Plain and simple, heart failure is the number one disease in our country. This is a poorly recognized fact that results from the confluence of society’s excesses with the medical community’s success in staving off the inevitable consequences of sedentary overconsumption and self-indulgence. Because we live at a time and in a place where myocardial infarction is not a uniformly fatal event, where obesity exists in epidemic proportions, where the coronary artery stent and coronary artery bypass graft (CABG) are part of the routine layperson’s coffee table vernacular, and where hypertensive and diabetic individuals routinely live for scores of years after their diagnosis, we have created an entire subpopulation of Americans who survive with serious compromise to their cardiovascular function.

As recently as 30 years ago, these patients simply died of complications from their diseases. Today they commonly survive, only to reenter the medical establishment in later years with the development of heart failure. Thus, heart failure has become the disease of the 21st century. It is also the chronic ailment that steals the quality of life from the golden years of America’s fastest growing demographic segment: the elderly. No other single disease causes more hospitalizations, and few other pathologies can as effectively maim and suffocate its victims, as heart failure is routinely manifested.

Unfortunately, in its early stages, heart failure is relatively asymptomatic and passes unnoticed until the patient presents with symptoms of progressive shortness of breath. Although the patient may give a history of a relatively new onset of dysfunction, in reality the underlying syndrome has been present chronically, sometimes for years. It is the symptom of suffocation that drives heart failure patients to the emergency department. As has been shown in data from the ADHERE registry, more than 90% of heart failure patients present acutely with shortness of breath. It is ultimately dyspnea that results in their hospitalization and it is breathlessness that is
the limiting parameter preventing their discharge home. Consequently, the relief of shortness of breath becomes the driving event determining both the length of hospitalization required and the quality of life in the heart failure patient.

Heart failure has been termed the “merry-go-round” disease. This is because of the well-known cycle of worsening symptoms, hospital admission, discharge home, followed by worsening symptoms and repeat of the same cycle. If only it were so. The unfortunate reality is that the long-term course of heart failure more resembles a roller coaster than a merry-go-round. On a merry-go-round, the cycle is repeated and the patient returns to where he or she started. However, on a roller coaster, the highest level of function is the first day, and it is all downhill from there. In heart failure, the patient is initially functional, worsens, and is hospitalized and is discharged, usually not in as good a condition as when first stricken, only to repeat this cycle. Therefore, what seems like a repeating cycle is actually a downward spiral ending inevitably, usually within 5 years, with the patient’s death.