George C. Sutton

Mode of death in patients with newly diagnosed heart failure in the general population.

Early prognosis for incident (new) heart failure (HF) patients in the general population is poor. Clinical trials suggest approximately half of chronic HF patients die suddenly but mode of death for incident HF cases in the general population has not been evaluated.

Predictors of prognosis in severe chronic heart failure

A total of 127 patients with chronic heart failure referred to our exercise laboratory were studied retrospectively to identify parameters predictive of prognosis. Patients were followed for a mean of 14.6 months. The group as a whole had severe ventricular dysfunction with a median ejection fraction of 17% and a median peak rate of oxygen consumption of 13.7 ml/kg/min. During the follow-up period 23 patients (18%) died and 18 (14%) underwent cardiac transplantation. The effect of the following variables on outcome (death or transplantation) were examined: age, cause of heart failure, cardiothoracic ratio on chest radiography, left ventricular end-systolic dimension on echocardiography, left ventricular ejection fraction on radionuclide ventriculography, mean dose of diuretic, plasma sodium and urea concentrations, and peak oxygen consumption during exercise. Although all variables except cause of heart failure affected outcome on univariate analysis, multivariate analysis identified three variables that were statistically significant and independent predictors of outcome. In order of importance these were plasma sodium level, left ventricular ejection fraction and peak oxygen consumption. Even in this group of patients with severe heart failure, these variables were predictive of outcome.

Epidemiologic aspects of heart failure

The prevalence of heart failure in Northwest London is 0.4%, a lower figure than that quoted for the United States. Heart failure is a common reason (5%) for medical admission to the hospital in the London area. The problem of heart failure is predominantly in persons over 65 years. Coronary artery disease is the most frequent cause, and hypertension is relatively uncommon. In those patients admitted to the hospital, the prognosis is poor.

Haemoglobin concentration and prognosis in new cases of heart failure

Anaemia is common in severe chronic heart failure and is reported to be a predictor of death. We investigated 552 patients (median age 76 years, range 29-95; 54% men [n=296]), in whom the duration of heart failure was sufficiently short that it would be unlikely to affect haemoglobin concentrations. By contrast with studies in established chronic heart failure, haemoglobin was not independently associated with prognosis when age and serum creatinine concentration were included in the analysis. The adverse effects of anaemia on survival might be a consequence of chronic heart failure rather than a separate process causing disease progression.

Incidence and outcome of persons with a clinical diagnosis of heart failure in a general practice population of 696,884 in the United Kingdom.

There are few large population‐based studies of the incidence and outcome of heart failure where the diagnosis of heart failure (HF) has been made by a General Practitioner (GP) in the community.

Improving survival in the 6 months after diagnosis of heart failure in the past decade: population-based data from the UK.

Objective: To investigate the secular trend in survival after a new diagnosis of heart failure in the UK population. Design and Setting: Comparison of all-cause mortality in the 6 months after diagnosis of heart failure in population-based studies in the south east of England in 2004–5 (Hillingdon–Hastings Study) and 1995–7 (Hillingdon–Bromley Studies). Participants: 396 patients in the 2004–5 cohort and 552 patients in the 1995–7 cohort with incident (new) heart failure. Main Outcome Measures: All-cause mortality. Results: All-cause mortality rates were 6% (95% CI 3% to 8%) at 1 month, 11% (8% to 14%) at 3 months and 14% (11% to 18%) at 6 months in the 2004–5 cohort compared with 16% (13% to 20%), 22% (19% to 25%) and 26% (22% to 29%), respectively, in the 1995–7 cohort (difference between the two cohorts, p<0.001). The difference in survival was not explained by any difference in the demographics or severity of heart failure at presentation. There was a difference at baseline and thereafter in the use of neurohormonal antagonists (β-blockers and angiotensin-converting enzyme inhibitors). Conclusions: Although early mortality remains high among patients with newly diagnosed heart failure in the UK general population, there is strong evidence of a marked improvement in survival from 1995–7 to 2004–5, perhaps partly explained by an increased usage of neurohormonal antagonists.

A Rapid Access Heart Failure Clinic provides a prompt diagnosis and appropriate management of new heart failure presenting in the community.

The diagnosis of heart failure is an important clinical problem and yet reported diagnostic accuracy in primary care is less than 50%. We established a Rapid Access Heart Failure Clinic (RAHFC) in a district general hospital serving a population of 292000 in SE London, UK, to diagnose and manage new cases of heart failure presenting for the first time in the community.

The variable effects of angiotensin converting enzyme inhibition on myocardial ischaemia in chronic stable angina.

The effect of angiotensin converting enzyme inhibition on myocardial ischaemia was studied in 12 normotensive patients with chronic stable angina and exercise induced ST segment depression. The study was randomised, double blind, placebo controlled, and crossover with treatment periods of two weeks. Enalapril was used to inhibit angiotensin converting enzyme. Assessment was by angina diaries and maximum symptom limited treadmill exercise tests. The results for the whole group showed a significant reduction in systolic blood pressure at rest and at peak exercise. Mean total exercise duration was 466 s (95% confidence interval 406 to 525) when the patients were taking placebo and 509 s (436 to 583) when they were taking enalapril. Four patients prolonged their total exercise time (mean 450 to mean 591 s) by more than 20%. Two patients, however, developed ischaemia earlier on exercise and reduced their total exercise duration (mean 490 to mean 390 s). Although angiotensin converting enzyme inhibition tended to reduce myocardial ischaemia in the group as a whole, some patients improved while others deteriorated. Thus the effects of enalapril are variable and this may have important implications when enalapril is used to treat heart failure in patients with underlying severe ischaemic heart disease.

The epidemiological enigma of heart failure with preserved systolic function.

Current epidemiological evidence suggests that the prevalence of preserved systolic function in patients with heart failure varies widely from 13 to 74%. This inconsistency suggests a lack of consensus as to what this condition really is and how it has been characterised for epidemiological studies.

Effects of combined alpha and beta adrenoceptor blockade in patients with angina pectoris. A double blind study comparing labetalol with placebo.

The effects of a combined alpha and beta receptor antagonist, labetalol, were investigated in 10 patients with chronic stable angina pectoris. The optimal dose was determined during an initial dose titration study when the patients were treated with 200 mg, 400 mg, and 600 mg (six patients) of labetalol a day. The effective dose was then compared with placebo in a double blind randomised study. The effects of the drug were monitored with angina diaries, treadmill exercise testing, and 48 hour ambulatory electrocardiographic ST segment monitoring. Plasma labetalol concentrations were measured during each treatment period. The mean effective antianginal dose of labetalol was 480 (SD 140) mg/day given by mouth twice a day. There was a dose related reduction in daytime and nocturnal heart rate, the frequency of pain was significantly reduced by 41%, and exercise duration was significantly increased by 44% with labetalol when compared with placebo. The frequency and duration of the episodes of ST segment depression were significantly reduced by 56% and 73% respectively with labetalol. Adverse effects resulted in a reduction of the dose of labetalol in two patients. Thus labetalol is an effective agent in the treatment of angina pectoris.