Ten-year Prognosis of Heart Failure in the Community
Ten-year Prognosis of Heart Failure in the Community
Aims This study investigates the 10-year survival in the ECHOES (Echocardiographic Heart of England Screening) study and examines factors associated with prognosis.
Methods and results A prospective study was carried out to investigate 10-year survival in those with heart failure (HF) and/or left ventricular systolic dysfunction (LVSD). The mean age of participants in ECHOES was 64, and 50% were male. Records of all 6162 screened participants were flagged, and deaths up to 25 February 2009 were coded. Causes of death were categorized according to diagnosis on death certificate. Kaplan–Meier curves and log rank tests were used to compare survival times of participants with HF and LVSD in different diagnostic groups. A Cox proportional hazards regression model was used to identify variables associated with risk of death. A total of 2062 of the 6162 (33.5%) participants had died at the census date in February 2009. Of these deaths, 902 (43.7%) were due to cardiovascular disease, including 263 (12.8%) due to HF. Ten-year survival was 75% for participants without HF, 26.7% for those with HF, 37.6% for those with LVSD, and 27.4% for those with HF and LVSD. Multiple-cause HF had a 10-year survival of 11.6%. Multiple variables including diabetes, valvular disease, diuretic use, and a previous label of HF, as well as lifestyle factors such as smoking and obesity, were associated with increased risk of death.
Conclusions Patients with HF and LVSD have a poor prognosis. However, the mortality rates of all-cause, all-stage HF as measured in the ECHOES cohort are around half those reported for patients diagnosed for the first time with HF during hospital admission.
Data used to estimate prognosis of patients with heart failure are mainly derived from hospital-based registries, where a code of heart failure may be inaccurately reported, or from community-based studies, where frequently not all causes of heart failure are investigated. Estimates of prognosis are therefore dependent on the population studied and may change over time. Mortality data based on hospital-diagnosed heart failure and left ventricular systolic dysfunction (LVSD) are particularly subject to referral and spectrum bias, including patients who are usually more symptomatic and representing more severe stages of disease. The hospital-led MONICA study in Glasgow, though inviting screened patients from the community, only investigated LVSD.
The main examples of community-based studies which have investigated the prognosis of heart failure in the general population are shown in Table 1. The Framingham Heart Study was a prospective epidemiological study established in 1948 in Framingham, MA, USA. A total of 5209 participants were in the original cohort and were aged between 28 and 62 years from a predominantly white middle-class population. Initial assessment included medical history, physical examination, laboratory tests, and electrocardiogram (ECG), and participants were followed up biennially. Subsequent re-screening in Framingham has used echocardiographic assessment. The Rochester Epidemiology Project is a medical record system which was set up in Olmstead County, MN, USA in 1966. The records of the residents of Rochester and Olmstead County are linked to allow the medical information from the main healthcare providers to be stored in a single database. The records are comprehensive and include details of all healthcare encounters for nearly all residents, but are predominantly from a white population and the diagnoses are not validated. The Rotterdam Study is a prospective cohort study established in Rotterdam, The Netherlands in 1990. Participants undergo examination (including history taking, physical examination, bloods, and imaging) every 3–4 years. The Rotterdam study uses clinical criteria alone for diagnosing heart failure which is less reliable than studies requiring objective evidence of structural or functional cardiac abnormality, in addition to symptoms and signs.
The Echocardiographic Heart of England Screening (ECHOES) study is therefore unique, following up a large, representative, and contemporary community cohort of patients within central England with well categorized heart failure and LVSD. All ECHOES participants underwent detailed initial clinical assessment to screen for evidence of heart failure or LVSD, defined as an ejection fraction of <40%. All deaths in the cohort have been collated from routine mortality data. We previously reported the 5-year prognosis of patients in the ECHOES cohort according to the presence or absence of heart failure and LVSD. The 5-year survival rate was 53% in patients with heart failure and LVSD, 62% in patients with heart failure and no LVSD, and 69% in those with LVSD without heart failure compared with 93% for the general population over the age of 45. Overall, the mortality rate for all-cause heart failure was 9% per year. The ECHOES study now has prospective follow-up data for >10 years. The aim of the present study was to assess the 10-year prognosis of participants in the ECHOES cohort and factors associated with risk of death.
Abstract and Introduction
Abstract
Aims This study investigates the 10-year survival in the ECHOES (Echocardiographic Heart of England Screening) study and examines factors associated with prognosis.
Methods and results A prospective study was carried out to investigate 10-year survival in those with heart failure (HF) and/or left ventricular systolic dysfunction (LVSD). The mean age of participants in ECHOES was 64, and 50% were male. Records of all 6162 screened participants were flagged, and deaths up to 25 February 2009 were coded. Causes of death were categorized according to diagnosis on death certificate. Kaplan–Meier curves and log rank tests were used to compare survival times of participants with HF and LVSD in different diagnostic groups. A Cox proportional hazards regression model was used to identify variables associated with risk of death. A total of 2062 of the 6162 (33.5%) participants had died at the census date in February 2009. Of these deaths, 902 (43.7%) were due to cardiovascular disease, including 263 (12.8%) due to HF. Ten-year survival was 75% for participants without HF, 26.7% for those with HF, 37.6% for those with LVSD, and 27.4% for those with HF and LVSD. Multiple-cause HF had a 10-year survival of 11.6%. Multiple variables including diabetes, valvular disease, diuretic use, and a previous label of HF, as well as lifestyle factors such as smoking and obesity, were associated with increased risk of death.
Conclusions Patients with HF and LVSD have a poor prognosis. However, the mortality rates of all-cause, all-stage HF as measured in the ECHOES cohort are around half those reported for patients diagnosed for the first time with HF during hospital admission.
Introduction
Data used to estimate prognosis of patients with heart failure are mainly derived from hospital-based registries, where a code of heart failure may be inaccurately reported, or from community-based studies, where frequently not all causes of heart failure are investigated. Estimates of prognosis are therefore dependent on the population studied and may change over time. Mortality data based on hospital-diagnosed heart failure and left ventricular systolic dysfunction (LVSD) are particularly subject to referral and spectrum bias, including patients who are usually more symptomatic and representing more severe stages of disease. The hospital-led MONICA study in Glasgow, though inviting screened patients from the community, only investigated LVSD.
The main examples of community-based studies which have investigated the prognosis of heart failure in the general population are shown in Table 1. The Framingham Heart Study was a prospective epidemiological study established in 1948 in Framingham, MA, USA. A total of 5209 participants were in the original cohort and were aged between 28 and 62 years from a predominantly white middle-class population. Initial assessment included medical history, physical examination, laboratory tests, and electrocardiogram (ECG), and participants were followed up biennially. Subsequent re-screening in Framingham has used echocardiographic assessment. The Rochester Epidemiology Project is a medical record system which was set up in Olmstead County, MN, USA in 1966. The records of the residents of Rochester and Olmstead County are linked to allow the medical information from the main healthcare providers to be stored in a single database. The records are comprehensive and include details of all healthcare encounters for nearly all residents, but are predominantly from a white population and the diagnoses are not validated. The Rotterdam Study is a prospective cohort study established in Rotterdam, The Netherlands in 1990. Participants undergo examination (including history taking, physical examination, bloods, and imaging) every 3–4 years. The Rotterdam study uses clinical criteria alone for diagnosing heart failure which is less reliable than studies requiring objective evidence of structural or functional cardiac abnormality, in addition to symptoms and signs.
The Echocardiographic Heart of England Screening (ECHOES) study is therefore unique, following up a large, representative, and contemporary community cohort of patients within central England with well categorized heart failure and LVSD. All ECHOES participants underwent detailed initial clinical assessment to screen for evidence of heart failure or LVSD, defined as an ejection fraction of <40%. All deaths in the cohort have been collated from routine mortality data. We previously reported the 5-year prognosis of patients in the ECHOES cohort according to the presence or absence of heart failure and LVSD. The 5-year survival rate was 53% in patients with heart failure and LVSD, 62% in patients with heart failure and no LVSD, and 69% in those with LVSD without heart failure compared with 93% for the general population over the age of 45. Overall, the mortality rate for all-cause heart failure was 9% per year. The ECHOES study now has prospective follow-up data for >10 years. The aim of the present study was to assess the 10-year prognosis of participants in the ECHOES cohort and factors associated with risk of death.
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