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Heart failure may be defined as an inability of the heart to pump sufficient blood to meet the metabolic needs of the body's tissues or the ability to do so only at the expense of elevated intracardiac pressures. Heart failure represents a clinical syndrome rather than a specific diagnosis, and, to a large extent, it is a geriatric syndrome in much the same way that dementia and incontinence are geriatric syndromes. Indeed, heart failure may be viewed as the quintessential disorder of cardiovascular aging since, as discussed later in this chapter, extensive age-related changes in cardiovascular structure and function, in conjunction with the rising prevalence of cardiovascular diseases with advancing age and the recent decline in premature cardiovascular deaths, all contribute to an exponential rise in the prevalence of heart failure with advancing age. Thus, although the clinical syndrome of heart failure has been recognized by physicians for more than 2000 years, it has only been within the past two decades that it has been identified as a major public health concern, a development that is largely attributable to the aging of the population.

Despite progressive declines in age-adjusted mortality rates from coronary heart disease and hypertensive cardiovascular disease, both the incidence and the prevalence of heart failure are increasing, and it is projected that these trends will continue for the next several decades. As shown in Table 78-1, several factors have contributed to the progressive rise in heart failure. Foremost among these is the increasing number of older adults who, by virtue of advanced age and the high prevalence of hypertension, coronary heart disease, and cardiac valvular disorders in older individuals, are predisposed to the development of heart failure. In addition, advances in the treatment of other acute and chronic cardiac and noncardiac conditions, most notably atherosclerotic heart disease, hypertension, renal failure, cancer, and infectious diseases, have paradoxically contributed to the increasing burden of heart failure. Thus, individuals who 20 years ago might have died in middle age from acute myocardial infarction are now surviving to older age only to develop heart failure in their later years. Similarly, improved blood pressure control has led to a 60% decline in stroke mortality over the last 30 years, yet these same patients remain at risk of the subsequent development of heart failure as a complication of hypertension and left ventricular hypertrophy.

Table 78-1 Factors Contributing to the Rising Incidence and Prevalence of Heart Failure

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