Prognosis of congestive heart failure in patients with normal versus reduced ejection fractions: Results from a cohort of 2,258 hospitalized patients

doi:10.1054/jcaf.2003.13

Journal of Cardiac Failure

Volume 9, Issue 2, April 2003, Pages 107-112

https://doi.org/10.1054/jcaf.2003.13 Get rights and content

Abstract

Background: Patients with congestive heart failure have an annual mortality of 10% to 20% depending on disease severity. Though one third of these patients have normal left ventricular (LV) ejection fraction (EF), their natural history is poorly defined. Small population-based studies have suggested a more benign prognosis for patients with preserved LVEF. However, prognosis in hospitalized patients, who form a higher risk group, is not known. Methods: We investigated the survival patterns of 2,258 patients with a primary hospital discharge diagnosis of congestive heart failure between 1990 and 1999. Survival was analyzed and patients with normal and reduced LVEF were compared. Results: Their age was 71 ± 11 years, and 97% were men. There were 1,535 deaths over a mean follow up of 786 days. Of these, 963 (43%) patients had a normal LVEF (≥55%). Patients with normal LVEF were of the same age as those with reduced LVEF, but had a lower prevalence of atrial fibrillation (20 versus 26%, P =.03), left bundle branch block (2 versus 12%, P <.0001), significant mitral regurgitation (5 versus 31%, P <.0001) and electrocardiographic evidence of myocardial infarction (38 versus 60%, P <.0001). Despite lesser comorbidities, they had a higher mortality hazard, with a 5-year survival of 22% compared with 28% for those with systolic heart failure (P =.007). Proportional hazards model showed presence of normal EF as a categoric variable to be an independent predictor of mortality in those with heart failure after correcting for age and rhythm. Conclusions: Prognosis of hospitalized patients with congestive heart failure and normal LVEF is worse than those with reduced EF despite lesser comorbidities. Studies addressing optimal management of these patients are warranted.

Section snippets

Patient population

The hospital medical record discharge diagnosis database was electronically searched for a primary discharge diagnosis (on both alive and dead patients) of CHF between 1990 and 1999. This yielded a list of 2,678 patients. The diagnosis was made by or approved by a cardiology attending physician or an internist based on clinical, radiologic, and echocardiographic data. Of these patients, 2,258 patients had an echocardiogram during the index hospital admission or within a month of admission. For

Patient characteristics

Of the 2,258 patients with CHF, 963 (43%) had preserved LV systolic function defined as an LVEF ≥55%. The mean (± standard deviation) age was 71 ± 11 years; 97% were men. The LV ejection fraction was 45 ± 18%. Over a mean follow up of 786 days, there were 1,535 deaths.

Discussion

This study, which perhaps is the largest addressing the prognosis of patients with presumed diastolic heart failure, indicates that patients with diastolic CHF have a worse prognosis compared with those with systolic CHF, despite the fact that patients with diastolic heart failure had lesser cardiac comorbidities. Correcting for comorbidities amplified the difference in survival. Our CHF patients probably formed a higher risk group compared with population and outpatient-based studies because

Conclusions

We conclude that presence of CHF increases mortality in those with normal LVEF. Prognosis of hospitalized patients with CHF and normal LVEF is worse than of those with reduced EF, despite lesser comorbidities. Studies addressing optimal management of these patients are warranted.

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Integrative review of electrocardiographic characteristics in patients with reduced, mildly reduced, and preserved heart failure
2024, Heart and Lung
Electrocardiographic (ECG) changes in heart failure with reduced, mildly reduced, and preserved ejection fractions can be critical in clinical assessment while waiting to perform echocardiograms or when it is unavailable. This integrative review aimed to identify ECG characteristics among hospitalized patients demonstrating three types of heart failure during acute decompensation.
We searched an electronic database of PubMed, Web of Science, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov using medical subject headings (MeSH) terms and keywords. Sixteen studies were synthesized and reported.
Heart failure with reduced ejection fraction (HFrEF) was more common in men, comorbid with coronary artery diseases and diabetes mellitus, higher BNP/Pro-BNP, wide QRS, and left bundle branch block on ECG. On average, clients with heart failure with preserved ejection fraction (HFpEF) were older and more likely to have a history of atrial fibrillation, valvular heart diseases, hypertension, chronic obstructive pulmonary, and atrial fibrillation (AF) on ECG. Patients with mildly reduced (HFmrEF) were more similar to HFpEF in older patients, comorbid with hypertension, AF and valvular diseases, and AF on ECG.
ECG characteristics might be related to left ventricular ejection fraction. Demographics, BNP/Pro-BNP, and ECG changes might help differentiate different heart failure types. Therefore, ECG might be a prognostic tool while caring for heart failure patients when highly skilled resources are unavailable. These identified ECG characteristics help generate research hypotheses and warrant validation in future research.
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2017, International Journal of Cardiology
Mortality associated with heart failure (HF) remains high. There are limited clinical data on mortality among HF patients from African populations. We examined the clinical characteristics, long-term outcomes, and prognostic factors of African HF patients with preserved, mid-range or reduced left ventricular ejection fraction (LVEF).
We conducted a retrospective longitudinal cohort study of individuals aged ≥ 18 years discharged from first HF admission between January 1, 2009 and December 31, 2013 from the Cardiac Clinic, Directorate of Medicine of the Komfo Anokye Teaching Hospital, Ghana. A total of 1488 patients diagnosed of HF were included in the analysis. Of these, 345 patients (23.2%) had reduced LVEF (LVEF < 40%) [HFrEF], 265(17.8%) with mid-range LVEF (40% ≥ LVEF < 50%) [HFmEF] and 878 (59.0%) had preserved LVEF (LVEF ≥ 50%) [HFpEF]. Kaplan–Meier curves and log-rank test demonstrated better prognosis for HFpEF compared to HFrEF and HFmEF patients. An adjusted Cox analysis showed a significantly lower risk of mortality for HFpEF (hazard ratio (HR); 0.74; 95% confidence interval (CI) 0.57–0.94) p = 0.015). Multivariate analyses showed that age, higher New York Heart Association (NYHA) functional class, lower LVEF, chronic kidney disease, atrial fibrillation, anemia, diabetes mellitus and absence of statin and aldosterone antagonist treatment were independent predictors of mortality in HF. Although, prognostic factors varied across the three groups, age was a common predictor of mortality in HFpEF and HFmEF.
This study identified the clinical characteristics, long-term mortality and prognostic factors of African HF patients with reduced, mid-range and preserved ejection fractions in a clinical setting.
QRS Duration Is a Predictor of Adverse Outcomes in Heart Failure With Preserved Ejection Fraction
2016, JACC: Heart Failure
This study examined the relationship between baseline QRS duration and clinical outcomes in subjects enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial.
Heart failure with preserved ejection fraction (HFPEF) is a heterogeneous clinical syndrome. Whether QRS duration identifies HFPEF subjects at an increased risk of adverse outcomes has not been well studied.
QRS duration was analyzed as a dichotomous variable (≥120 ms or <120 ms) and as a continuous variable to determine its relation to the primary outcome (composite of cardiovascular death, aborted cardiac arrest, or HF hospitalization [HFH]) and to each component of the primary outcome. Multivariate analyses were conducted in the entire study cohort as well as in separate analyses for subjects enrolled only from North and South America, or from Russia and Georgia.
The QRS duration of ≥120 ms was independently associated with an increased risk of the primary outcome (p = 0.009) and HFH (p = 0.003) in the entire study cohort and in the subset enrolled in the Americas. There was a linear relation of QRS duration with risk of the primary outcome and HFH. No interaction was observed between treatment with spironolactone and QRS duration. The risk of adverse outcomes was increased independently of the type of conduction abnormality underlying prolonged QRS duration.
This post hoc analysis demonstrated that prolonged QRS duration identifies HFPEF subjects at a higher risk of adverse clinical outcomes and that spironolactone had a similar effect on outcomes independent of QRS duration. (Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function [TOPCAT]; NCT00094302)
Comparison of Risk of Re-hospitalization, All-Cause Mortality, and Medical Care Resource Utilization in Patients with Heart Failure and Preserved Versus Reduced Ejection Fraction
2015, American Journal of Cardiology
Citation Excerpt :
Most previous studies of mortality comparing HFrEF with HFpEF have reported greater mortality in patients with HFrEF,2,3,15 with relative differences as high as twofold.4,5 However, 1 study found equal mortality,1 whereas another reported lower mortality among patients with HFrEF compared with those with HFpEF.6 Interestingly, a recent European study found that for a given level of B-type natriuretic peptide (BNP), mortality of patients with HFrEF did not differ from that of HFpEF.16
Because heart failure (HF) with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) are different clinical entities with differing demographic characteristics, common HF outcomes may occur at different rates. Comparative outcome studies have been equivocal, and studies comparing resource utilization are scant. We used an observational cohort design to study 6,513 patients hospitalized for HF who had an EF measured during the hospitalization and were discharged alive within 30 days. We excluded 677 patients with borderline EF values (41% to 49%) and categorized the remaining as HFrEF (EF ≤40%, n = 2,205) and HFpEF (EF >50%, n = 3,631). Patients were followed for up to 1 year for all-cause re-hospitalization and mortality and annualized medical resource utilization. Patients with HFrEF and HFpEF experienced similar adjusted incidence rates of re-hospitalization, but those with HFrEF had a 39% increased risk of mortality at 30 days (rate ratio 1.39, 95% confidence interval 1.10 to 1.76) and 25% greater risk at 1 year (rate ratio1.25, 95% confidence interval 1.12 to 1.41). After adjustment for covariates, patients with HFpEF incurred significantly more annualized outpatient visits (21.5 vs 20.1, p = 0.002) and emergency room visits (3.24 vs 2.94, p = 0.002) than those with HFrEF, but absolute differences were small. High inpatient and pharmacy utilization did not differ. Our study suggests that whether a patient has HFrEF or HFpEF has little bearing on risk of re-hospitalization or inpatient resource utilization in the year after an HF hospitalization. Both groups experienced high mortality, but those with HFrEF had greater risk. In conclusion, from the standpoint of resource use, HF can be considered a single entity.
Yoga based cardiac rehabilitation after coronary artery bypass surgery: One-year results on LVEF, lipid profile and psychological states - A randomized controlled study
2014, Indian Heart Journal
To compare the long term effects of yoga based cardiac rehabilitation program with only physiotherapy based program as an add-on to conventional rehabilitation after coronary artery bypass grafting (CABG) on risk factors.
In this single blind prospective randomized parallel two armed active control study, 1026 patients posted for CABG at Narayana Hrudayalaya Institute of Cardiac Sciences, Bengaluru (India) were screened. Of these, 250 male participants (35–65 years) who satisfied the selection criteria and consented were randomized into two groups.
Within and between group comparisons were done at three points of follow up (i.e. 6th week, 6th month, and 12th month) by using Wilcoxon's signed ranks test and Mann Whitney U test respectively.
Yoga group had significantly (p = 0.001, Mann Whitney) better improvement in LVEF than control group in those with abnormal baseline EF (<53%) after 1 year. There was a better reduction in BMI in the yoga group (p = 0.038, between groups) in those with high baseline BMI (≥23) after 12 months. Yoga group showed significant (p = 0.008, Wilcoxon's) reduction in blood glucose at one year in those with high baseline FBS ≥110 mg/dl. There was significantly better improvement in yoga than the control group in HDL (p = 0.003), LDL (p = 0.01) and VLDL (p = 0.03) in those with abnormal baseline values. There was significantly better improvement (p = 0.02, between groups) in positive affect in yoga group. Within Yoga group, there was significant decrease in perceived stress (p = 0.001), anxiety (p = 0.001), depression (p = 0.001), and negative affect (p = 0.03) while in the control group there was reduction (p = 0.003) only in scores on anxiety.
Addition of yoga based relaxation to conventional post-CABG cardiac rehabilitation helps in better management of risk factors in those with abnormal baseline values and may help in preventing recurrence.
National patterns of heart failure hospitalizations and mortality by sex and age
2013, Journal of Cardiac Failure
Earlier work has demonstrated significant sex and age disparities in ischemic heart disease. However, it remains unclear if an age or sex gap exists for heart failure (HF) patients.
Using data from the 2007–2008 Healthcare Cost and Utilization Project, we constructed hierarchic regression models to examine sex differences and age-sex interactions in HF hospitalizations and in-hospital mortality. Among 430,665 HF discharges, 51% were women and 0.3%, 27%, and 73% were aged <25, 25–64, and >64 years respectively. There were significant sex differences among HF risk factors, with a higher prevalence of coronary disease among men. Men had higher hospitalization rates for HF and in-hospital mortality across virtually all ages. The relationship between age and HF mortality appeared U-shaped; mortality rates for ages <25, 25–64, and >64 years were 2.9%, 1.4%, and 3.8%, respectively. No age-sex interaction was found for in-hospital mortality for adults >25 years old.
Using a large nationally representative administrative dataset we found age and sex disparities in HF outcomes. In general, men fared worse than women regardless of age. Furthermore, we found a U-shaped relationship between age and in-hospital mortality during an HF hospitalization, such that young adults have similar mortality rates to older adults. Additional studies are warranted to elucidate the patient-specific and treatment characteristics that result in these patterns.

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^*: Reprint requests: Ramdas G. Pai, MD, FRCP (Edin), FACC, Professor of Medicine, Director of Cardiovascular Research and Fellowship Programs, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354.

^**: 1071-9164/03/0902-0006$30.00/0

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Clinical InvestigationsPrognosis of congestive heart failure in patients with normal versus reduced ejection fractions: Results from a cohort of 2,258 hospitalized patients*,**

Abstract

Section snippets

Patient population

Patient characteristics

Discussion

Conclusions

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

Chest

J Am Coll Cardiol

Am J Card

Am Heart J

Clinical Investigations
Prognosis of congestive heart failure in patients with normal versus reduced ejection fractions: Results from a cohort of 2,258 hospitalized patients*,**