Changes in Mortality From Heart Failure—United States, 1980-1995 FREE

MMWR. 1998;47:633-637

2 figures, 1 table omitted

HEART failure is a disabling chronic disease and the leading principal diagnosis for hospitalization among older adults. Among the estimated 4.8 million U.S. residents who have heart failure, 70% are aged ≥60 years.¹ During the past decade, the number of hospitalizations for heart failure have increased among Medicare beneficiaries,² and these numbers are expected to increase with progressive aging of the U.S. population even though the case-fatality rate for heart failure is high. This report summarizes trends in mortality from heart failure in the United States for 1980-1995 and presents state-specific death rates for 1995 (the most recent year for which such data are available).

National mortality statistics are based on information from death certificates filed in state vital statistics offices and are compiled by CDC. Cause-of-death statistics are based on the underlying cause of death* recorded on the death certificate by the attending physician, medical examiner, or coroner in a manner specified by the World Health Organization and endorsed by CDC. Population estimates from the Bureau of the Census were used to calculate death rates for the U.S. population. Heart failure deaths were defined as those for which the underlying cause of death listed on the death certificate was International Classification of Diseases, Ninth Revision (ICD-9), code 428. This category includes congestive heart failure (ICD-9 code 428.0), left heart failure (428.1), and unspecified heart failure (428.9). Age-adjusted estimates were standardized to the 1970 U.S. population. Race-specific rates were limited to blacks and whites because numbers for other racial/ethnic groups were too small for meaningful analysis. The average annual percentage change in mortality from 1988 through 1995 was calculated as the 1995 rate minus the 1988 rate divided by the 1988 rate divided by seven and multiplied by 100.

From 1980 to 1995, the number of deaths with heart failure as the underlying cause increased from 27,415 to 46,484; in 1995, approximately 43,600 (94%) of these deaths occurred among adults aged ≥65 years. The overall rate changed from 10.3 in 1980 to 11.7 in 1995. Death rates for heart failure per 100,000 population were directly proportionate to age. For example, in 1995, age-specific rates were 633.5 for persons aged ≥85 years, 130.8 for persons aged 75-84 years, and 32.2 for persons aged 65-74 years. The rate for persons aged ≥85 years increased during 1980-1988 but declined slightly during 1989-1992. Similar small declines also were observed during the same period for adults aged 75-84 years and those aged 65-74 years.

For persons aged ≥65 years, age-adjusted death rates for heart failure increased during 1980-1988 and declined after 1988 in each racial and sex group. Age-adjusted rates for the U.S. population aged ≥65 years declined from 116.9 per 100,000 standard population in 1988 to 107.6 in 1995 (an average annual decline of 1.1% compared with 1988 rates). Among persons aged ≥65 years, age-adjusted rates for 1995 were 126.1 for black men, 117.0 for white men, 107.6 for black women, and 101.2 for white women. The largest average annual percentage decline compared with 1988 rates occurred among black men (3.0% per year), followed by black women (2.2%), white men (1.7%), and white women (0.5%). Because of greater declines in death rates for heart failure among black adults, from 1980 to 1995 the black:white ratio for men narrowed from 1.3:1 to 1.1:1 and for women from 1.4:1 to 1.1:1.

In 1995, age-adjusted death rates for heart failure among all ages varied substantially among the states and ranged from 3.4 (New Hampshire) to 29.7 (Mississippi). For persons aged ≥65 years, age-adjusted rates for 1995 ranged from 30.7 (New Hampshire) to 255.6 (Alabama).

GA Haldeman, A Rashidee, R Horswell, Louisiana Health Care Review, Inc., Baton Rouge, Louisiana. Cardiovascular Health Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

The findings in this report are consistent with a previously observed increase in age-adjusted death rates for heart failure during 1980-1988³ that was followed by a decline after 1988. The decline suggests improved survival of older adults with heart failure or misdiagnosis of the underlying cause of death among adults with heart failure. For example, heart failure is five to six times more likely to be reported as a contributor rather than as the underlying cause of death on the death certificate.

Adults who survive a myocardial infarction or other hypertension-related diseases remain at increased risk for heart failure as they age. Among Medicare beneficiaries who are hospitalized for heart failure, hypertension is the secondary condition most commonly observed among black adults, and coronary heart disease is most common among white adults.² Declines in death rates for heart failure during 1988-1995 among black adults and white men may reflect improved early detection of and changes in the therapeutic management of patients with hypertension,⁴ myocardial infarction,⁵ and heart failure.^6- 9 Since 1988, declines in death rates were greater among black adults than among white adults. Narrowing of the black-white ratio for heart failure mortality may reflect improved control of hypertension and access to medical care among older black adults.

Low numbers of deaths in some states should be interpreted with caution because they may reflect random variation. However, variations by state in death rates for heart failure also may reflect regional differences in the prevalence and treatment of predisposing conditions (e.g., hypertension, myocardial infarction, and other heart diseases) and variations in access to early diagnosis and therapeutic management of heart failure. Medical specialty differences in treating heart failure⁹ and state variations in mortality from heart failure suggest that national professional education initiatives may be needed to ensure that the clinical practice guidelines for evaluation and care of patients with heart failure are followed appropriately by all physicians to improve survival and reduce the risk for hospitalization through consistent pharmacologic management of this condition. Peer review organizations in states such as Louisiana¹⁰ have begun to assess statewide practices of evaluating and treating heart failure as the first stage for implementing standardized quality improvement efforts that will target the hospital care of all Medicare patients with heart failure.

Historically, the treatment of heart failure included combinations of diuretics and digitalis. Guidelines for clinical practice^7- 8 recommend a trial of angiotensin-converting enzyme (ACE) inhibitors for heart failure patients with left ventricular systolic dysfunction (i.e., an ejection fraction of ≤40%), unless specific contraindications exist, and use of diuretics for patients with volume overload. Digoxin should be initiated with ACE inhibitors and diuretics in patients with severe heart failure and should be added in patients who remain symptomatic despite optimal management with ACE inhibitors and diuretics.

Although mortality for heart failure is declining, an increasing number of older adults with heart failure will have a substantial impact on national health-care resources and expenditures. Despite potential progress in the treatment of heart failure, public health and clinical efforts should continue to target the prevention and treatment of high blood pressure and acute myocardial infarction—the two major, preventable underlying conditions associated with increased risk for heart failure. Primary prevention of heart failure includes adherence to everyday health practices associated with preventing hypertension and myocardial infarction (e.g., reduced dietary fat and/or sodium intake, moderate alcohol intake, weight maintenance, regular physical activity, and nonsmoking or smoking cessation). In addition, adults with hypertension should control blood pressure levels by improving daily health practices and using antihypertensive medications to prevent the development of heart failure.

*Defined by the World Health Organization's International Classification of Diseases, Ninth Revision, as "(a) the disease or injury which initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence which produced the fatal injury."

MMWR. 1998;47:638

SINCE July 26, CDC and Health Canada, in cooperation with local public health authorities, have been investigating reports of febrile respiratory illness and associated pneumonia among persons traveling on land and sea, both independently and on tour packages, in Alaska and the Yukon Territory. Commonly reported symptoms include fever and cough, and laboratory evidence suggests that influenza A infection may be a cause of many of the illnesses. Summertime outbreaks of Influenza A have previously been reported among tourists in the United States and Canada.^1- 2 No evidence suggests increased respiratory illness activity among residents of these areas.

From June 5 through August 4, 1998, a total of 419 cases of acute respiratory infection (ARI), including 20 cases of pneumonia during June-July, have been reported to the investigation team in Anchorage. No deaths have been reported. The median age of persons with ARI is 63 years (range: 3-88 years); the median age of persons with pneumonia is 74 years (range: 61-88 years). Many cases have occurred in clusters, particularly among groups of 40-50 passengers sharing common transportation and accommodation packages on overland tours between Anchorage and Skagway or Anchorage and Seward during June-July. Affected passengers have traveled on several different tours from different companies. Information from case reports suggests that after touring inland, ill persons are boarding cruise ships, possibly resulting in further spread. In some instances, travelers are becoming ill and seeking medical attention for their respiratory illnesses only after returning home.

During June-September, approximately 70,000 overland tour and cruise ship passengers visit Alaska and the Yukon Territory each week. Most do not experience febrile respiratory illness. No special prevention measures are recommended at this time for travelers in good health.

Systematic surveillance for febrile respiratory illness and pneumonia is being initiated by CDC, Health Canada, and other public health officials in the region to better define the scope of the outbreak. Health-care providers who see patients with febrile respiratory illness and/or pneumonia should obtain a travel history and consider influenza A in the differential diagnosis for those with recent travel to Alaska or the Yukon Territory. Additional cases should be reported to CDC's Special Investigation Team; telephone (907) 729-3431; fax (907) 729-3429; or e-mail, SITEAM@cdc.gov.

Alaska Dept of Health and Social Svcs; Bur of Infectious Diseases and Office of Special Health Initiatives, Laboratory Center for Disease Control, Occupational Health and Safety Agency, Health Canada, Ottawa. Arctic Investigations Program, Div of Viral and Rickettsial Diseases and Div of Quarantine, National Center for Infectious Diseases; and EIS officers, CDC.