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A 72-year-old man with a history of coronary artery disease is admitted with acute pulmonary edema secondary to acute coronary syndrome (confirmed by 12-lead ECG and a positive high-sensitivity troponin test). Following initial emergency management with intravenous loop diuretics, nitrate therapy, and continuous-positive airway pressure support, he is admitted to the hospital’s coronary care unit for 2 days and then spends a further 5 days in a general medical unit. A coronary angiogram shows that a previous drug-eluting stent in the right coronary artery remains patent, but there is evidence of progressive diffuse disease in the left anterior descending and circumflex artery. Echocardiography reveals morphological and functional changes indicative of ischemic cardiomyopathy with left ventricular systolic dysfunction (left ventricular ejection fraction of 38%). Discharged to home on gold-standard medical therapy with follow-up by an outpatient heart failure management team, he is diagnosed with chronic heart failure (NYHA class II-III but clinically stable) requiring ongoing surveillance and treatment.

This de novo, heart failure–related event did not occur in isolation. Nor does it prove to be the last time this patient’s quality of life and prognosis are influenced by a costly syndrome that is as malignant as many forms of cancer.1


In the United States and Europe alone, there are currently more than 20 million people affected by heart failure.2 Heart failure is routinely ascribed to be the number one cause of hospitalizations in those aged >65 years; hospital care traditionally consumes more than two-thirds of health care costs.3

As shown in Figure 1-1, the genesis of this particular case of heart failure began almost 20 years ago when, as a middle-aged man, the patient’s increasingly sedentary lifestyle and diet contributed to the development of metabolic syndrome and undiagnosed and untreated hypertension. The sequence of events highlights the key economic aspects of heart failure.

Figure 1-1

Cascade of increasingly costly (at the individual to society level) cardiac events in a 72-year-old man who initially presents with acute heart failure and dies 3 years later from advanced heart failure and multimorbidity.


Heart failure patients experience regular visits with primary care personnel and are mainly cared for by their primary care physician by requesting clinic appointments. Secondary care presents when the heart failure patient is admitted into hospital.


Once established, the syndrome of heart failure (usually presenting as acute decompensation requiring hospitalization) is typically characterized by progressive cardiac dysfunction, multimorbidity (including concurrent cerebrovascular and renal disease), and costly inpatient and outpatient management and treatment prior to death. Additionally, treatment and management options are rarely curative, but target achieving clinical stability (by reducing costly rehospitalization) and ...

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