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The combination of carvedilol and digoxin appears generally superior to either carvedilol or digoxin alone in the management of AF in patients with HF.

Background and Methods. Heart failure is common and effective therapy exists but as yet there is little evidence that the overall prognosis is improving in clinical practice. We sought to determine if mortality, re-admission with heart failure and re-admission for any cause, had changed between cohorts of first-time admissions for heart failure identified in 1984, 1988 and Ž . 1992 using linked hospital discharge and mortality data from Scotland population approximately 5 million . Findings. The number of first-time admissions for heart failure increased by 30% between 1984 and 1992, from 9716 to 12 640. Their mean age was 74 years and 54% were women. Over the same period 3-year mortality declined in patients -65 years from 53 to 41% Ž Ž . reduction in risk 12% 95% confidence interval 9᎐15%. Log-rank 70.0; P-0.001 and for patients G 65 years from 71% to Ž Ž . 66% reduction in risk 5% 95% confidence interval 3᎐6%. Log-rank 74.5; P -0.0001 . Time to death or first re-admission with heart failure also improved but not time to death or first re-admission for any cause. The total number of re-admissions increased between 1984 and 1992 but bed-days occupancy for heart failure and for any cause, adjusted for days alive, declined due to a reduction in length of stay. Interpretation. These data suggest that the prognosis of patients with a first admission for heart failure is improving. The timing of improvement coincides with the gradual increase in the use of angiotensin converting enzyme inhibitors for heart failure although a causal link cannot be proved from these data. ᮊ

Recent epidemiological studies suggest that 30% to 50% of patients with heart failure (HF) have preserved left ventricular (LV) systolic function. These patients, often presumed to have diastolic heart failure (DHF), appear to have lower short-term but similar long-term mortality when compared to patients with HF and LV systolic dysfunction. Rates of recurrent hospitalization and costs of care appear similar in the two groups of patients. Therefore, DHF may contribute significantly to the burden of disease caused by HF. Exertional breathlessness, the principal symptom of HF, has many causes, including obesity, pulmonary disease and myocardial ischemia. A diagnosis of DHF by exclusion, based on symptoms in the absence of important LV systolic dysfunction or major valve disease, is unsatisfactory. Unfortunately, as yet, no reliable definition with which to make a positive diagnosis of DHF has been agreed on, frequently rendering this diagnosis uncertain. Echocardiography has several limitations, whereas hemodynamic confirmation of DHF by cardiac catheterization is potentially complex and not practically feasible for many patients. Treatment of DHF remains empirical and unsatisfactory because of the lack of large-scale randomized controlled trials in this area. Currently, three large outcome studies on DHF are in progress along with other smaller trials. These should start to provide some of the answers we need to diagnose and effectively treat DHF.