Heart Failure in the Community

描述(由申请人提供)：心力衰竭(HF)被指定为一种新出现的流行病。然而，它还没有完全被描述出来。大多数数据来自医院出院，无法测量发病率，具有不确定的有效性，并且由于转向门诊护理，无法涵盖心力衰竭的全部负担。关于其病因，高血压和冠心病(CHD)各自的作用是有争议的。此外，肥胖和糖尿病的患病率正在增加，这两种疾病都通过几种机制与心力衰竭联系在一起，因此可以想象，它们对心力衰竭的贡献可能会增加，但仍有待研究。最后，虽然舒张性心衰的存在是公认的，但它的诊断是基于无左室收缩功能不全的心衰症状而排除的。这种方法并不令人满意，因此DHF对HF的贡献仍然存在争议。这些令人震惊的知识差距突显了对出血热疫情进行严格调查的必要性。通过对奥姆斯特县社区的监测，我们证实了CHD向高龄推迟，住院MI的严重程度和MI后心衰的发生率随着时间的推移而下降。这意味着，如果CHD是心力衰竭的主要原因，心力衰竭应该推迟到年龄较大的年龄，其发病率相对稳定。在同一时期，心力衰竭监测的初步结果表明，首次临床诊断心力衰竭的发病率可能不会像出院时所暗示的那样增加，不良趋势可能优先发生在较年轻的人群中。来自同一社区的这些数据很难与CHD对HF流行的持续主要贡献的概念相一致，从而强调了严格研究HF流行病学的必要性，这是本应用的重点。我们提出了3个具体目标和社区监测方法，结合我们正在进行的CHD监测工作，通过描述其大小和决定因素，并前瞻性地研究DHF的贡献，来调查奥姆斯特县的HF流行。目的1评估有效的心力衰竭的发病率和结局的长期趋势，以检验以下假设：心力衰竭的发病率随着年龄和性别的不同而增加，心力衰竭的存活率随着心力衰竭住院人数的增加而提高。目的2采用病例对照的方法来描述心力衰竭的病因及其随时间的变化，以检验以下假设：冠心病和高血压使心力衰竭的危险性增加，肥胖和糖尿病使心力衰竭的危险性增加，心力衰竭的人群归因危险度降低，而肥胖和糖尿病的人群归因危险度随时间增加。目的3将前瞻性地用脑利钠肽(BNP)来描述DHF对HF的贡献，并确定BNP在所有HF病例中的预后价值。因此，这些目标的完成将为研究心力衰竭的流行病学提供重要的见解。

DESCRIPTION (provided by applicant): Heart failure (HF) is designated as an emerging epidemic. Yet, it is not fully characterized. Most data, derived from hospital discharges, cannot measure incidence, have uncertain validity and cannot capture the full burden of HF because of the shift towards outpatient care. Regarding its etiology, the respective role of hypertension and coronary heart disease (CHD) is controversial. Moreover, the prevalence of obesity and diabetes mellitus is increasing, both conditions linked to HF via several mechanisms such that their contribution to HF could conceivably be increasing but remains to be examined. Finally, while the existence of diastolic HF is recognized, its diagnosis is exclusionary based on symptoms of HF in the absence of LV systolic dysfunction. This approach is unsatisfactory, thus the contribution of DHF to HF remains contentious. These striking gaps in knowledge underscore the necessity of a rigorous investigation of the HF epidemic. Through surveillance of the Olmsted County community, we demonstrated the postponement of CHD towards older ages and the decline over time in the severity of hospitalized MI and the incidence of HF after MI. This implies that, if CHD is the main cause of HF, HF should be postponed towards older ages and its incidence rate relatively stable. During the same period, preliminary findings on HF surveillance suggest that the incidence of first clinical diagnosis of HF may not be increasing as much as implied by hospital discharges and that adverse trends may be occurring preferentially among younger ages. These data from the same community are challenging to reconcile with the concept of an ongoing major contribution of CHD to an epidemic of HF, thereby underscoring the need to rigorously study the epidemiology of HF, which is the focus of this application. We propose 3 specific aims and a community surveillance approach, integrated with our ongoing work on CHD surveillance to investigate the HF epidemic in Olmsted County by characterizing its magnitude and determinants and studying prospectively the contribution of DHF. Aim 1 will estimate the secular trends in the incidence and in the outcome of validated HF to test the hypotheses that there has been an increase in the incidence of HF, which differs by age and sex and that the survival of HF improved while hospitalization for HF has increased. Aim 2 will use a case-control approach to characterize the etiology of HF and its changes over time to test the hypotheses that CHD and hypertension confer an excess risk of HF, the magnitude of which is declining over time, that obesity and diabetes mellitus confer an excess risk of HF the magnitude of which is increasing and that the population attributable risk of CHD and hypertension for HF is declining, while that of obesity and diabetes mellitus is increasing over time. Aim 3 will prospectively characterize the contribution of DHF to HF using brain natriuretic peptide (BNP) among persons with HF and define the prognostic value of BNP in all cases of HF. Thus, the completion of these aims will provide important insights into the epidemiology of HF.