Epidemiology of Heart Failure Stages in Middle-Aged Black People in the Community: Prevalence and Prognosis in the Atherosclerosis Risk in Communities Study.

Background Black individuals have a higher burden of risk factors for heart failure (HF) and subclinical left ventricular remodeling. Methods and Results We evaluated 1871 Black participants in the Atherosclerosis Risk in Communities Study cohort who attended a routine examination (1993-1996, median age 58 years) when they underwent echocardiography. We estimated the prevalences of 4 HF stages: (1) Stage 0: no risk factors; (2) Stage A: presence of HF risk factors (hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, coronary artery disease without clinical myocardial infarction), no cardiac structural/functional abnormality; (3) Stage B: presence of prior myocardial infarction, systolic dysfunction, left ventricular hypertrophy, regional wall motion abnormality, or left ventricular enlargement; and (4) Stage C/D: prevalent HF. We assessed the incidence of clinical HF, atherosclerotic cardiovascular disease events, and all-cause mortality on follow-up according to HF stage. The prevalence of HF Stages 0, A, B, and C/D were 3.8%, 20.6%, 67.0%, and 8.6%, respectively, at baseline. On follow-up (median 19.0 years), 309 participants developed overt HF, 390 incurred new-onset cardiovascular disease events, and 651 individuals died. Incidence rates per 1000 person-years for overt HF, cardiovascular disease events, and death, respectively, were Stage 0, 2.4, 0.8, and 7.6; Stage A, 7.4, 9.7, and 13.5; Stage B 13.6, 15.9, and 22.0. Stage B HF was associated with a 1.5- to 2-fold increased adjusted risk of HF, cardiovascular disease events and death compared with Stages 0/A. Conclusions In our large community-based sample of Black individuals, we observed a strikingly high prevalence of Stage B HF in middle age that was a marker of high cardiovascular morbidity and mortality.

Clinical correlates and prognostic significance of change in standardized left ventricular mass in a community-based cohort of African Americans.

BACKGROUND: Though left ventricular mass (LVM) predicts cardiovascular events (CVD) and mortality in African Americans, limited data exists on factors contributing to change in LVM and its prognostic significance. We hypothesized that baseline blood pressure (BP) and body mass index (BMI) and change in these variables over time are associated with longitudinal increases in LVM and that such increase is associated with greater incidence of CVD. METHODS AND RESULTS: We investigated the clinical correlates of change in standardized logarithmically transformed-LVM indexed to height2.7 (log-LVMI) and its association with incident CVD in 606 African Americans (mean age 58±6 years, 66% women) who attended serial examinations 8 years apart. Log-LVMI and clinical covariates were standardized within sex to obtain z scores for both visits. Standardized log-LVMI was modeled using linear regression (correlates of change in standardized log-LVMI) and Cox proportional hazards regression (incidence of CVD [defined as coronary heart disease, stroke, heart failure and intermittent claudication]). Baseline clinical correlates (standardized log-LVM, BMI, systolic BP) and change in systolic BP over time were significantly associated with 8-year change in standardized log-LVMI. In prospective analysis, change in standardized LVM was significantly (P=0.0011) associated with incident CVD (hazards ratio per unit standard deviation change log-LVMI 1.51, 95% CI 1.18 to 1.93). CONCLUSIONS: In our community-based sample of African Americans, baseline BMI and BP, and change in BP on follow-up were key determinants of increase in standardized log-LVMI, which in turn carried an adverse prognosis, underscoring the need for greater control of BP and weight in this group.

Palliative care for the terminal heart failure patient.

Heart failure is a chronic disease afflicting millions of patients worldwide. Advances in treatment have allowed sufferers to enjoy overall prolonged survival and enhanced quality of life. Yet, a consequence of these therapeutic successes is that more patients survive to end-stage disease, with severe symptoms, poor quality of life, and no options available to prolong their survival reasonably. End-stage heart failure patients require a comprehensive palliative approach to care during their final months, with treatment goals focusing on symptom relief. Often, specific heart failure therapies can further this cause and should be administered when appropriate to alleviate specific symptoms, while other general palliative measures should also be considered as with other terminal patients. End-of-life palliative strategies must conform to accepted principles of ethical care. Constant communication with patients and families is essential to achieve best treatment goals for this growing segment of the population.