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European Journal of Heart Failure 2005 7(3):295-302; doi:10.1016/j.ejheart.2004.10.017
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© 2005 European Society of Cardiology

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

Federica de Giulia, Kay-Tee Khawb, Martin R. Cowiec, George C. Suttonc, Roberto Ferrarid and Philip A. Poole-Wilsonc,*

a Salvatore Maugeri Foundation IRCCS, Gussago (Brescia), Italy
b Clinical Gerontology Unit, University of Cambridge Cambridge, UK
c Cardiac Medicine, National Heart and Lung Institute, Imperial College London Dovehouse Street, London SW3 6LY, UK
d University of Ferrara Ferrara, Italy

* Corresponding author. Tel.: +44 20 7351 8179; fax: +44 20 7351 8113. E-mail address: p.poole-wilson{at}imperial.ac.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Background: 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.

Methods: From the General Practice Research Database in the UK, we selected a population of 686,884 people 45 years or older. Incident cases of HF in 1991 were classified definite HF, possible HF, or a first prescription of diuretics without a diagnosis of HF. The population was followed for 3-year mortality.

Results: A total of 6478 patients had definite HF (mean age 77.2 years, 55.5% women), 14,050 had possible HF and 6076 persons were prescribed diuretics without a definite or possible diagnosis of HF. The overall incidence of definite HF was 9.3/1000 persons/year and of possible HF 20.2/1000 persons/year. Diuretics were prescribed for the first time for other reasons for 8.7 persons/1000/year. The incidence of HF was higher in men. The incidence of definite HF increased with age. Survival curves showed higher mortality rates in the first 3 months after the diagnosis of HF. One-year cumulative probability of death for patients with definite HF was 15.9 times higher in men and 14.7 times higher in women in comparison with the UK population.

Conclusion: The diagnosis of HF by a GP successfully identifies patients at high risk of death, comparable to patients with HF identified by cardiologists on the basis of defined diagnostic criteria. HF is common in the general population, increases sharply with age, and has a poor prognosis.

Key Words: Heart failure • General Practitioners • Diagnosis • Incidence • Prognosis

Received June 18, 2004; Revised August 23, 2004; Accepted October 20, 2004


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Epidemiological studies in heart failure (HF) often report discordant results in terms of incidence and mortality rates [1]. There are many reasons. HF can be mimicked by other conditions and is a clinical syndrome with numerous causes, of which coronary artery disease is the most frequent [1–3]. The definition of HF has changed in the last three decades and few definitions are easily applicable to epidemiological studies. Technological advances have led to the use of investigations such as the echocardiogram prior to a formal diagnosis being made [1–4]. The diagnostic approach may differ depending on whether the diagnosis has been made by a cardiologist in a hospital environment or in General Practice [1,4,5]. Most community studies on patients with HF have been conducted by specialists who determined the diagnostic criteria and who report a population of HF patients meeting those criteria [1,5–11]. Much of the data on prognosis have been obtained from clinical trials where the population of patients is not typical of the community as a whole.

The purpose of this study was to determine the incidence and the prognosis of the diagnosis of HF made by General Practitioners (GPs) in a large community based population in the UK. The study was observational in design. Outcome was evaluated according to the certainty of the diagnosis.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
2.1. General practice research database
The General Practice Research Database (GPRD) is a database set up in the UK in 1987. GPs were asked to record clinical data from their patients. Since September 1994, the database has been managed by the Office of National Statistics (ONS) on behalf of the Department of Health. As of May 1994, 525 practices were participating, with a total population of 3.4 million patients, representing 6.4% of the population of England and Wales and 6% of the UK. The quality of the data is assessed regularly to ensure the maintenance of a database suitable for research purposes. Data from each practice are examined routinely each month so as to monitor whether the research protocol has been followed. Quality assessment and other checks are carried out to determine the completeness of the recording of demographic and registration data, the percentage of acute and repeat prescriptions that have appropriate indications recorded, referrals, recording of the fact and the cause of death. Comparison of the population registered in the GPRD database and the population derived from the 1991 census in the UK (England and Wales) shows that the age distributions are broadly similar [12]. Detailed descriptions of the database have been published and the information validated [13,14,16].

2.2. Population
The population for this study was derived from the GPRD database by selecting individuals aged ≥45 years (38.2% of the total population), who were in the registry in 1991 and who had been previously registered in the database for at least 12 months. Only patients in practices which collected data for the whole period of observation (1991–1994) were included. This period of time was chosen as it had the most complete and stable data collection, at the time this study began. This population is referred to as GP91, and comprises 696,884 individuals. GP91 is the denominator used in the analyses. Life tables, by age group and gender, were derived from GP91 with data summarised every 3 months, for the entire 3-year follow-up period.

From GP91, we classified incident cases in 1991 into three groups: definite HF, possible HF, and first prescription of diuretics without concomitant and/or previous diagnosis of HF (neither definite nor possible). Criteria were established for allocating patients to the three groups. Those coded as "definite" were those where the written diagnosis and clinical description in the database unequivocally indicated an intention to make a diagnosis of HF. Examples are phrases such as congestive cardiac failure, ventricular failure, and pulmonary oedema. Those coded as "possible" mainly had descriptions of signs and symptoms suggestive of HF or had related cardiac abnormalities such as heart enlargement or ventricular hypertrophy. In this group, there was a possibility of a non-cardiac pathology or of heart disease in the absence of the features of HF. For each of the three groups, baseline characteristics and the date of death were recorded up to the end of 1994. A specific variable was created to describe whether the diagnosis of HF had been made by the GP alone or on the basis of discharge letters from a hospital. The investigation conforms with the principles outlined in the Declaration of Helsinki. The study was approved by an advisory Committee of the GPRD, set up under the auspices of the Department of Health.

2.3. Statistical methods
Incidence rates of HF (both "definite" and "possible") and diuretic prescription were calculated using the GP91 population registered at 1st July 1991 as the denominator. Possible differences in age among the three groups were analysed with one-way analysis of variance (ANOVA), with Bonferroni's correction for multiple comparisons. Differences in survival were analysed with the log-rank test. The standardised mortality ratio (SMR) for total mortality was calculated using the appropriate national age group and gender specific death rates in 1994 as the standard population [15]. The 3-year SMR was calculated using the mortality rates of the GP91 population as the standard since GP91 patients had the same follow-up and the same rate of ageing. The relative risks of death comparing the three populations were analysed by the Cox proportional hazards model, adjusted by gender, age and for the interaction between age and gender. 95% confidence intervals (CI) and two-tailed tests of significance are reported. The statistical package SPSS 9.0 (Chicago, IL, US) was used for data analyses.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
The calculated incidence of HF in each of the groups (with 95% confidence intervals) is shown in Fig. 1. The overall incidence of definite HF in those ≥45 years of age (38.2% of the total population), was 9.3/1000 persons/year, and of possible HF 20.2/1000 persons/year. New diuretic treatment without HF was initiated in 8.7/1000 persons/year. The incidence increased with age in each group. For definite HF, the incidence rose from 3.4/1000 persons/year for those aged 55–64 years to 25.5/1000 persons/year for those aged 75–84 years. In each age band, the incidence was higher in men than in women, with a mean incidence ratio for men compared with women of 1.4 (±0.3).


Figure 1
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  		Fig. 1 The annual incidence per 1000 persons (with 95% confidence intervals) of those identified with definite heart failure (a), possible heart failure (b) and those with first prescription of diuretics but without heart failure (c). Data are shown for all ages broken by gender (first bars on the left) and broken down by age-group and gender.

 
Table 1 shows the baseline characteristics of the patients and the registration status at the end of 1994 by diagnostic group and gender. In each group there were more women than men. In definite HF, there was a higher proportion of men than women in younger patients (56%) but lower (38%) after 75 years. The mean (±S.D.) age for new cases of definite HF was 75±9 years in men and 79±9 years in women (p<0.001). The age distribution of persons on diuretics without HF was almost a decade younger. In each group, the number of patients in whom the diagnosis was made by the General Practitioner either on the basis of his/her clinical judgement or according to the diagnosis described in discharge letters from hospitals indicated that the diagnosis was most commonly made by GPs alone (>76%). The population of patients lost to follow-up ranged from 8% to 13%. The proportion of patients dying in each group from 1991 through to 1994 ranged from 67% for men with definite HF to 17% for women on diuretics without HF. The proportion of patients admitted to hospital in the first year after diagnosis was higher than in the following years, in all the three groups and for both genders. In the group with definite HF, the proportion of patients hospitalised in the first year was 28% and 24% in men and women, respectively, 70% of these admissions being in either General Medicine or Departments of Geriatrics.


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  		Table 1 Baseline characteristics and registration status at the end of follow-up of the three populations

 
Survival is shown in Fig. 2. The mean survival time for definite HF was 23.8 months (95% CI 23.4–24.1), 22.9 months in men and 24.5 months in women (p<0.001). The mean survival for definite HF was worse than that for possible HF (31.4 months; 95% CI 31.2–31.6, p<0.001) and that for those with first prescription of diuretics (33.8 months; 95% CI 33.6–34.0, p<0.001). The values of mean and median survival were identical in patients with possible HF and in persons on diuretics without HF while were discordant in patients with definite HF (median survival being 30.8 and 36.5 months, in men and women, respectively). In the Cox analysis adjusted by age, gender, and age and gender interaction, with definite HF as the reference, the relative risk of possible HF and those with first prescription of diuretics was 0.56 (95% CI 0.54–0.58) and 0.38 (95% CI 0.35–0.41), respectively.


Figure 2
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  		Fig. 2 Cumulative probability of survival in the denominator population (GP91) and those with definite heart failure, possible heart failure or those with first prescription of diuretics without heart failure. Results are provided for entire population (a), men only (b) and women only (c).

 
The survival for definite HF was non-linear, being steeper in the first 3 months after diagnosis. The trend was less marked for possible HF or for those with first prescription of diuretics. The relative risk of death (adjusted for age and gender) if diagnosed in hospital rather than by the GP was 1.31 for definite HF, 1.26 for possible HF. The standardised mortality ratio (SMR) is the ratio of the cumulative probability of dying in the study population compared with age and sex matched general population in England and Wales expressed as a percentage. The SMR is shown in Table 2. The 1-year SMR of 110 for the GP91 database population is close to 100, indicating that this population is broadly representative of the national population (Table 2). Small differences are present in some age groups. The SMR for definite HF was 1590% (95% CI 1490–1700) for men and 1470% (95% CI 1390–1570) for women. The SMR for definite HF was the highest, for every age group and gender, followed by the SMR for possible HF and then that for patients with first prescription of diuretics. In each group, SMR progressively decreased with increasing age. This partly reflects the increasing mortality with age in the general population. In those on diuretics, in the oldest age group of women, SMR is not elevated. There are no clear gender differences in SMR, within each group. The 3-year SMR was lower than the 1-year SMR confirming the reduction in mortality after the first year and the effect of ageing.


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  		Table 2 Standardised mortality ratio by age group and gender

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
This study has the largest group of patients with a diagnosis of newly acquired HF ever examined in the community, that is 6478 cases of definite HF from a population of 696,884 persons. The study was based upon a diagnosis of HF made in General Practice and provides a description of the clinical approach in the UK in the years 1991 to 1994. The findings show that HF is common, carries a poor prognosis, is most often diagnosed by GPs, and is largely a disease of old age. In the elderly, there are more women with HF than men, although the incidence rate is higher in men than in women in all age groups. The highest rates of admission to hospitals are in those with definite HF and the lowest in patients with a first prescription of diuretics, thus showing a relation to the severity of HF. The differences are statistically significant when considering hospital admission to Departments of Geriatrics or General Medicine but not for other specialties such as surgery (data not shown). Hospitalisation rate was consistently higher in men than in women. Men were more frequently admitted to General Medicine than to Geriatics in comparison with women.

There have been few similar studies. The published community-based studies used highly specific criteria for the diagnosis of HF and had many fewer incident cases (Framingham 652 [17] and 1075 [18]), Rochester 46 [9], Eastern Finland 51 [19], Transition project in the Netherlands 245 [20], Nijmegen 197 [21], General Practice UK 1076 [22], Hillingdon 220 [11], Bromley 332 [23] and UK general practice 1200 [16].

Comparisons among studies can be problematic because of the selection of populations under investigation. Incidence rates in the literature are generally lower than those estimated from this study, apart from the annual incidence rate of HF in the age group 85–94 years (54/1000 persons/year in men and 88/1000 persons/year in women) showed in recent data from the Framingham study [24].

In the oldest age group of our study (>85 years) there were 1408 patients (21.7%) and 547 (8.4%) of them were aged between 90 and 101 years. Such a large group of elderly is not generally represented in the other studies in the literature. Our study enrolled all persons aged ≥45 years (38.2% of the whole population) and the overall figure for the incidence of definite HF in the population aged ≥45 years, 9.3/1000 persons/year, is approximately equivalent to 3.7/1000 persons/year assuming incidence rate 0.02 cases/1000 person/year in the population <45 years. The differences between our study and others can at least in part be explained by the upper limit of age (62 years) of the population at the time of enrolment in the Framingham study, by the lower limit of age used in different studies, by the follow-up of populations in which cardiovascular risks were modified resulting in possibly a lower incidence of cardiovascular disease and by differences in criteria to define heart failure.

The incidence of HF depends critically on the definition of HF. From our findings, an upper and lower estimate can be made by adding together definite and possible HF. The lower estimate is 3.6/1000 persons/year and the upper estimate is 11.6/1000 persons/year.

The mean age of patients with definite HF (77±9.6 S.D. years) was higher than that in the Framingham HF population (70±10.8 S.D. years). The Framingham study enrolled a population aged between 28 and 62 years [17] and only a few patients were very old at the time of the observation period [10]. The mean age of definite HF is similar to the mean age observed in the patients enrolled in other UK studies performed by Cowie et al. [11] (76 years) and Fox et al. [23] (76 years), where all ages in the population were selected and only three and one patients were below 45 years, respectively. The mean age of patients with definite HF is equal to the mean age observed in the study conducted in Minnesota [10].

In each diagnostic group, there were more women than men (Table 1). The probable reasons for this finding differ in the three groups. In definite HF, it is due to the greater age of these patients and to the higher proportion of women still alive at those ages, as confirmed by the incidence data which have been corrected by the denominator and show a higher incidence in men, as reported in the literature [1,10,11,17]. In possible HF, the higher proportion of women is not just the consequence of greater numbers of older women because it is also associated with a higher age specific incidence in women. Women may report symptoms and signs suggestive of HF more often than men. The first prescription of diuretics was commoner in women (Table 1) and the incidence was higher in women in all age groups except ≥85 years (Fig. 1). The majority of these patients have hypertension (62%) and the prevalence of hypertension in the elderly is independent of gender [25].

One- and three-year probability of survival of definite HF observed in our study does not differ greatly from the HF population observed in the community in other studies (Framingham [26] and Minnesota [10]). In the study conducted by Cowie et al. [27], with rather "strict" diagnostic criteria for HF, the 1-year probability of survival was 0.62. The shape of the survival curve of patients with definite HF is similar to that usually reported in the literature in patients with new diagnosis of HF [10,27,28]. Even survival curves in patients with signs and symptoms of HF but without a stated or confirmed diagnosis show a rapid decline in survival (even less steep than in definite HF) in the first 3 months after the beginning of clinical manifestations.

The 1-year SMR for definite HF is high, especially for the youngest age group (with mortality rate more than 100 times higher than that in the general population for men, and 50 times for women). The 1-year SMR for possible HF indicates that these patients have about 6 times higher mortality rate than the matched general population (14 times higher than that in the general population in men and 10 times higher in women in the youngest age group), suggesting the occurrence of important disease.

The lack of gender differences in SMR with increasing age could indicate that the advantage observed in women for survival is generic, being also present in the general population. The high proportion of women and the age specific SMR suggests that old women with HF lose some of the survival advantage which younger women have.

We were interested in evaluating the group which received a prescription for diuretic treatment for the first time, without having a diagnosis of HF. One reason was the need to have a comparison group, since almost all the patients with HF are treated with diuretics. A second reason was that the prescription of diuretics has been used as an indicator of, or as a part of the definition of HF in order to calculate prevalence [4,5,29,30]. We have observed that a high number of patients received diuretic treatment without having HF (this number being similar to that of the patients with HF). In these patients, hypertension was present in just over 50%, while the list of other concomitant diagnoses was very wide (data not shown). The almost "normal" survival in the oldest age group of patients with first prescription of diuretics, especially in women, suggests that in the elderly there is an over-prescription of diuretics [31], or at least, prescription for conditions not associated with increased mortality. In the youngest age group, mortality rate was 2–3 times higher than the mortality in the general population. The diuretic group is very different from the groups with HF.

There are a number of limitations to this study. No standardised definition of HF was used at the time of diagnosis—the study describes actual diagnostic procedure in the UK. It could be argued that the worse outcome observed in the patients of this study in comparison with the national mortality rates is due to the observation of an unusual database. However, the SMR of GP91 of 110 suggests that this population was not unusually ill. No accurate data were available to determine cause specific mortality.

It has been reported that the diagnosis of HF is especially difficult in elderly and women and there is a high rate of misdiagnosis of HF in primary care [32,33]. However, studies quoted to support the high rate of misdiagnosis of HF either asked GPs to screen patients with low probability of the disease [11,19,23] or confirmed the diagnosis only on the basis of left ventricular systolic dysfunction [32]. It has also been observed that among patients with preserved left ventricular systolic function (excluding also valvular heart disease and AF) and suspected HF, 67% had "diastolic" HF (using the E/A ratio) but also other concomitant diseases that could explain symptoms, i.e. obesity (37%), respiratory diseases (50%) and coronary artery diseases ({approx}30%) [34]. However, this observation does not necessarily imply that the diagnosis of diastolic HF was wrong: several patients with systolic dysfunction also complain of obesity, respiratory diseases and coronary artery diseases, being the last one actually an aetiologic factor of HF. The agreement of incidence and mortality rates observed in our study (both in terms of absolute values and shape of curves) with results in the literature supports the hypothesis that the diagnosis of HF made by GPs is not so unreliable as previously thought. Our results also support the previous finding that, within patients admitted with complains of shortness of breath but discharged without a diagnosis of HF, 44% had left ventricular ejection fraction ≤40% and 51% met the Framingham criteria for HF diagnosis [35]. The selection of "true HF cases" implies the exclusion of mild cases as suggested by the increased SMR and the shape of survival curves of patients with signs and symptoms of HF or cardiac abnormalities without a definite diagnosis of the disease.

These findings have substantial implications for clinical practice and for health care policy. HF is very much a disease of the elderly, is common and likely to increase in prevalence over the next two decades due chiefly to demographic changes in the structure of the population. GPs using clinical skills are the clinicians who most frequently make the first diagnosis of HF in the community, and, when attaching the label of HF, do identify a group of patients with a poor outcome. The diagnosis may well be correct and certainly results in a simple and cheap method for the identification of patients with HF in the population. Effective and safe treatments are available and could be used earlier in the natural history of HF by relying on clinical evaluation. Patients who are included in controlled clinical trials of new therapies do not resemble the generality of patients with HF—substantial differences exist with regard to age and gender. There is a need to evaluate current therapies for HF in the elderly and in women, in order to confirm the benefit of therapies in the great majority of patients who are seen in general practice.


   Acknowledgement
 
The authors are indebted to Alessandro Bettini for editing the manuscript.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

  1. Cowie M.R., Mosterd A., Wood D.A., Deckers J.W., Poole-Wilson P.A., Sutton G.C., et al. The epidemiology of heart failure. Eur. Heart J. (1997) 18:208–225.[Free Full Text]
  2. Poole-Wilson P.A. Heart failure. Poole-Wilson P.A., Colucci W.S., Massie B.M., Chatterjee K., Coats A.J.S., eds. (1997) New York: Churchill Livingstone. 269–277.
  3. Katz A.M. Heart failure in 2001: a prophecy. Am. J. Cardiol. (1992) 70:126C–131C.[CrossRef][Medline]
  4. Purcell I.F., Poole-Wilson P.A. Heart failure: why and how to define it? Eur. J. Heart Fail. (1999) 1:7–10.[Free Full Text]
  5. Hoes A.W., Mosterd A., Grobbee D.E. An epidemic of heart failure? Recent evidence from Europe. Eur. Heart J. (1998) 19:L2–L8.[Medline]
  6. McKee P.A., Castelli W.P., McNamara P.M., Kannel W.B. The natural history of congestive heart failure: the Framingham study. N. Engl. J. Med. (1971) 285:1441–1446.[Web of Science][Medline]
  7. Eriksson H., Svardsudd K., Caidahl K., Bjuro T., Larsson B., Welin L., et al. Early heart failure in the population. The study of men born in 1913. Acta Med. Scand. (1988) 197–209.
  8. Schocken D.D., Arrieta M.I., Leaverton P.E., Ross E.A. Prevalence and mortality rate of congestive heart failure in the United States. J. Am. Coll. Cardiol. (1992) 20:301–306.[Abstract]
  9. Rodeheffer R.J., Jacobsen S.J., Gersh B.J., Kottke T.E., McCann H.A., Bailey K.R., et al. The incidence and prevalence of congestive heart failure in Rochester, Minnesota. Mayo Clin. Proc. (1993) 68:1143–1150.[Web of Science][Medline]
  10. Senni M., Tribouilloy C.M., Rodeheffer R.J., Jacobsen S.J., Evans J.M., Bailey K.R., et al. Congestive heart failure in the community. A study of all incident cases in Olmsted county, Minnesota, in 1991. Circulation (1998) 98:2282–2289.[Abstract/Free Full Text]
  11. Cowie M.R., Wood D.A., Coats A.J.S., Thompson S.G., Poole-Wilson P.A., Suresh V., et al. Incidence and aetiology of heart failure. A population-based study. Eur. Heart J. (1999) 20:421–428.[Abstract/Free Full Text]
  12. The general practice research database. In: Information for Researchers (1996) London: Office for National Statistics.
  13. Jick H., Jick S., Derby L.E. Validation of information recorded on General Practitioner based computerised data resource in the United Kingdom. Br. Med. J. (1991) 30.2:766–768.[Abstract/Free Full Text]
  14. Jick H., Jick S., Derby L.E., Vasilakis C., Myers M.W., Meier C.R. Calcium-channel blockers and risk of cancer. Lancet (1997) 349:525–528.[CrossRef][Web of Science][Medline]
  15. Johansson S., Wallender M.A., Ruigómez A., Rodróguez L.A.G. Incidence of newly diagnosed heart failure in UK general practice. Eur. J. Heart Fail. (2001) 3:225–231.[Abstract/Free Full Text]
  16. Office for National Statistics. Mortality statistics: general. In: Review of the Registrar General on Deaths in England and Wales, 1993–1995. DH1 (1997) vol. 28, 4. London: The Stationery Office. 107–108.
  17. Ho K.K.L., Pinsky J.L., Kannel W.B., Levy D. The epidemiology of heart failure: the Framingham study. J. Am. Coll. Cardiol. (1993) 22:6A–13A.[Medline]
  18. Levy D., Kenchaiah S., Larson M.G., Benjamin E.J., Kupka M.J., Ho K.K.L., et al. Long-term trends in the incidence of and survival with heart failure. N. Engl. J. Med. (2002) 347(18):1397–1402.[Abstract/Free Full Text]
  19. Remes J., Reunanen A., Aromaa A., Pyorala K. Incidence of heart failure in eastern Finland: a population-based surveillance study. Eur. Heart J. (1992) 13:588–593.[Abstract/Free Full Text]
  20. Lamberts H., Brouwe H.J., Mohrs J. Reason for encounter and episode and process oriented standard out-put from the transition project. Part 1 and 2. (1993) Amsterdam: Dept. of General Practice.
  21. Van de Lisdonk E.H., Van den Bosch W.J.H.M., Huygen F.J.A., Lagro-Jansen A.L.M. Diseases in general practice. (1990) Utrecht, The Netherlands: Bunge.
  22. Royal College of General Practitioners, Office of Population Census and Survey, Department of Health and Social Security. Morbidity statistics from General Practice: fourth national study, 1991;92. (1995) London: HMSO.
  23. Fox K.F., Cowie M.R., Wood D.A., et al. Coronary artery disease as the cause of incident heart failure in the population. Eur. Heart J. (2001) 22:228–236.[Abstract/Free Full Text]
  24. Kannel W.B. Epidemiology and prevention of cardiac failure: Framingham study insights. Eur. Heart J. (1987) 8:23–29.[Abstract/Free Full Text]
  25. National Center for Health Statistics. Blood pressure levels and hypertension in persons aged a6–74 years: United States 1976–80. Advance data from vital and health statistics N. 84, DHHS Pub. No. (PHS)82-1250. Rowland W, Roberts J, eds. (1982) Hyattsville, MD: Public Health Service. October 8.
  26. Ho K.L., Anderson K.M., Kannel W.B., Grossman W., Levy D. Survival after the onset of congestive heart failure in Framingham heart study subjects. Circulation (1993) 88:107–115.[Abstract/Free Full Text]
  27. Cowie M.R., Wood D.A., Coats A.J.S., Thompson S.G., Suresh V., Poole-Wilson P.A., et al. The survival of patients with a new diagnosis of heart failure: a population-based study. Heart (2000) 83:505–510.[Abstract/Free Full Text]
  28. Cleland J.G.F., Clark A. Has the survival of heart failure population changed? Lessons from trials. Am. J. Cardiol. (1999) 83:112D–119D.[Web of Science][Medline]
  29. Clarke K.W., Gray D., Hampton J.R. How common is heart failure? Evidence from PACT (Prescribing Analysis and Cost) data in Nottingham. J. Public Health Med. (1995) 17:459–464.[Abstract/Free Full Text]
  30. Parameshwar J., Shackell M.M., Richardson A., Poole-Wilson P.A., Sutton G.C. Prevalence of heart failure in three general practices in north west London. Br. J. Gen. Pract. (1992) 287–289.
  31. vanKraaij D.J.W., Jansen R.W.M.M., Bruijns E., Gribnau F.W.J., Hoefnagels W.H.L. Diuretic usage and withdrawal patterns in a Dutch geriatric patient population. J. Am. Geriatr. Soc. (1997) 45:918–922.[Web of Science][Medline]
  32. Wheeldon N.M., MacDonald T.M., Flucker C.J., McKendrick A.D., McDevitt D.G., Struthers A.D. Echocardiography in chronic heart failure in the community. Q. J. Med. (1993) 86:17–23.[Web of Science][Medline]
  33. Remes J., Miettinen H., Reunanen A., Pyörälä K. Validity of clinical diagnosis of heart failure in primary health care. Eur. Heart J. (1991) 12:315–321.[Abstract/Free Full Text]
  34. Caruana L., Petrie M.C., Davie A.P., McMurray J.J.V. Do patients with suspected heart failure and preserved ventricular systolic function suffer from "diastolic heart failure" or from misdiagnosis? A prospective descriptive study. Br. Med. J. (2000) 321:215–219.[Abstract/Free Full Text]
  35. Akosah K.O., Moncher K., Schaper A., Havlik P., Devine S. Chronic heart failure in the community. Missed diagnosis and missed opportunities. J. Card. Fail. (2001) 7:232–238.[CrossRef][Web of Science][Medline]

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