Académie royale de Médecine de Belgique


Résumé de Dirk Brutsaert (Séance du 28 avril 2007)


par D. L. BRUTSAERT (Universiteit Antwerpen), invité.

Over the past 25 years, considerable progress has been made in the diagnosis and management of patients with heart failure.  At the same time, a progressif and profound change has been observed in the clinical profile of the patient with heart failure. In particular, these patients are now older; heart failure is more often the consequence of chronic hypertension with hypertrophy or cardiac ischemia; the symptoms are more subtle and the diagnosis is made sooner through the worldwide application of Echo-Doppler as the investigation of choice in cardiology as well as through the introduction of novel biomarkers such as e.g. BNP; former contra-indications (beta-blockade, exercise, pacemaking,…) have now been turned into recommended strategies. Despite this progress, however, the prognosis of heart failure has remained ominous and the morbidity and mortality continue to rise.

In order to search for possible causes, it seems appropriate to first discuss a few obvious but unresolved observations. These can be summarized into four paradoxes. Paradox I originates from the natural history of the disease and emphasizes the increased mortality of chronic heart failure despite the diminishing mortality due to coronary artery diseases.  Paradox II concerns the diagnosis of the disease and follows from the divergence between the pathophysiological progression of heart failure and the manifestation of signs and symptoms. Paradox III results from the generally correct theoretical perception of evidence based treatment guidelines and management by the physician which contrasts with the poor reality and compliance of these principles in daily practice. Finally, paradox IV concerns the financial implications and emphasizes the unavoidable increase in cost in the presence of a continued restricted governmental budget available.