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Is the Epidemic of Heart Disease Really Over or Just Evolving?

      To the Editor:
      We were surprised to read that Dalen et al
      • Dalen J.E.
      • Alpert J.S.
      • Goldberg R.J.
      • Weinstein R.S.
      The epidemic of the 20th century: coronary heart disease.
      confidently predict that the 20th century is likely to be the only one in which heart disease is the most common cause of death among Americans. Perhaps this is explained by the authors' rather narrow definition of what constitutes heart disease?
      There has been a decline in the age-adjusted incidence of clinically overt coronary disease, but age is a major determinant of risk and the lower annual incidence of coronary disease is offset, at a population level, by greater longevity. Moreover, myocardial infarctions in older patients are often not attended by symptoms that bring them to immediate medical attention.
      • Schelbert E.B.
      • Cao J.J.
      • Sigurdsson S.
      • et al.
      Prevalence and prognosis of unrecognized myocardial infarction determined by cardiac magnetic resonance in older adults.
      However, heart failure has, for a long time, been a more common cause of hospital admission than acute coronary syndromes. Indeed, few people die of coronary disease without first developing heart failure,
      • Torabi A.
      • Rigby A.S.
      • Cleland J.G.
      Declining in-hospital mortality and increasing heart failure incidence in elderly patients with first myocardial infarction.
      but only a minority of cases of heart failure have a history of acute coronary syndrome.
      • Cleland J.G.
      • Cohen-Solal A.
      • Aguilar J.C.
      • et al.
      Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey.
      Hypertension, atrial fibrillation, chronic kidney disease, and valve disease are alternative pathways to heart failure, all of which are increasing in prevalence as longevity increases.
      Heart failure may be a much larger problem than currently appreciated. There are no robust data on the prevalence of heart failure due both to a lack of an agreed diagnostic standard and to diagnostic inertia. Breathlessness is often inadequately investigated. Adoption of a sedentary lifestyle avoids symptoms induced by exertion. Prescription of powerful loop diuretics exceeds the reported prevalence of heart failure by several fold. The reason for prescribing loop diuretics is usually unclear, but patients rarely receive the investigations required to exclude heart failure.
      • van Riet E.E.
      • Hoes A.W.
      • Limburg A.
      • et al.
      Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion.
      Despite a substantial body of research, patients with heart failure often remain neglected “second-class” citizens when it comes to diagnosis and care; many do not even get to see a cardiologist. Perhaps coronary care units should switch some of their resources to tackle heart failure, a much larger, more difficult and deadly problem than acute coronary syndromes. The epidemic of coronary disease may be over, either because of human intervention or other factors, but other more common and deadly forms of heart disease are on the increase.

      References

        • Dalen J.E.
        • Alpert J.S.
        • Goldberg R.J.
        • Weinstein R.S.
        The epidemic of the 20th century: coronary heart disease.
        Am J Med. 2014; 127: 807-812
        • Schelbert E.B.
        • Cao J.J.
        • Sigurdsson S.
        • et al.
        Prevalence and prognosis of unrecognized myocardial infarction determined by cardiac magnetic resonance in older adults.
        JAMA. 2012; 308: 890-896
        • Torabi A.
        • Rigby A.S.
        • Cleland J.G.
        Declining in-hospital mortality and increasing heart failure incidence in elderly patients with first myocardial infarction.
        J Am Coll Cardiol. 2009; 55: 79-81
        • Cleland J.G.
        • Cohen-Solal A.
        • Aguilar J.C.
        • et al.
        Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey.
        Lancet. 2002; 360: 1631-1639
        • van Riet E.E.
        • Hoes A.W.
        • Limburg A.
        • et al.
        Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion.
        Eur J Heart Fail. 2014; 16: 772-777

      Linked Article

      • The Epidemic of the 20th Century: Coronary Heart Disease
        The American Journal of MedicineVol. 127Issue 9
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          Heart disease was an uncommon cause of death in the US at the beginning of the 20th century. By mid-century it had become the commonest cause. After peaking in the mid-1960s, the number of heart disease deaths began a marked decline that has persisted to the present. The increase in heart disease deaths from the early 20th century until the 1960s was due to an increase in the prevalence of coronary atherosclerosis with resultant coronary heart disease, as documented by autopsy studies. This increase was associated with an increase in smoking and dietary changes leading to an increase in serum cholesterol levels.
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      • The Reply
        The American Journal of MedicineVol. 128Issue 3
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          Pellicori and Cleland1 are correct that heart failure is a serious public health problem and is a leading cause of hospitalization. The most frequent cause of heart failure is coronary heart disease.2
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