CHAPTER 3.2 138 present with higher prevalence of hypercholesterolaemia and obesity (50.7% vs 43.5% and 33.6% vs 27.8% for hypercholesterolaemia and obesity compared to men). Similar elevated rates of HF hospitalization in men compared to women were observed in other countries.[20,27] Thus, public health strategies aimed to mitigate tobacco exposure in men could provide effective means to reduce CVD burden, including HF hospitalization. Compared to industrialised countries, Malaysian HF patients experience earlier onset of new HF hospitalizations compared to patients in Australia and the United States (mean age range 63.6 – 64.8 years vs 73.3- 74.2 years). [19,28] Next, our study confirms and extends the findings from other studies that the incidence of HF hospitalization increases with each age strata up to the 80 to <85 age group.[19] A sharp drop in incidence of HF hospitalization among the eldest group might be due to their often complex comorbidities and presentation with gradual onset of symptoms or lack of typical ones such as shortness of breath. [29] Concomitant conditions such as mobility issues further complicates diagnosis, resulting in HF being diagnosed as secondary diagnoses instead of primary diagnosis. [29,30] This ten-year study period has seen changes in the HF hospitalization incidence that differed by age. Firstly, steady declines were seen in both men and women above the age of 65 years and this can be attributed to more active screening and treatment of cardiovascular risk factors in older persons and improved quality of care after acute coronary syndrome. It is also possible that middle-aged and older patients are increasingly being hospitalized for other primary diagnoses such as pneumonia and influenza, with HF being the secondary diagnosis.[31] Secondly, in contrast to the decrease in incidence among older persons, we observed a slight increase in incidence among men in the younger ages of 30 to 65 years. This suggests a shift to earlier onset of atherosclerotic disease in the population, which is likely given the high underlying prevalence of atherogenic risk factors.[25] What is more worrying is the large proportion of these patients who were not diagnosed and treated. In 2011, the National Health and Morbidity survey found that about half of the patients with diabetes and 75% of those with hypercholesterolaemia were undiagnosed.[32] Another noteworthy point is the slowing decrease in incidence among women older than 80 years compared to the men. Possible explanations include greater longevity in women and increase in readiness to diagnose HF with preserved ejection fraction, which is more prevalent in older women.[33]
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