The leading cause of hospital admission in Medicare patients is decompensated heart failure, which accounts for approximately 800,000 hospitalizations annually. Multiple studies have addressed the impact of medications on controlling symptoms, slowing disease progression, and improving survival in these patients. However, few studies have examined the natural history of decompen-sated heart failure. Understanding the natural history may allow physicians to target some of the symptoms before the disease progresses to the point where hospitalization is required. Schiff and colleagues evaluated the time course, contributing factors, and patient responses to decompensated heart failure.

Patients diagnosed with heart failure who were admitted to an urban hospital during a 10-week period were eligible to participate. Patients who met eligibility criteria answered a structured questionnaire given by a nurse interviewer. The questionnaire included information about patients' awareness of their diagnosis, presence of heart failure symptoms, and the time course of clinical decompensation. The questionnaire used a timeline follow-back technique to help patients estimate dates of onset, duration, and response to symptoms, and to remember reasons for worsening of their symptoms. Patients were asked whether these reasons were major or minor factors in the worsening of their symptoms. The final part of the questionnaire asked if there were any interventions or programs the patients might find helpful in preventing hospitalization.

Of the 83 patients interviewed, 59 percent were aware that they had been diagnosed with heart failure, 98 percent reported dyspnea, 77 percent had edema, and 41 percent reported weight gain. The mean onset of symptoms was 12.4 days before admission in patients with edema, 11.4 days in patients with weight gain, and 8.4 days in patients with walking dyspnea. One of the major contributing factors patients reported for decompensation of heart failure was missing or skipping medications; this was particularly true in patients who had missed outpatient appointments before their hospitalization.

The authors conclude that hospital admission in patients with decompensated heart failure is preceded by a period of days or weeks of worsening symptoms. This finding suggests that there is a period between the onset of symptoms and hospitalization when interventions may reduce the hospitalization rate. The major contributing factor for heart failure decompensation was medication lapses. Providing more timely contact between patients and their outpatient caregivers, and developing a more reliable system for preventing medication lapses may help reduce the hospitalization rate in patients with decompensated heart failure.