dosages that high. Currently, whether these high dosages are necessary is unknown, and an ongoing trial is comparing high and low doses of lisinopril (Assessment of Treatment With Lisinopril and Survival or the ATLAS study). Until a comparable survival benefit is demonstrated with low-dose angiotensin-converting enzyme inhibitor therapy, clinicians should use these medications in dosages comparable to those in the published studies. Finally, the survival benefit of vasodilators and angiotensin-converting enzyme inhibitors, albeit statistically significant and relatively striking, has been modest. Most studies have reported a 15 to 20% reduction in mortality, but when this benefit is averaged for the entire population treated, it translates into a mean increase in survival of less than 6 months. Although life may be prolonged substantially in individual persons, the mean increase in survival may not be apparent in large populations. Thus, the prognosis will most likely remain poor in patients with symptomatic heart failure. Therefore, perhaps the most important recent advance has been the demonstration that the onset of heart failure can be prevented or delayed in patients with asymptomatic or minimally symptomatic left ventricular systolic dysfunction. Both the Survival and Ventricular Enlargement (SAVE) trial,16Pfeffer MA Braunwald E Moyé LA Basta L Brown Jr, EJ Cuddy TE et al.Effect of Captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival and Ventricular Enlargement trial.N Engl J Med. 1992; 327: 669-677Crossref PubMed Scopus (5462) Google Scholar in which captopril was administered to patients with recent myocardial infarction and ejection fractions of less than 40%, and the SOLVD prevention trial,15The SOLVD Investigators Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions.N Engl J Med. 1992; 327: 685-691Crossref PubMed Scopus (3505) Google Scholar in which enalapril was used to treat patients with ejection fractions of less than 35%, showed that angiotensin-converting enzyme inhibition impressively decreases the proportions of patients who ultimately have clinical heart failure and the number of initial hospitalizations for heart failure. In the SAVE trial, the substantial decrease in mortality suggested that the optimal time for intervention is early after the onset of left ventricular dysfunction. In this context, the differences in incidence and prevalence of congestive heart failure evidenced in the epidemiologic studies reviewed herein assume a new significance. The higher incidence and prevalence rates in the studies in which patients participated in longitudinal follow-up or were systematically interviewed and examined for signs and symptoms of heart failure, in comparison with the Rochester and Finnish studies in which heart failure was identified from medical records, suggest that many cases of mild heart failure are not identified. Perhaps the most effective strategy for decreasing mortality attributable to heart failure will be to educate patients at risk for the development of heart failure and to be attuned to the early symptoms of this syndrome. Routine measurements of left ventricular function after large myocardial infarctions will also identify a group of patients who are prime candidates for early intervention. This strategy may have the most promise for improving long-term survival in patients with left ventricular dysfunction and heart failure. Thus, the Rochester study reported in this issue of the Proceedings, in conjunction with other epidemiologic data on heart failure, provides an important insight into the magnitude of this problem and a hint about how the associated prognosis may be improved. Epidemiologic studies also offer an excellent opportunity to determine whether evolving management approaches will change the course of this disease. Therefore, this study should be repeated in 5 to 10 years, to determine whether the incidence of heart failure has been decreased and whether the related prognosis has been improved. We believe that it is reasonable to hypothesize that by decreasing the number of coronary events, limiting myocardial infarct size with thrombolytic therapy, and providing early intervention to prevent the progression of left ventricular dysfunction, more substantial improvements should be noted in the incidence and prognosis of heart failure during the next decade.