Clinical and economic burden of chronic heart failure

National Heart and Lung Institute
Imperial College London and Royal Brompton Hospital

Clinical and economic burden of chronic heart failure

by M. R. Cowie, United Kingdom

Around 2% of the adult population in the developed world have heart failure (HF), the prevalence of which rises steeply with age. Male gender, advanced age, more severe symptoms, coronary artery disease (particularly acute coronary syndrome), hypotension, impaired renal function, hyponatremia, and elevated plasma brain natriuretic peptide concentration are all factors associated with poorer prognosis. In Europe, HF accounts for 5% of adult internal medicine and geriatric hospitalizations, and the median duration of hospitalization is 11 days. Readmission rates are high, with one third to one half of patients being readmitted within 12 months. Although the prognosis of the syndrome is still severe, available data suggest that it is improving even though it remains worse than that of many common malignancies. The improving prognosis, coupled with a rapidly aging population, is driving a steep increase in the total number of people with HF: conservative estimates suggest that 6 million Europeans have this syndrome. It is a costly condition to treat: between 1% and 2% of national health care budgets are spent on HF, with more than 60% of this cost related to hospitalization. The condition has a major impact on many aspects of an individual’s quality of life, which is regarded as being worse in HF than in chronic lung disease, arthritis, or diabetes.

Medicographia. 2011;33:370-376 (see French abstract on page 376)

The epidemiology of heart failure (HF), and its impact on health services, has been well described, at least for the developed world. Published studies, which have used a range of methodologies, have been supplemented by data from surveys of hospital practice in North America and Europe. The literature on quality of life in HF is limited, but suggests that the syndrome has a major impact on many aspects of daily life.


Reliable estimates of the incidence of HF are available from studies such as the Framingham Heart Study in the United States,1 and the Hillingdon and Bromley Heart Failure Studies in London, UK.2,3 The Framingham Study employed set criteria at biennial examinations of a cohort of individuals initially free of HF. The London studies employed an expert panel approach that reviewed all the available data for those with a new diagnosis of HF within a geographically defined population, using a systematic method of assessment that included imaging of the heart by Doppler echocardiography. Table I summarizes the results of these and other key incident studies.4

Table I
Table I. Incidence of heart failure in a selection
of population-based studies.

Modified from reference 4: Cowie et al. Eur Heart J.
1997;18:208-225. © The European Society of Cardiology

The crude incidence rate in the general population ranges from 1 to 5 cases per 1000 population per year, with a steep increase with advancing age: the annual incidence is estimated to be 0.2%-0.3% in those aged 50-59 years; in those aged 80-89,5 this rises tenfold (Figure 1).6 The median age at first presentation in most recent studies (in the developed world) is the mid-70s, with a higher incidence in men than in women at all ages (male:female ratio is ≈1.8:1).7,8 It is not clear whether the incidence of HF has changed in the past few decades. The Framingham Heart Study reported no change during the period from 1950 to 1999 for men, but a small decrease in the early stages of HF during the same period for women.9 Elsewhere, data from Olmsted County, Minnesota, showed no change in the incidence of HF from 1979 through 2000,10,11 while the Kaiser Permanente database in the Pacific Northwest of the United States suggests an increase of 14% in the HF incidence rate between 1970 and 1994.12


Studies from both Europe and North America suggest that the prevalence of HF is approximately 2% of the adult population, with a steep rise with age. Few adults aged younger than 40 years of age have HF. Early studies used a range of methods to estimate prevalence, including medical record reviews that were supplemented by direct questioning and/or examination of individuals within the general population, drug prescription data analysis, monitoring of general practice activity, and appropriately sampled cohorts from the general population. The results of some key studies are shown in Table II (page 372).4

The first population-based study to use two-dimensional Doppler echocardiography was in Glasgow, UK. The prevalence of HF was reported as 1.5% in 1647 participants aged 25 to 74 years.13 The definition of HF was left ventricular ejection fraction (EF) less than 30% and cardiac shortness of breath on questionnaire or use of a loop diuretic. Asymptomatic left ventricular systolic dysfunction was almost as common as HF, at 1.4% in this population. A population-based study in Rotterdam, The Netherlands, reported a prevalence of HF of 0.7% in those 55 to 64 years of age, 2.7% at 65 to 74 years of age, 13% at 75 to 84 years of age, and over 10% in those 85 years of age or older.14 A trained nonmedical interviewer administered a standardized questionnaire, a clinician detected pulmonary rales and ankle edema in a subsample of individuals, and an electrocardiograph and echocardiogram were recorded. HF was considered present if the individual did not have chronic pulmonary disease, but had evidence of cardiac disease and at least two of the following three characteristics: history of dyspnea, ankle edema, or pulmonary rales.

Figure 1
Figure 1. Incidence of heart failure by age group and gender in the Hillingdon Heart
Failure Study, London, from 1995 to 1997 (cases per 1000 population per year).

Modified from reference 6: Cowie et al. Eur Heart J. 1999;20:421-428. © 1999, The European Society
of Cardiology.

Table II
Table II. Prevalence of heart failure in a selection of populationbased studies.

Abbreviations: EF, ejection fraction; ESC, European Society of Cardiology; HF, heart failure.
Modified from reference 4: Cowie et al. Eur Heart J. 1997;18:208-225. © The European Society of Cardiology.

Definite HF, defined as individuals who were breathless on exertion and who had objective evidence of underlying cardiac dysfunction, such as EF <40%, atrial fibrillation, or moderate-to-severe valve disease, was present in 2.3% of the general population 45 years of age and older in Birmingham, UK.15 Probable HF was reported in a further 0.8%.

In North America, several studies have reported similar figures, including the Cardiovascular Health Study16 and the National Health and Nutrition Examination Survey.17 In Olmsted County, Redfield and colleagues recently reported a prevalence of 2.2% in the population aged 45 years or older, applying the Framingham criteria to data in community- and hospital-based medical records.18 Of the 45 participants with a validated diagnosis of HF, 20 (44%) had an EF ≥50%. The prevalence of HF increased steeply with age: 0.7% for those 45 to 54 years of age; 1.3% in those 55 to 64 years of age; 5% in those 65 to 74 years of age; and 8.4% for those 75 years of age or older.

On the basis of these studies, a conservative estimate of the burden of HF would be that 4 million Americans and 6 million Europeans have HF out of a total population of 300 million and 460 million, respectively.


Despite the current use of life-prolonging therapies, such as angiotensin-converting enzyme inhibitors, β-blockers, and aldosterone receptor antagonists, a new diagnosis of HF carries a prognosis similar to that of bowel cancer, which is worse than that of breast cancer.19,20 The comparative survival from HF and a variety of malignancies in the United States is shown in Figure 2.21,22 Factors associated with a poorer prognosis include male gender, advanced age, more severe symptoms (higher New York Heart Association [NYHA] class), coronary artery disease (particularly acute coronary syndrome), hypotension, impaired renal function, hyponatremia, and elevated plasma BNP concentration.19,23-25

The overall in-hospital mortality for patients admitted with HF is between 4% and 7%.26 Those presenting with cardiogenic shock (low cardiac output with organ hypoperfusion) have a particularly high in-hospital mortality of ≈40%. Within 12 weeks of initial discharge, 1 in 4 acute HF patients are readmitted to hospital and ≈15% are dead, rising to 30% at 12 months from discharge. Death is most likely to occur due to progressive HF in the more severe grades of HF (often after several decompensations requiring hospitalization), but sudden death can occur at any time. Predicting likely life expectancy is more difficult than in terminal malignancies, making management decisions more difficult. Although HF prognosis is today better than it once was, the long-term mortality rate remains high.

Figure 2
Figure 2. Comparative 5-year mortality rates of heart failure and a number of malignant
conditions in the United States from 1990 to 2000.

Abbreviations: HF, heart failure.
After reference 21: Altekruse et al. SEER Cancer Statistics Review 1975-2007. Bethesda, MD: National Cancer Institute; © 2011, National Cancer Institute; and after
reference 22: Lloyd-Jones et al; American Heart Association Statistics Committee and Stroke Statistics
Subcommittee. Circulation. 2010;121;e46-e215. © 2010, American Heart Association, Inc.

Figure 3
Figure 3. Cumulative survival of the 552 individuals with incident (new) heart failure identified in the Hillingdon and Bromley (London) Heart Failure Studies from 1995 to 1998.

The expected survival curve represents the age- and gender-matched UK population. Observed survival is shown with 95% confidence interval limits. Based on the author’s own data.

Figure 3 shows long-term survival in a cohort of 552 new cases of HF identified in the London Heart Failure Studies from 1995 to 1998. The survival of incident cases was similar in the Rotterdam Study, with 1-, 2-, and 5-year survival rates of 63%, 51%, and 35%, respectively.27 Mortality is particularly high in the 3 months after diagnosis. The most recent data from the Framingham Heart Study shows a similar picture, but with evidence of improvement in prognosis in the past 30 years (Figure 4).9 Recent epidemiological data from the Olmsted County Rochester Epidemiology Project11 and the United Kingdom confirm this improvement.28,29

Temporal trends in heart failure

The number of people living with HF in Europe and North America is set to increase steeply. The rapid aging of the population in developed countries, lack of a fall in incidence, and improving prognosis of HF are all acting to increase the number of people with chronic HF—with no likely decrease anticipated in the near future. In 2002, 12.6% of the population was older than 65 years of age in the United States. This is expected to rise to 16.3% in 2020, 19.6% in 2030, and 22.4% in 2040.30 Similar population projections have been made for Europe.31

Health-care burden

In the United States, HF continues to be the most common cause of hospitalization in people older than 65 years of age,22,32 with a reported 26% rise in hospital discharge rates from 877 000 in 1996 to 1 106 000 in 2006. In Europe, 5% of adult internal medicine and geriatric hospitalizations occur as a result of HF—a larger proportion than those that occur as a result of myocardial infarction.33 The age-adjusted rates for hospitalization may have peaked.34 The duration of hospitalization for HF, particularly in Europe, is long with a median duration in the Euroheart Heart Failure survey of 11 days.35 The typical duration of hospitalization in the United States is closer to 5 days.36,37

Figure 4
Figure 4. Secular trends in survival of incident (new) heart failure in the Framingham Heart Study.

Modified from reference 9: Levy et al. N Engl J Med. 2002;347:1397-1402. © 2002, Massachusetts Medical Society.

The readmission rate is also high, with one third to one half of patients being readmitted within 6 months in the United States32 or 12 months in Europe.33,38 Mortality after hospitalization is also high, with 13% dying within 12 weeks in Europe. 35 Not all admissions are as a result of HF, but 20% to 50% of the emergency readmissions are likely to be so,38,39 with some patients being readmitted multiple times.

Hospitalization is the main driver of the cost of HF to the health service. Approximately 60% of the total direct costs of HF relate to hospitalization, 1% to 2% of the total health care budget of many developed countries.39,40 Added to the direct health care costs are the economic consequences of HF to patients and their families: the total (direct and indirect) cost of HF was estimated to be $39.2 billion in the United States for 2010.22

From an individual perspective, the diagnosis of HF is associated with annual costs of approximately $8500 per patient according to data from the National Heart and Lung Institute cardiovascular health study.41 These estimates may underestimate the real costs as they are based on data featuring HF as the primary diagnosis; HF treatment costs also need to be taken into account for the many patients primarily hospitalized for one of the multiple comorbidities that typically accompany HF, such as hypertension, diabetes, and renal or lung disease. Whellan et al42 studied almost 1.4 million Medicare beneficiaries after their initial hospitalization for HF and found that 66% made a subsequent in-patient claim the following year. HF hospitalizations accounted for 15% of total in-patient costs, while 57% of costs were associated with noncardiovascular diagnoses.

Quality of life

HF has a major impact on many aspects of health-related quality of life. Studies from Europe have reported that people with HF have more severe physical impairment than those with chronic lung disease, arthritis, or diabetes and similar impairment to those with Parkinson’s disease or motor neuron disease (Figure 5).43-45

Figure 5
Figure 5. Forest plot showing the mean EuroQOL (EQ-5D index) score of patients enrolled in the CARE-HF study compared with the mean EuroQol scores of patients with other chronic diseases and those of a sample of the UK population.

Abbreviations: CARE-HF, CArdiac REsynchronisation in Heart Failure.; EQ-5D, EuroQol 5 Dimension [mobility, self-care, usual activities, pain/discomfort, anxiety/depression health survey].
After reference 45: Calvert et al. Eur J Heart Fail. 2005;7: 243-251. © 2005,European Society of Cardiology.

HF affects mobility and the ability to carry out usual activities. Mental health is affected, but less so than in patients with depression, although this can often coexist in patients with HF.43,46 Assessment of quality of life is not routine in clinical practice, although NYHA class appears to correlate relatively closely with overall health-related quality of life, as assessed by the Short Form-36 questionnaire.43 Work from the United States47 suggests that a disease-specific questionnaire (the 23-item Kansas City Cardiomyopathy Questionnaire) is more sensitive to changes in overall clinical condition, than the EQ- 5D (a more generic, and much simpler, quality of life instrument),48 or NYHA class. Narrative meta-analysis of the small number of published qualitative studies of HF suggests that social isolation, living in fear, and the loss of a sense of control are very common consequences of HF.49


HF remains a major public health issue that is likely to increase in importance as the world’s population ages and survival from the syndrome continues to improve. The already huge cost of delivering care is also likely to increase. At a personal level, a diagnosis of HF will have an important impact on the individual’s length and quality of life, particularly where chronic disease management is poor. _

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Keywords: heart failure; epidemiology; economics; quality of life