In contrast to the complex issues related to the incidence of heart failure, changes in the rate of death due to heart failure may be relatively easy to understand. A previous Framingham Heart Study investigation in which survival after heart failure was analyzed for the period from 1948 to 198813 and a small, population-based study in which survival after heart failure was analyzed in 1981 and 19915 showed no improvement in survival after heart failure. These studies were performed before the widespread integration of angiotensin-converting–enzyme inhibitors into community-based practice. With data from the 1990s now incorporated, the Framingham Heart Study indicates that survival among patients with heart failure has improved. Again, the timing of the improvement cannot be determined from the statistical analysis, but examination of the data suggests that the improvement occurred primarily in the 1990s. These data are consistent with the results of a large study from Scotland that found decreases in mortality at one year among patients hospitalized for heart failure between 1986 and 1995.14
As emphasized by the authors of the current report, the reasons for the improvement in survival cannot be definitively ascertained. However, there is evidence that the use of angiotensin-converting–enzyme inhibitors and beta-blockers in patients with heart failure is increasing.15 This is the most appealing explanation and one that promises further improvements if the use of optimal therapy for heart failure in the community continues to increase. However, there are other possible explanations, including changes in the distribution of systolic and diastolic heart failure and changes in the causes of heart failure over time. Paradoxically, this much needed good news for patients in whom heart failure is diagnosed will translate into further increases in the overall number of persons with heart failure in the community.
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