Importance of heart failure as a cause of death. Changing contribution to overall mortality and coronary heart disease mortality in Scotland 1979–1992

Aims As heart failure is a syndrome arising from another condition, such as coronary heart disease, it is rarely oYcially coded as the underlying cause of death regardless of the cause recorded by the physician at the time of certification. We sought to assess the true contribution of heart failure to overall mortality and coronary heart disease mortality and to examine how this contribution has changed over time. Methods and Results We carried out a retrospective analysis of all death certificates in Scotland between 1979 and 1992 for which heart failure was coded as the underlying or a contributory cause of death. From a total of 833 622 deaths in Scotland between 1979 and 1992, heart failure was coded as the underlying cause in only 1·5% (13 695), but as a contributory cause in a further 14·3% (126 073). In 1979, 28·5% of male and 40·4% of female deaths attributed to coronary heart disease (coded as the underlying cause of death) also had a coding for heart failure. In 1992 these percentages had risen significantly to 34·1% and 44·8%, respectively (both P<0·001). Mortality rates for heart failure as the underlying or contributory cause of death, standardized by age and sex, fell significantly over the period studied in all ages and in both sexes: by 31% in men and 41% in women <65 years and 15·8% in men and 5·1% in women §65 years, respectively (P<0·01 for all changes). Conclusions Death from heart failure is substantially underestimated by oYcial statistics. Furthermore, one third or more of deaths currently attributed to coronary heart disease may be related to heart failure and this proportion appears to be increasing. While the absolute numbers of deaths caused by heart failure remains constant, this study is the first to show that standardized mortality rates are declining. (Eur Heart J 1998; 19: 1829‐1835)