Result card

  • CUR9: What is the natural course of the disease or health condition?

What is the natural course of the disease or health condition?

Authors: Ingrid Wilbacher, Nadine Berndt, Francesca Gillespie

Internal reviewers: Alessandra Lo Scalzo, Christian Vladescu, Christina Mototolea, Kristina Lampe, Maria Camerlingo

  • The basic search for the CUR domain was used to answer this question. No article of the basic search was relevant for this assessment element. Therefore, a manual search was done to find relevant information about the natural course of the health condition as published in evidence-based guidelines on the HF epidemiology. European and American guidelines for the diagnosis and treatment of acute and chronic HF were consulted by doing a manual search on the website of the European Society of Cardiology (ESC) and the American Heart Association (AHA), and the references of the ESC guidelines published in 2008 and 2012 and the AHA practice guideline published in 2013 were reviewed and this led to one additional article that was relevant for this assessment element (Mosterd & Hoes, 2007) {82}. The references from the selected studies for the CUR domain were also reviewed, leading to seven additional relevant references.
  • The searches for the guidelines were additionally conducted the 06th of January 2015 by one of the investigators (NB).

In patients with left ventricular systolic dysfunction, the maladaptive changes occurring in the cardiac muscle after myocardial infarction lead to pathological adaptation of the ventricle with dilatation and impaired contractility. This in turn is one measure of a reduced ejection fraction {76}. In the absence of treatment of the systolic dysfunction, these maladaptive changes worse progressively over time, leading to further enlargement of the left ventricle and further decline in the ejection fraction. The patient may yet initially not reveal any particular HF symptoms. Two mechanisms are thought to account for this progression. The first is occurrence of recurrent myocardial infarction leading to additional myocyte death. The other is the systemic responses induced by the decline in systolic function, particularly neurohumoral activation. Two important neurohumoral systems activated in HF are the renin-angiotensin-aldosterone system and sympathetic nervous system. In addition to causing further myocardial injury, these systemic responses have destructive effects on the blood vessels, kidneys, muscles, bone marrow, lungs, and liver. They account for many clinical features of the HF syndrome. Clinically, the maladaptive changes after myocardial infarction account for the development of HF symptoms (pump failure or ventricular arrhythmia) and these worsen over time. The ultimate consequences are a reduced quality of life, a reduced functional capacity, decompensation leading to hospital (re-)admission, and death. The impaired cardiac function also depends on atrial contraction, synchronized contraction of the left ventricle, and a normal interaction between the right and left ventricles. Events affecting any of these or imposing an additional load on the heart (e.g. anemia) can lead to acute decompensation {77}.


The initial cause of HF influences its further prognosis. As such, HF caused by viral myocarditis may lead to complete recovery, while acute myocardial infarction complicated by HF significantly increases the risk of mortality. Comorbidities known to lead to premature death in HF patients include renal dysfunction, depression and anemia. Patients with both HF and chronic renal failure have an extremely poor prognosis {82}.


Not even three decades ago the majority of HF patients died a few years after the diagnosis, and admission to hospital with worsening symptoms was frequent and recurrent. This led to high hospitalization rates for HF in many countries. Effective treatment has reduced hospitalization rates for HF to 30–50 % and has led to small but significant decreases in mortality {104},{53}. Nowadays, the mortality rate reaches approximately 50 % within 5 years of admission among HF patients {19}. Patients with a new onset of HF have a mortality risk varying generally between 20 % and 40 % within the first year after hospital admission for HF {121}, {68},{53},{36}. Between 20 and 30 % patients are readmitted within the first month after hospital discharge and almost 50 % at 6 months. Due to the aging population these percentages are expected to rise  {37},{30}. Hence, life expectancy is considerably reduced in HF patients and acute or slow worsening of HF occurs in most of the patients leading to a (highly) reduced quality of life {82}.


The pattern of readmissions in HF patients has been referred to as the “three-phase terrain” of HF readmissions because epidemiological data revealed that 30 % of readmissions occur during the first two months after hospital discharge, 50 % of readmissions occur within the last two months before death, and the remaining 20 % of readmissions occur in-between {122}.


Wilbacher I et al. Result Card CUR9 In: Wilbacher I et al. Health Problem and Current Use of the Technology In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: