- Email: [email protected]
Psychiatric illness and mortality after hip fracture
RESEARCH LETTERS
node involvement at diagnosis (p=0·0015), performance status (p=0·0001), and T stage (p=0·0097, table). We then looked at local recurrence and metastasis-free survival in the two groups of patients with low or high serum sIL–2R concentrations. A trend towards an association between serum sIL–2Rα concentrations and local recurrence was observed but it did not reach significance (p=0·081 in univariate analysis, table). The most significant predictive factors of local recurrence in multivariate analysis were T stage (p=0·0001), lymph node involvement (p=0·0004), and performance status (p=0·045, table). Serum sIL-2Rα levels were highly correlated with the distant metastasis-free survival. 11·5% of patients (5·3–17·7%) who had low serum sIL–2R concentrations at diagnosis developed distant metastasis during the 36 months’ follow-up, compared with 34% (15·4%–52·6%) of patients in the group with high serum sIL-2Rα concentrations. In multivariate analysis, lymph-node involvement (p<0·0001) and sIL–2Rα concentrations (p=0·0002) were each correlated with distant-metastasis-free survival in an independent manner when adjusted for each other (table). A similar correlation between sIL–2Rα serum concentrations and overall survival and distant-metastasisfree survival was found when sIL–2Rα was introduced as a continuous variable (data not shown). In our series, 20% of deaths were related to the presence of metastasis, which might explain the effect of this variable on overall survival. The predictive value of sIL–2Rα did not appear to change when the type of treatment was taken into account (surgery followed by radiotherapy, or radiotherapy before surgery, with or without adjuvant chemotherapy [data not shown]). We have shown a highly significant association between the risk of developing metastasis and serum sIL–2Rα concentration at diagnosis. Wang et al have shown that distant metastases occurred often among patients with oesophageal squamous-cell carcinoma who had persistently high sIL–2R levels after oesophagectomy.4 In some patients with Hodgkin’s disease, serum sIL–2Rα concentrations are increased several months before clinical evidence of recurrent metastatic disease.5 Our study strongly suggests that sIL–2R α concentrations should be considered as an independent serum biomarker when adjusted for other variables to predict the risk of development of distant metastasis and overall survival in patients with head and neck cancer.
2
3
4
5
Sharon Nightingale, John Holmes, James Mason, Allan House People with dementia or delirium have increased mortality in the 6 months after hip fracture, but depression might take longer to have an effect. We assessed the psychiatric status of 731 participants with hip fracture and analysed the effect of psychiatric illness on mortality during the next 2 years. We found that dementia, delirium, and depression all increased the risk of mortality (p<0·0001, p<0·0001, and p=0·0359, respectively), and that mortality differed significantly between hospitals (p=0·0003). We suggest that psychiatric interventions should be asssessed in hip-fracture patients with adequate follow up of outcome measures.
Hip fracture is a common cause of morbidity and mortality in older adults.1 Psychiatric illness is thought to worsen prognosis of patients with hip fractures, although we questioned the evidence for this assertion in a recent systematic review.2 We noted that small sample sizes had led to imprecise findings, dementia and delirium had not been distinguished, and that analysis was based on only one psychiatric diagnosis. We have shown that survival at 6 months after hip fracture is adversely affected by dementia (hazard ratio 2·57 [95% CI 1·65–4·01]) and delirium (2·88 [1·76–4·72]), but not by depression (1·01 [0·53–1·94]).3 However, more than 6 months of follow up might be needed to detect the effect of depression.4 We did a 2-year follow up of the cohort from our previous study to establish whether depression affects long-term survival after hip fracture. All patients aged 65 years or older, admitted to two teaching hospitals (A and B) in the same city, and having hipfracture operations during a 19-month period, were eligible for inclusion.3 Neither hospital had a dedicated hip-fracture service; one hospital had weekly visits from a consultant geriatrician, whereas the other had no formal orthogeriatric collaboration. Psychiatric input in each hospital was by consultation. Psychiatric status was assessed by use of Geriatric Mental State/AGECAT software (community version 3a). Cognitive impairment was diagnosed with this software or by the standardised mini-mental state examination, and was classed as dementia, delirium, or both, 1·0 0·9 0·8
Mineta H, Miura K, Suzuki I, et al. Low p27 expression correlates with poor prognosis for patients with oral tongue squamous cell carcinoma. Cancer 1999; 85: 1011–17 Smith BD, Smith GL, Carter D, et al. Prognostic significance of vascular endothelial growth factor protein levels in oral and oropharyngeal squamous cell carcinoma. J Clin Oncol 2000; 18: 2046–52. Tartour E, Deneux L, Mosseri V, et al. Soluble interleukin-2 receptor serum level as a predictor of local control and survival for patients with head and neck carcinoma: results of a multivariate prospective study. Cancer 1997; 79: 1401–08. Wang LS, Chow KC, Li WY, et al. Clinical significance of serum soluble interleukin 2 receptor-alpha in esophageal squamous cell carcinoma. Clin Cancer Res 2000; 6: 1445–51. Viviani S, Camerini E, Bonfante V, et al. Soluble interleukin-2 receptors (sIL–2R) in Hodgkin’s disease: outcome and clinical implications. Br J Cancer 1998; 77: 992–97.
Institut Curie Head and Neck oncology group, 26 Rue d’Ulm 75248 Paris Cedex 05, France (E Tartour PhD, V Mosseri MD, T Jouffroy MD, L Deneux, C. Jaulerry MD, F Brunin MD, WH Fridman PhD, J Rodriguez MD), Correspondence to: Eric Tartour, Hopital Européen Georges Pompidou, INSERM U 255, 20 Rue Leblanc, 75908 Paris, Cedex 15, France (e-mail: [email protected])
1264
Proportion surviving
1
Psychiatric illness and mortality after hip fracture
Well
0·7 0·6
Depression
0·5
Delirium
0·4 Dementia
0·3 0·2 0·1 0 0
200
400 Time (days)
600
208 93 108 294
172 79 65 176
161 71 56 151
153 62 49 128
800
Numbers at risk Well Depression Delirium Dementia
148 56 46 113
Kaplan-Meier curves of survival after hip fracture stratified by psychiatric diagnosis
THE LANCET • Vol 357 • April 21, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
RESEARCH LETTERS
Variable
Hazard ratio (95% CI)
p
Age (per year) Male sex Hospital B Daily activities (per unit increase) Physical illness Mild Moderate Severe Psychiatric diagnosis Dementia Delerium Depression
1·024 (1·007–1·040) 1·653 (1·255–2·176) 1·494 (1·204–1·855) 0·976 (0·952–0·999)
0·0050 0·0003 0·0003 0·0438
1·377 (0·994–1·906) 2·000 (1·445–2·768) 2·928 (1·764–4·861)
0·0541 <0·0001 <0·0001
2·620 (1·883–3·645) 2·404 (1·659–3·484) 1·566 (1·030–2·381)
<0·0001 <0·0001 0·0359
Multivariate survival analysis of hazard ratios for mortality 2 years after hip fracture in 731 elderly patients
with the delirium rating scale. If patients had depression and cognitive impairment, impairment was given diagnostic precedence. We recorded: age; sex; concurrent physical illness (by the Burvill scale); type of fracture; type of operation anaesthetic; hospital; and prefracture daily activities (using the Barthel score), socioeconomic status, accommodation, and support network. A researcher, unaware of the initial diagnosis, assessed survival at 2 years from time of admission by asking general practitioners and by searching a local health-service database. Data were analysed with a multivariate Cox’s proportional hazards model by stepwise variable selection and analysis of interactions between variables; significant variables were retained (p<0·05). Assumption of constant proportionality over time of variables in the final model was validated. We obtained ethical approval. 903 patients met our inclusion criteria. Of these, 172 (19%) were excluded: 78 (9%) refused consent, 41 (5%) were too physically ill to be interviewed, 19 (2%) were too deaf to interview, 14 (2%) died before interview, ten (1%) did not have surgery, eight had dysphasia, one spoke no English, and one was transferred to another hospital. Hence, our sample size was 731 patients. Of these patients: 208 (28%) were psychiatrically well, 294 (40%) had dementia, 108 (15%) had delirium, and 93 (13%) had depression. 66 patients with depression had not been prescribed antidepressants, which suggested that they either had newonset depression or had not previously been diagnosed. 28 people (4%) were diagnosed with other psychiatric disorders (alcohol misuse, schizophrenia, anxiety disorders, and phobias), which we did not include in our analysis. 2 years after admission 347 (47%) included patients had died, 384 (53%) remained alive, and none were lost to follow up. The figure shows unadjusted survival of patients stratified by psychiatric diagnosis soon after hip fracture. Results of multivariate analysis of survival, adjusted for confounding factors, showed that diagnosis of depression, delirium, or dementia soon after hip fracture substantially increased risk of death in the following 2 years (table). Risk of mortality was greater in one hospital than the other, even after controlling for confounding variables such as sociodemographic status (table). Observational studies can be biased. Nevertheless, we have shown a substantial effect of psychiatric illness, especially dementia and delirium, on postoperative survival, which is unlikely to be totally attributable to confounding factors. Our findings have three implications. First, psychiatric illness is common in older people admitted to hospital with hip fracture, and its adverse effect justifies development of psychiatric or psychosocial interventions to complement physical rehabilitation in orthogeriatric care models. We found only one trial of a psychosocial intervention in geriatric people. Participants in this trial were screened for psychiatric illness and, if such illness were found, were randomly assigned psychosocial assessment and care package, or
THE LANCET • Vol 357 • April 21, 2001
treatment as usual.5 Length of hospital stay and costs were reduced, but the intervention was not clearly described; hence general conclusions cannot be drawn. Second, prospective studies of depression in physical illness must be followed up for sufficient time, or important effects might be missed.1 Third, differences in outcomes between hospitals might be caused by variations in the total package of care.1 Thus, mortality rates after hip fracture were well chosen by the National Health Service executive as good clinicalperformance indicators. Knowledge of variation in outcomes caused by service factors should aid evaluation, planning, and redesign of health-care services for older adults. We thank Alison Torn for help with recruiting and interviewing participants. Work was supported by project grant M/52 from North Thames and Northern and Yorkshire Research and Development Funds, Leeds Community and Mental Health Services National Health Service Trust, and the Yorkshire Deanery. 1
2 3
4
5
Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of hip: the East Anglian audit. BMJ 1995; 310: 904–08. Holmes J, House A. Psychiatric illness in hip fracture: a systematic review. Age Ageing 2000; 29: 537–46. Holmes J, House A. Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychol Med 2000; 30: 921–29. Cole MG, Bellavance F. Depression in elderly medical inpatients: a meta-analysis of outcomes. Can Med Assoc J 1997; 157: 1055–60. Strain JJ, Lyons JS, Hammer JS, et al. Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. Am J Psychiatry 1991; 148: 1044–49.
High Royds Hospital, Menston, Ilkley, West Yorkshire, UK (S Nightingale MRCPsych); Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK (J Holmes MD, Prof A House DM); and Centre for Health Economics, University of York, Heslington, York (J Mason PhD) Correspondence to: Dr John Holmes (e-mail: [email protected])
A common mitochondrial DNA variant associated with susceptibility to dilated cardiomyopathy in two different populations Saib S Khogali, Bongani M Mayosi, James M Beattie, William J McKenna, Hugh Watkins, Joanna Poulton Idiopathic dilated cardiomyopathy is a recognised manifestation of mitochondrial disease due to specific mitochondrial (mt) DNA mutations. However, whether mtDNA polymorphisms predispose to sporadic dilated cardiomyopathy is not known. We analysed two populations with this disorder for a general mtDNA variant (T16189C), previously implicated in susceptibility to type 2 diabetes. We noted an increased frequency of the polymorphism in both populations compared with controls (p=0·002). The polymorphism occurred on different mtDNA backgrounds, suggesting that it might be a functional variant. This association of an mtDNA variant with increased susceptibility to dilated cardiomyopathy provides evidence for a mitochondrial cause in sporadic disease.
Idiopathic dilated cardiomyopathy is a primary disorder of heart muscle characterised by dilatation and impaired contraction of the heart. There is a 50% mortality 5 years after diagnosis, and heart transplantation is the only treatment for the progressive heart failure that occurs. Because the causes of this disease are unknown there are no specific therapies. 20–30% of cases are familial, and
1265
For personal use. Only reproduce with permission from The Lancet Publishing Group.
node involvement at diagnosis (p=0·0015), performance status (p=0·0001), and T stage (p=0·0097, table). We then looked at local recurrence and metastasis-free survival in the two groups of patients with low or high serum sIL–2R concentrations. A trend towards an association between serum sIL–2Rα concentrations and local recurrence was observed but it did not reach significance (p=0·081 in univariate analysis, table). The most significant predictive factors of local recurrence in multivariate analysis were T stage (p=0·0001), lymph node involvement (p=0·0004), and performance status (p=0·045, table). Serum sIL-2Rα levels were highly correlated with the distant metastasis-free survival. 11·5% of patients (5·3–17·7%) who had low serum sIL–2R concentrations at diagnosis developed distant metastasis during the 36 months’ follow-up, compared with 34% (15·4%–52·6%) of patients in the group with high serum sIL-2Rα concentrations. In multivariate analysis, lymph-node involvement (p<0·0001) and sIL–2Rα concentrations (p=0·0002) were each correlated with distant-metastasis-free survival in an independent manner when adjusted for each other (table). A similar correlation between sIL–2Rα serum concentrations and overall survival and distant-metastasisfree survival was found when sIL–2Rα was introduced as a continuous variable (data not shown). In our series, 20% of deaths were related to the presence of metastasis, which might explain the effect of this variable on overall survival. The predictive value of sIL–2Rα did not appear to change when the type of treatment was taken into account (surgery followed by radiotherapy, or radiotherapy before surgery, with or without adjuvant chemotherapy [data not shown]). We have shown a highly significant association between the risk of developing metastasis and serum sIL–2Rα concentration at diagnosis. Wang et al have shown that distant metastases occurred often among patients with oesophageal squamous-cell carcinoma who had persistently high sIL–2R levels after oesophagectomy.4 In some patients with Hodgkin’s disease, serum sIL–2Rα concentrations are increased several months before clinical evidence of recurrent metastatic disease.5 Our study strongly suggests that sIL–2R α concentrations should be considered as an independent serum biomarker when adjusted for other variables to predict the risk of development of distant metastasis and overall survival in patients with head and neck cancer.
2
3
4
5
Sharon Nightingale, John Holmes, James Mason, Allan House People with dementia or delirium have increased mortality in the 6 months after hip fracture, but depression might take longer to have an effect. We assessed the psychiatric status of 731 participants with hip fracture and analysed the effect of psychiatric illness on mortality during the next 2 years. We found that dementia, delirium, and depression all increased the risk of mortality (p<0·0001, p<0·0001, and p=0·0359, respectively), and that mortality differed significantly between hospitals (p=0·0003). We suggest that psychiatric interventions should be asssessed in hip-fracture patients with adequate follow up of outcome measures.
Hip fracture is a common cause of morbidity and mortality in older adults.1 Psychiatric illness is thought to worsen prognosis of patients with hip fractures, although we questioned the evidence for this assertion in a recent systematic review.2 We noted that small sample sizes had led to imprecise findings, dementia and delirium had not been distinguished, and that analysis was based on only one psychiatric diagnosis. We have shown that survival at 6 months after hip fracture is adversely affected by dementia (hazard ratio 2·57 [95% CI 1·65–4·01]) and delirium (2·88 [1·76–4·72]), but not by depression (1·01 [0·53–1·94]).3 However, more than 6 months of follow up might be needed to detect the effect of depression.4 We did a 2-year follow up of the cohort from our previous study to establish whether depression affects long-term survival after hip fracture. All patients aged 65 years or older, admitted to two teaching hospitals (A and B) in the same city, and having hipfracture operations during a 19-month period, were eligible for inclusion.3 Neither hospital had a dedicated hip-fracture service; one hospital had weekly visits from a consultant geriatrician, whereas the other had no formal orthogeriatric collaboration. Psychiatric input in each hospital was by consultation. Psychiatric status was assessed by use of Geriatric Mental State/AGECAT software (community version 3a). Cognitive impairment was diagnosed with this software or by the standardised mini-mental state examination, and was classed as dementia, delirium, or both, 1·0 0·9 0·8
Mineta H, Miura K, Suzuki I, et al. Low p27 expression correlates with poor prognosis for patients with oral tongue squamous cell carcinoma. Cancer 1999; 85: 1011–17 Smith BD, Smith GL, Carter D, et al. Prognostic significance of vascular endothelial growth factor protein levels in oral and oropharyngeal squamous cell carcinoma. J Clin Oncol 2000; 18: 2046–52. Tartour E, Deneux L, Mosseri V, et al. Soluble interleukin-2 receptor serum level as a predictor of local control and survival for patients with head and neck carcinoma: results of a multivariate prospective study. Cancer 1997; 79: 1401–08. Wang LS, Chow KC, Li WY, et al. Clinical significance of serum soluble interleukin 2 receptor-alpha in esophageal squamous cell carcinoma. Clin Cancer Res 2000; 6: 1445–51. Viviani S, Camerini E, Bonfante V, et al. Soluble interleukin-2 receptors (sIL–2R) in Hodgkin’s disease: outcome and clinical implications. Br J Cancer 1998; 77: 992–97.
Institut Curie Head and Neck oncology group, 26 Rue d’Ulm 75248 Paris Cedex 05, France (E Tartour PhD, V Mosseri MD, T Jouffroy MD, L Deneux, C. Jaulerry MD, F Brunin MD, WH Fridman PhD, J Rodriguez MD), Correspondence to: Eric Tartour, Hopital Européen Georges Pompidou, INSERM U 255, 20 Rue Leblanc, 75908 Paris, Cedex 15, France (e-mail: [email protected])
1264
Proportion surviving
1
Psychiatric illness and mortality after hip fracture
Well
0·7 0·6
Depression
0·5
Delirium
0·4 Dementia
0·3 0·2 0·1 0 0
200
400 Time (days)
600
208 93 108 294
172 79 65 176
161 71 56 151
153 62 49 128
800
Numbers at risk Well Depression Delirium Dementia
148 56 46 113
Kaplan-Meier curves of survival after hip fracture stratified by psychiatric diagnosis
THE LANCET • Vol 357 • April 21, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
RESEARCH LETTERS
Variable
Hazard ratio (95% CI)
p
Age (per year) Male sex Hospital B Daily activities (per unit increase) Physical illness Mild Moderate Severe Psychiatric diagnosis Dementia Delerium Depression
1·024 (1·007–1·040) 1·653 (1·255–2·176) 1·494 (1·204–1·855) 0·976 (0·952–0·999)
0·0050 0·0003 0·0003 0·0438
1·377 (0·994–1·906) 2·000 (1·445–2·768) 2·928 (1·764–4·861)
0·0541 <0·0001 <0·0001
2·620 (1·883–3·645) 2·404 (1·659–3·484) 1·566 (1·030–2·381)
<0·0001 <0·0001 0·0359
Multivariate survival analysis of hazard ratios for mortality 2 years after hip fracture in 731 elderly patients
with the delirium rating scale. If patients had depression and cognitive impairment, impairment was given diagnostic precedence. We recorded: age; sex; concurrent physical illness (by the Burvill scale); type of fracture; type of operation anaesthetic; hospital; and prefracture daily activities (using the Barthel score), socioeconomic status, accommodation, and support network. A researcher, unaware of the initial diagnosis, assessed survival at 2 years from time of admission by asking general practitioners and by searching a local health-service database. Data were analysed with a multivariate Cox’s proportional hazards model by stepwise variable selection and analysis of interactions between variables; significant variables were retained (p<0·05). Assumption of constant proportionality over time of variables in the final model was validated. We obtained ethical approval. 903 patients met our inclusion criteria. Of these, 172 (19%) were excluded: 78 (9%) refused consent, 41 (5%) were too physically ill to be interviewed, 19 (2%) were too deaf to interview, 14 (2%) died before interview, ten (1%) did not have surgery, eight had dysphasia, one spoke no English, and one was transferred to another hospital. Hence, our sample size was 731 patients. Of these patients: 208 (28%) were psychiatrically well, 294 (40%) had dementia, 108 (15%) had delirium, and 93 (13%) had depression. 66 patients with depression had not been prescribed antidepressants, which suggested that they either had newonset depression or had not previously been diagnosed. 28 people (4%) were diagnosed with other psychiatric disorders (alcohol misuse, schizophrenia, anxiety disorders, and phobias), which we did not include in our analysis. 2 years after admission 347 (47%) included patients had died, 384 (53%) remained alive, and none were lost to follow up. The figure shows unadjusted survival of patients stratified by psychiatric diagnosis soon after hip fracture. Results of multivariate analysis of survival, adjusted for confounding factors, showed that diagnosis of depression, delirium, or dementia soon after hip fracture substantially increased risk of death in the following 2 years (table). Risk of mortality was greater in one hospital than the other, even after controlling for confounding variables such as sociodemographic status (table). Observational studies can be biased. Nevertheless, we have shown a substantial effect of psychiatric illness, especially dementia and delirium, on postoperative survival, which is unlikely to be totally attributable to confounding factors. Our findings have three implications. First, psychiatric illness is common in older people admitted to hospital with hip fracture, and its adverse effect justifies development of psychiatric or psychosocial interventions to complement physical rehabilitation in orthogeriatric care models. We found only one trial of a psychosocial intervention in geriatric people. Participants in this trial were screened for psychiatric illness and, if such illness were found, were randomly assigned psychosocial assessment and care package, or
THE LANCET • Vol 357 • April 21, 2001
treatment as usual.5 Length of hospital stay and costs were reduced, but the intervention was not clearly described; hence general conclusions cannot be drawn. Second, prospective studies of depression in physical illness must be followed up for sufficient time, or important effects might be missed.1 Third, differences in outcomes between hospitals might be caused by variations in the total package of care.1 Thus, mortality rates after hip fracture were well chosen by the National Health Service executive as good clinicalperformance indicators. Knowledge of variation in outcomes caused by service factors should aid evaluation, planning, and redesign of health-care services for older adults. We thank Alison Torn for help with recruiting and interviewing participants. Work was supported by project grant M/52 from North Thames and Northern and Yorkshire Research and Development Funds, Leeds Community and Mental Health Services National Health Service Trust, and the Yorkshire Deanery. 1
2 3
4
5
Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of hip: the East Anglian audit. BMJ 1995; 310: 904–08. Holmes J, House A. Psychiatric illness in hip fracture: a systematic review. Age Ageing 2000; 29: 537–46. Holmes J, House A. Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychol Med 2000; 30: 921–29. Cole MG, Bellavance F. Depression in elderly medical inpatients: a meta-analysis of outcomes. Can Med Assoc J 1997; 157: 1055–60. Strain JJ, Lyons JS, Hammer JS, et al. Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. Am J Psychiatry 1991; 148: 1044–49.
High Royds Hospital, Menston, Ilkley, West Yorkshire, UK (S Nightingale MRCPsych); Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK (J Holmes MD, Prof A House DM); and Centre for Health Economics, University of York, Heslington, York (J Mason PhD) Correspondence to: Dr John Holmes (e-mail: [email protected])
A common mitochondrial DNA variant associated with susceptibility to dilated cardiomyopathy in two different populations Saib S Khogali, Bongani M Mayosi, James M Beattie, William J McKenna, Hugh Watkins, Joanna Poulton Idiopathic dilated cardiomyopathy is a recognised manifestation of mitochondrial disease due to specific mitochondrial (mt) DNA mutations. However, whether mtDNA polymorphisms predispose to sporadic dilated cardiomyopathy is not known. We analysed two populations with this disorder for a general mtDNA variant (T16189C), previously implicated in susceptibility to type 2 diabetes. We noted an increased frequency of the polymorphism in both populations compared with controls (p=0·002). The polymorphism occurred on different mtDNA backgrounds, suggesting that it might be a functional variant. This association of an mtDNA variant with increased susceptibility to dilated cardiomyopathy provides evidence for a mitochondrial cause in sporadic disease.
Idiopathic dilated cardiomyopathy is a primary disorder of heart muscle characterised by dilatation and impaired contraction of the heart. There is a 50% mortality 5 years after diagnosis, and heart transplantation is the only treatment for the progressive heart failure that occurs. Because the causes of this disease are unknown there are no specific therapies. 20–30% of cases are familial, and
1265
For personal use. Only reproduce with permission from The Lancet Publishing Group.