Diagnostic Challenge: The Young HF Patient (JACC in a Flash)
One result of the nation's obesity epidemic seems to be a growing number of young adults with HF. Existing studies have largely defined "younger" as age <60 or 65 years, probably because most studies have very few adults in the third to sixth decades of life. However, given that CVD, in general, is occurring earlier and earlier, investigators have now taken a close look at this much younger population with HF.1
It's important to have some idea of the symptom burden, quality of life, and hospitalization/mortality rates in HF patients aged 20–60 years because it is in these individuals where estimates of prognosis may be most keenly sought by patients and their families. Additionally, it's in younger patients that the most invasive and expensive therapeutic interventions are most commonly considered.
Consequently, knowledge of the causes, characteristics, and consequences of HF in young patients is clinically important. Therefore, investigators analyzed the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity Programme (CHARM) database to get a comprehensive description of HF in younger patients.
Compared to the oldest patients, the youngest patients with HF are:
- much more likely to be obese (23% vs. 6%)
- more likely to be black (18% vs. 2%)
- more likely to have idiopathic dilated cardiomyopathy (62% vs. 9%)
- much less likely to adhere to medication (24% vs. 7%)
- less likely to adhere to recommendations regarding salt intake and other dietary measures (21% vs. 9%)
- less likely to have clinical and radiological signs of HF during hospitalization
- almost as likely to be hospitalized (24% vs. 28%)
- more likely to report much worse quality of life
The only bright spot: all-cause mortality was lower in the youngest HF patients. Even that's hardly great news. While mortality in the young was not as high as the oldest patients, the mortality rate for 20- to 30-year-olds was similar to CHARM participants 50–60 years of age. Given that mortality rates increase with age, it's alarming that the youngest adults with HF have the mortality rate of people 30–40 years their senior.
With almost 660 participants younger than 50, the CHARM investigators have demonstrated some major differences between older and younger HF patients in terms of demographics, etiology, comorbidity, symptoms, quality of life, treatment adherence, potential precipitants of decompensation, and nonfatal and fatal outcomes.
Given that the younger CHARM population has a slightly better New York Heart Association functional class, what explains the "strikingly worse" quality of life in the youngest HF patients? The authors think it reflects the greater impact of HF symptoms and functional limitations in an age group that is more active (or desires to be more active) but is finding it difficult to meet the demands of employment and family/social commitments.
As for clinical implications, young patients were much less likely to show classic dyspnea, peripheral edema, or rales, meaning they present a diagnostic challenge. Instead, they were more likely to present with signs of paroxysmal nocturnal dyspnea, increased jugular venous pressure, and hepatomegaly. This is important to know to reduce the risk of a missed diagnosis.
In an accompanying commentary, Adriaan A. Voors, MD, and Peter van der Meer, MD, University of Groningen, the Netherlands, wrote, "Given the obvious difference in signs and symptoms and clinical outcome, it might be reasonable to suggest that diagnosis and treatment of younger heart failure patients might differ from the large group of elderly heart failure patients."2 That was not evaluated in this analysis of the CHARM program, but they suggest the question be addressed in future studies.
1. Wong CM, Hawkins NM, Jhund PS, et al. J Am Coll Cardiol. 2013 July 10. [Epub ahead of print] http://content.onlinejacc.org/article.aspx?articleid=1711123
2. Voors AA, van der Meer P. J Am Coll Cardiol. 2013 July 10. [Epub ahead of print] http://content.onlinejacc.org/article.aspx?articleid=1711142
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