Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Epidemiology and causes of heart failure

Ramachandran S Vasan, MD, DM, FACC
Peter WF Wilson, MD
Section Editor
Wilson S Colucci, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Aging of the population and prolongation of the lives of cardiac patients by modern therapeutic innovations has led to an increasing prevalence of heart failure (HF). Despite improvements in therapy, the mortality rate in patients with HF has remained unacceptably high [1], making early detection of susceptible persons who would benefit from preventive measures imperative.

The epidemiology and causes of HF will be reviewed here. Diastolic dysfunction, asymptomatic left ventricular dysfunction, and causes of HF decompensation are discussed separately. (See "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Management and prognosis of asymptomatic left ventricular systolic dysfunction" and "Evaluation of acute decompensated heart failure".)


The magnitude of the problem of heart failure (HF) cannot be assessed with precision since reliable, population-based estimates of its prevalence, incidence, and prognosis are lacking [2,3]. Part of the problem is that large differences exist among studies in their definition of the condition and the methods used to establish its presence. In addition, presymptomatic left ventricular (LV) dysfunction is now used increasingly as an indicator of impending, if not existing, HF [4].

Prevalence — At least six HF scoring methodologies based upon symptoms and signs have been developed to assess the presence of HF. Clinical diagnostic criteria for HF have generally included history, physical examination, and chest radiographs [5,6]. A 2013 update from the American Heart Association (AHA) estimated that there were 5.1 million people with HF in the United States in 2006 [7]. There are an estimated 23 million people with HF worldwide [8].

Regardless of the definition used, the prevalence of HF and LV dysfunction increases steeply with age [1,9-14]. As an example, the Framingham Heart Study found a prevalence of HF in men of 8 per 1000 at age 50 to 59 years, increasing to 66 per 1000 at ages 80 to 89 years; similar values (8 and 79 per 1000) were noted in women [1]. The prevalence in African-Americans is reported to be 25 percent higher than in whites.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 21, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 1993; 22:6A.
  2. Cowie MR, Mosterd A, Wood DA, et al. The epidemiology of heart failure. Eur Heart J 1997; 18:208.
  3. Hoes AW, Mosterd A, Grobbee DE. An epidemic of heart failure? Recent evidence from Europe. Eur Heart J 1998; 19 Suppl L:L2.
  4. Bonneux L, Barendregt JJ, Meeter K, et al. Estimating clinical morbidity due to ischemic heart disease and congestive heart failure: the future rise of heart failure. Am J Public Health 1994; 84:20.
  5. Mosterd A, Deckers JW, Hoes AW, et al. Classification of heart failure in population based research: an assessment of six heart failure scores. Eur J Epidemiol 1997; 13:491.
  6. Roger VL. The heart failure epidemic. Int J Environ Res Public Health 2010; 7:1807.
  7. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation 2013; 127:e6.
  8. McMurray JJ, Petrie MC, Murdoch DR, Davie AP. Clinical epidemiology of heart failure: public and private health burden. Eur Heart J 1998; 19 Suppl P:P9.
  9. Vasan RS, Benjamin EJ, Levy D. Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol 1995; 26:1565.
  10. Redfield MM, Jacobsen SJ, Burnett JC Jr, et al. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003; 289:194.
  11. McDonagh TA, Morrison CE, Lawrence A, et al. Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population. Lancet 1997; 350:829.
  12. Gardin JM, Siscovick D, Anton-Culver H, et al. Sex, age, and disease affect echocardiographic left ventricular mass and systolic function in the free-living elderly. The Cardiovascular Health Study. Circulation 1995; 91:1739.
  13. Lauer MS, Evans JC, Levy D. Prognostic implications of subclinical left ventricular dilatation and systolic dysfunction in men free of overt cardiovascular disease (the Framingham Heart Study). Am J Cardiol 1992; 70:1180.
  14. Bleumink GS, Knetsch AM, Sturkenboom MC, et al. Quantifying the heart failure epidemic: prevalence, incidence rate, lifetime risk and prognosis of heart failure The Rotterdam Study. Eur Heart J 2004; 25:1614.
  15. McCullough PA, Philbin EF, Spertus JA, et al. Confirmation of a heart failure epidemic: findings from the Resource Utilization Among Congestive Heart Failure (REACH) study. J Am Coll Cardiol 2002; 39:60.
  16. WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, et al. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation 2010; 121:e46.
  17. Owan TE, Redfield MM. Epidemiology of diastolic heart failure. Prog Cardiovasc Dis 2005; 47:320.
  18. Brown AM, Cleland JG. Influence of concomitant disease on patterns of hospitalization in patients with heart failure discharged from Scottish hospitals in 1995. Eur Heart J 1998; 19:1063.
  19. Jessup M, Brozena S. Heart failure. N Engl J Med 2003; 348:2007.
  20. Topol EJ, Traill TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 1985; 312:277.
  21. Gaasch WH. Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction. JAMA 1994; 271:1276.
  22. Elesber AA, Redfield MM. Approach to patients with heart failure and normal ejection fraction. Mayo Clin Proc 2001; 76:1047.
  23. Vasan RS, Larson MG, Benjamin EJ, et al. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol 1999; 33:1948.
  24. Gottdiener JS, McClelland RL, Marshall R, et al. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. The Cardiovascular Health Study. Ann Intern Med 2002; 137:631.
  25. Bursi F, Weston SA, Redfield MM, et al. Systolic and diastolic heart failure in the community. JAMA 2006; 296:2209.
  26. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis, prognosis, and measurements of diastolic function. Circulation 2002; 105:1387.
  27. Havranek EP, Masoudi FA, Westfall KA, et al. Spectrum of heart failure in older patients: results from the National Heart Failure project. Am Heart J 2002; 143:412.
  28. Masoudi FA, Havranek EP, Smith G, et al. Gender, age, and heart failure with preserved left ventricular systolic function. J Am Coll Cardiol 2003; 41:217.
  29. Owan TE, Hodge DO, Herges RM, et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006; 355:251.
  30. Lloyd-Jones DM, Larson MG, Leip EP, et al. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation 2002; 106:3068.
  31. Brouwers FP, de Boer RA, van der Harst P, et al. Incidence and epidemiology of new onset heart failure with preserved vs. reduced ejection fraction in a community-based cohort: 11-year follow-up of PREVEND. Eur Heart J 2013; 34:1424.
  32. Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival with heart failure. N Engl J Med 2002; 347:1397.
  33. Roger VL, Weston SA, Redfield MM, et al. Trends in heart failure incidence and survival in a community-based population. JAMA 2004; 292:344.
  34. Barker WH, Mullooly JP, Getchell W. Changing incidence and survival for heart failure in a well-defined older population, 1970-1974 and 1990-1994. Circulation 2006; 113:799.
  35. Curtis LH, Whellan DJ, Hammill BG, et al. Incidence and prevalence of heart failure in elderly persons, 1994-2003. Arch Intern Med 2008; 168:418.
  36. Bibbins-Domingo K, Pletcher MJ, Lin F, et al. Racial differences in incident heart failure among young adults. N Engl J Med 2009; 360:1179.
  37. Wong CM, Hawkins NM, Jhund PS, et al. Clinical characteristics and outcomes of young and very young adults with heart failure: The CHARM programme (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity). J Am Coll Cardiol 2013; 62:1845.
  38. Djoussé L, Driver JA, Gaziano JM. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA 2009; 302:394.
  39. National Heart Lung and Blood Institute. Morbidity and Mortality Chartbook on Cardiovascular, Lung and blood Diseases. 1996. NIH Bethesda MD.
  40. Jhund PS, Macintyre K, Simpson CR, et al. Long-term trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: a population study of 5.1 million people. Circulation 2009; 119:515.
  41. Lam CS, Donal E, Kraigher-Krainer E, Vasan RS. Epidemiology and clinical course of heart failure with preserved ejection fraction. Eur J Heart Fail 2011; 13:18.
  42. Meta-analysis Global Group in Chronic Heart Failure (MAGGIC). The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction: an individual patient data meta-analysis. Eur Heart J 2012; 33:1750.
  43. Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275:1557.
  44. Kannel WB, Ho K, Thom T. Changing epidemiological features of cardiac failure. Br Heart J 1994; 72:S3.
  45. He J, Ogden LG, Bazzano LA, et al. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001; 161:996.
  46. Gheorghiade M, Bonow RO. Chronic heart failure in the United States: a manifestation of coronary artery disease. Circulation 1998; 97:282.
  47. Massie BM, Shah NB. Evolving trends in the epidemiologic factors of heart failure: rationale for preventive strategies and comprehensive disease management. Am Heart J 1997; 133:703.
  48. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med 2002; 347:305.
  49. Rahimtoola SH, Cheitlin MD, Hutter AM Jr. Cardiovascular disease in the elderly. Valvular and congenital heart disease. J Am Coll Cardiol 1987; 10:60A.
  50. Kalogeropoulos A, Georgiopoulou V, Kritchevsky SB, et al. Epidemiology of incident heart failure in a contemporary elderly cohort: the health, aging, and body composition study. Arch Intern Med 2009; 169:708.
  51. Baldasseroni S, Opasich C, Gorini M, et al. Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure. Am Heart J 2002; 143:398.
  52. Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342:1077.
  53. Sliwa K, Damasceno A, Mayosi BM. Epidemiology and etiology of cardiomyopathy in Africa. Circulation 2005; 112:3577.
  54. Stewart S, Wilkinson D, Hansen C, et al. Predominance of heart failure in the Heart of Soweto Study cohort: emerging challenges for urban African communities. Circulation 2008; 118:2360.
  55. Felker GM, Shaw LK, O'Connor CM. A standardized definition of ischemic cardiomyopathy for use in clinical research. J Am Coll Cardiol 2002; 39:210.
  56. Haider AW, Larson MG, Franklin SS, et al. Systolic blood pressure, diastolic blood pressure, and pulse pressure as predictors of risk for congestive heart failure in the Framingham Heart Study. Ann Intern Med 2003; 138:10.
  57. Richards AM, Nicholls MG, Troughton RW, et al. Antecedent hypertension and heart failure after myocardial infarction. J Am Coll Cardiol 2002; 39:1182.
  58. Hellermann JP, Goraya TY, Jacobsen SJ, et al. Incidence of heart failure after myocardial infarction: is it changing over time? Am J Epidemiol 2003; 157:1101.
  59. Velagaleti RS, Pencina MJ, Murabito JM, et al. Long-term trends in the incidence of heart failure after myocardial infarction. Circulation 2008; 118:2057.
  60. Fall T, Hägg S, Mägi R, et al. The role of adiposity in cardiometabolic traits: a Mendelian randomization analysis. PLoS Med 2013; 10:e1001474.
  61. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:1810.
  62. Gueyffier F, Bulpitt C, Boissel JP, et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. INDANA Group. Lancet 1999; 353:793.
  63. SOLVD Investigators, Yusuf S, Pitt B, et al. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992; 327:685.
  64. Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995; 273:1450.