Risk stratification in a Brazilian hospital-based cohort of 1220 outpatients with heart failure: role of Chagas' heart disease

doi:10.1016/j.ijcard.2004.05.025

International Journal of Cardiology

Volume 102, Issue 2, 10 July 2005, Pages 239-247

https://doi.org/10.1016/j.ijcard.2004.05.025 Get rights and content

Abstract

Background

Few studies evaluated prognostic factors of outpatients with heart failure of different etiologies including Chagas' heart disease.

Methods

We studied 1220 outpatients with heart failure in functional classes III and IV (NYHA) to evaluate prognostic factors. Patients aged 13–72 years (mean 45.5, standard deviation 11); 952 men (78%) and 268 women (22%) were followed up for 25.6±26 months from 1991 to 2000. Heart failure was attributed to idiopathic dilated cardiomyopathy in 454 (37%) patients. Etiologies were Chagas' heart disease in 242 (20%) patients, ischemic cardiomyopathy in 212 (17%), hypertensive cardiomyopathy in 170 (14%) and others in 142 (12%). Statistical analyses were performed with Kaplan–Meier and Cox proportional hazards methods, following a strategy of noninvasive model as well as in an invasive model to identify the risk of death.

Results

Four hundred fifteen (34%) patients died in the follow-up period, 71 (6%) patients underwent heart transplantation and 28 (2%) underwent other surgical interventions. In the noninvasive model, Chagas' heart disease (relative risk compared with other etiologies 2.26 to 2.97), left ventricular end diastolic diameter on echocardiography (relative risk 1.13) and left ventricular ejection fraction on radionuclide angiography (relative risk 0.96) were associated with higher mortality. In the invasive model, Chagas' heart disease (relative risk compared with other etiologies 2.66 to 9.13) was the most important determinant of mortality in association with the cardiac index (relative risk 0.40).

Conclusions

In this cohort of patients with heart failure of different etiologies, Chagas' heart disease was the main prognostic factor for mortality.

Introduction

Heart failure is a significant major public health problem worldwide [1]. There is a wide variation in the prognosis of symptomatic patients after the diagnosis of heart failure, which may be related to epidemiological, clinical and methodological characteristics of different studies.

Epidemiological characteristics influence prognosis [2], [3] and contribute to different survival experiences in population-based studies [4], [5], [6], [7], in hospital-based series [8], [9], [10], [11], [12] or in protocols of drug therapy [13], [14], [15], [16], [17], [18]. In addition, etiologies of heart failure [9], [12], [19], [20], severity of the disease [21] and some characteristics of medical treatment [22], [23] depend on peculiarities of local clinical settings. Further, criteria for patients' inclusion, as well as numbers of patients in the series [8], [11], [24], [25], are also heterogeneous.

Decisions regarding therapy, including surgical treatment of heart failure or heart transplantation, are to be made on the basis of knowledge of the long-term prognosis of affected patients. We hypothesized that variables elicited during clinical evaluation of outpatients might be identified and structured in models that would be of help in identifying patients at higher risk of dying. Specifically, we were interested in testing a sequence of a noninvasive as well as an invasive strategy previously published [19] that would assist us in identifying prognostic factors to guide decisions in therapy. In addition, there are few recently published large series of patients with heart failure that includes a significant proportion of patients with Chagas' heart disease in a single institution.

We performed this study to identify risk factors of mortality in a large series of outpatients with severe heart failure, including a significant proportion of patients with Chagas' heart disease, which were routinely submitted to angiotensin converting enzyme inhibitors therapy followed up in the 1990s in a single institution.

Section snippets

Patients

Patients (1220) with heart failure in functional classes III and IV of the New York Heart Association were studied from April 1991 to November 2000. The mean age of the patients was 45.5 years, standard deviation 11.0 (range 13–72 years); 952 (78%) were men and 268 (22%) were women. The mean duration of symptoms before entry in the study was 47.9 months, with a standard deviation of 48.1 months.

Inclusion criteria

Patients with age less than 75 years, diagnosis of symptomatic heart failure in functional class III

Clinical characteristics

The clinical characteristics are presented in Table 1 relative to the etiologies of heart failure and in Table 2 relative to survival, nonsurvival, heart transplantation and other surgical interventions in the follow-up.

There was male predominance in every etiology of heart failure studied; the mean age was less than 51.7±8.3 years and the mean left ventricular ejection fraction by radionuclide ventriculography was 22.1±7.9%. Invasive cardiac catheterization studies were performed in 357

Discussion

We studied a Brazilian cohort of outpatients with heart failure of different etiologies, including Chagas' heart disease with the aim of evaluating prognostic factors to support decisions regarding medical or surgical treatment of heart failure. In previous reports, patients with Chagas' heart disease were absent [8], [9], [11], [12], the degree of ventricular dysfunction has not always been estimated [21], and some studies were performed before availability of widespread therapy with

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Risk stratification in a Brazilian hospital-based cohort of 1220 outpatients with heart failure: role of Chagas' heart disease

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Inclusion criteria

Clinical characteristics

Discussion

J. Am. Coll. Cardiol.

Mayo Clin. Proc.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

J. Am. Coll. Cardiol.

Am. Heart J.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

The heart failure epidemic: exactly how big is it?

Eur. Heart J.

Speciality-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure

Eur. Heart J.

Noninvasive predictors of mortality for patients with Chagas' heart disease: a multivariate stepwise logistic regression study

Cardiology

Congestive heart failure in the community. A study of all incident cases in Olmsted county, Minnesota, in 1991

Circulation

Survival after the onset of congestive heart failure in the Framingham heart study subjects

Circulation

Clinical, hemodynamic, and cardiopulmonary exercise test determinants of survival in patients referred for evaluation of heart failure

Ann. Intern. Med.

Description and survival 190 consecutive patients with a diagnosis of chronic congestive heart failure based on clinical signs and symptoms

Eur. Heart J.

Clinical determinants of mortality in chronic congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy

Am. J. Cardiol.

For the US carvedilol study group The effect of carvedilol on morbidity and mortality in patients with chronic heart failure

N. Engl. J. Med.

Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

N. Engl. J. Med.

Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS)

N. Engl. J. Med.