Can We Predict and Prevent the Onset of Acute Decompensated Heart Failure?

Abstract

Watch the disease in time: For when, within the dropsy rages, and extends the skin, in vain for helebore the patient cries, and sees the doctor, but too late is wise: Too late for cure, he proffers half his wealth; ten thousand doctors cannot give him health. — —Benjamin Franklin, Poor Richard’s Almanack, 1749 This rather pessimistic representation of heart failure (dropsy) in the 18th century has some relevance to the presentation of acute decompensation in patients with chronic heart failure in our current century, despite the availability of various therapies that prolong survival and decrease the morbidity of this disorder. In 2006, >1 million hospitalizations for acute decompensated heart failure (ADHF) occurred, and the number of heart failure hospitalizations have increased 175% since 1979.1 The vast majority of these patients, 75.6%, had a history of heart failure,2 and the in-hospital mortality was 3.2%. Patients with preserved left ventricular (LV) systolic function have a slightly lower in-hospital mortality (2.9%) compared with those with an LV ejection fraction ≤40% (3.9%); however, the 3-month mortalities were similar at 9.5% to 9.8%.3 Rehospitalization rates remain high at 29% to 30% for patients with both preserved and decreased LV systolic function, and rehospitalization is an independent predictor of 1-year mortality, especially in elderly patients.4 In addition, patients with ADHF are at greater risk for death and morbidity than those with stable chronic heart failure.5 Thus, the natural history of heart failure may be altered by repeated episodes of decompensation requiring hospitalization. Finally, a tremendous financial burden is involved in the treatment of ADHF. Of the $30.2 billion spent on heart failure care in 2006, $17.8 billion (59%) was related to in-hospital care, an increase of $2.4 billion over the previous year.1 Article p 1549 The development of ADHF …