Elsevier

The Lancet

Volume 358, Issue 9280, 11 August 2001, Pages 439-444
The Lancet

Articles
Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study

https://doi.org/10.1016/S0140-6736(01)05620-3Get rights and content

Summary

Background

Accurate data for prevalence rates for heart failure due to various causes, and for left-ventricular systolic dysfunction in all adults are unavailable. Our aim was to assess prevalence of left-ventricular systolic dysfunction and heart failure in a large representative adult population in England.

Methods

Of 6286 randomly selected patients aged 45 years and older, 3960 (63%) participated in the study. They came from 16 randomly selected general practices. We assessed patients by history and examination, electrocardiography, and echocardiography. Prevalence of left-ventricular systolic dysfunction (defined as ejection fraction <40%) and heart failure was calculated for the overall population on the basis of strict criteria and, when necessary, adjudication by a panel.

Findings

Left-ventricular systolic dysfunction was diagnosed in 72 (1·8% [95% CI 1·4–2·3]) participants, half of whom had no symptoms. Borderline left-ventricular function (ejection fraction 40–50%) was seen in 139 patients (3·5% [3·0–4·1]). Definite heart failure was seen in 92 (2·3%, [1·9–2·8]) and was associated with an ejection fraction of less than 40% in 38 (41%) patients, atrial fibrillation in 30 (33%), and valve disease in 24 (26%). Probable heart failure was seen in a further 32 (0·8% [0·6–1·1]) patients. In total, 124 (3·1% [2·6–3·7]) patients aged 45 years or older had definite or probable heart failure.

Interpretation

Heart failure is often misdiagnosed or underdiagnosed in primary care. Our results suggest that assessment of left-ventricular function in patients with suspected heart failure could lead to more effective diagnosis and treatment of this disorder.

Introduction

Heart failure and left-ventricular systolic dysfunction are increasingly important disorders that are linked to poor outlook, poor quality of life, and some of the highest health-care costs for one disorder.1 Annual mortality attributable to severe heart failure is around 60%.2 In the general population, in which all grades of heart failure are represented, 5-year mortality is 50–75%,3 and morbidity (measured by severity of symptoms, quality of life, need for consultation, treatment, and hospital admission) is substantial. In the UK, 4·9% of admissions to one hospital were for heart failure, which would extrapolate to 120 000 admissions per year nationally if these single hospital data were representative,4 and such admissions continue to rise.5

Inhibitors of angiotensin-converting enzyme (ACE) improve both morbidity and mortality rates in all grades of symptomatic heart failure due to left-ventricular systolic dysfunction,6 and can delay or prevent progression of symptomless left-ventricular systolic dysfunction to symptomatic heart failure.7, 8 β blocker therapy also has substantial prognostic benefits in heart failure due to leftventricular systolic dysfunction.9 However, since few patients with suspected heart failure receive any assessment of left-ventricular function, heart failure is inadequately diagnosed and treated.10

In earlier work on prevalence of heart failure, researchers used clinical diagnostic criteria that are known to be inaccurate,11 especially early in the disease process. For example, diuretic prescription monitoring has produced widely differing estimates of heart failure prevalence, since not all patients taking diuretics have heart failure, and not all patients with heart failure might have presented for treatment.12 Investigations of prevalence of left-ventricular systolic dysfunction have also included objective assessment of left-ventricular function, usually by echocardiography.13 Such studies have indicated a prevalence of left ventricular systolic dysfunction of 2·9% in patients aged younger than 75 years13 and up to 7·5% in those aged 75–84 years,14 although this sample was not representative of the general population. However, no generalisable data are available for prevalence rates on left-ventricular systolic dysfunction prevalence rates in elderly people, or for those for heart failure due to other causes. We have used objective criteria to assess community prevalence of symptomatic and symptomless left-ventricular systolic dysfunction and investigated other causes of heart failure in a representative, general population aged 45 years or older.

Section snippets

Population

We stratified all primary care practices in the West Midlands region of England (population 5·3 million) into quartiles of the Townsend socioeconomic deprivation score15 of the populations they served. We then randomly selected four practices from each quartile (total 16 practices) for investigation. In seven practices, when it was either impractical to set up the screening clinic in the randomly selected practice or when participation was declined, we used an immediately neighbouring practice

Results

3960 (63%) of 6286 randomly selected patients responded to the postal invitation and underwent the full screening process. Reasons for the 2326 non-responses included too busy (25% [582]), not interested (15% [349]), already seeing other doctors (9% [209]), and scared to know the result (8% [186]). No further information is available about the disorders of the 9% of patients who were seeing another doctor. No significant differences were recorded between responders and nonresponders in age

Discussion

In our study, 72 (1·8%) people had either symptomless or symptomatic left-ventricular systolic dysfunction, and 54 (1·4%) people had definite heart failure from other causes. Thus the overall prevalence of prognostically significant cardiac dysfunction (heart failure from all causes, and symptomless left ventricular systolic dysfunction) is 3·2% (or 3·8% if probable heart failure is included).

Previous epidemiological studies on prevalence of heart failure have focused only on the most common

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