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，它并没有完全被描述。大多数数据来自医院出院，不能衡量发病率，有效性不确定，由于转向门诊治疗，不能反映心衰的全部负担。关于其病因，高血压和冠心病（CHD）各自的作用存在争议。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HF相关，因此它们对HF的贡献可能会增加，但仍有待研究。最后，虽然舒张期心衰的存在是公认的，但其诊断是基于心衰症状在没有左室收缩功能障碍的情况下的排除性诊断。这种方法并不令人满意，因此DHF对HF的贡献仍然存在争议。这些显著的知识差距强调了对心衰流行进行严格调查的必要性。通过对奥姆斯特德县社区的监测，我们证明了冠心病向老年推迟，住院心梗的严重程度和心梗后心衰的发生率随着时间的推移而下降。这意味着，如果冠心病是心衰的主要原因，那么心衰应该向老年推迟，其发病率相对稳定。在同一时期，心衰监测的初步结果表明，心衰首次临床诊断的发生率可能没有出院所暗示的那样增加，而且不良趋势可能优先发生在年轻人群中。来自同一社区的这些数据很难与冠心病对心衰流行的持续主要贡献的概念相一致，因此强调了严格研究心衰流行病学的必要性，这是本应用的重点。我们提出了3个具体目标和一种社区监测方法，结合我们正在进行的冠心病监测工作，通过描述其规模和决定因素，并前瞻性地研究登出血热的贡献，来调查奥姆斯特德县的HF流行。目的1将估计心衰发病率的长期趋势和结果，以检验心衰发病率增加的假设，其随年龄和性别的不同而不同，心衰的生存率提高，心衰住院率增加。目标2将使用病例对照方法描述心力衰竭的病因及其随时间变化来测试假设冠心病和高血压授予过多心力衰竭的风险,的大小随时间下降,肥胖和糖尿病带来超额风险的高频的大小增加,高频的人口由于冠心病和高血压的风险正在减少,而肥胖和糖尿病随着时间在不断的增加。目的3将利用脑利钠肽（BNP）在HF患者中前瞻性地表征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心衰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.