Background:
Most persons with congestive heart failure are elderly, and many elderly persons with congestive heart failure have normal left ventricular systolic function.
Objective:
To evaluate the relationship between left ventricular systolic function and outcome of congestive heart failure in elderly persons.
Design:
Population-based longitudinal study of coronary heart disease and stroke.
Setting:
Four U.S. sites: Forsyth County, North Carolina; Sacramento County, California; Allegheny County, Pennsylvania; and Washington County, Maryland.
Participants:
5888 persons who were at least 65 years of age and were recruited from the community.
Measurements:
Total mortality and cardiovascular morbidity and mortality.
Results:
Of 5532 participants, 269 (4.9%) had congestive heart failure. Among these, left ventricular function was normal in 63%, borderline decreased in 15%, and overtly impaired in 22%. The mortality rate was 25 deaths per 1000 person-years in the reference group (no congestive heart failure and normal left ventricular function at baseline); 154 deaths per 1000 person-years in participants with congestive heart failure and impaired left ventricular systolic function; 87 and 115 deaths per 1000 person-years in participants with congestive heart failure and normal or borderline systolic function, respectively; and 89 deaths per 1000 person-years in persons with impaired left ventricular function but no congestive heart failure. Although the risk for death from congestive heart failure was lower in persons with normal systolic function than in those with impaired function, more deaths were associated with normal systolic function because more persons with heart failure fall into this category.
Conclusions:
Community-dwelling elderly persons, especially those with impaired left ventricular function, have a substantial risk for death from congestive heart failure. However, more deaths occur from heart failure in persons with normal systolic function because left ventricular function is more often normal than impaired in elderly persons with heart failure.
References
- 1.
Schocken DD ,Arrieta MI ,Leaverton PE ,Ross EA . Prevalence and mortality rate of congestive heart failure in the United States. J Am Coll Cardiol. 1992;20:301-6. [PMID: 1634664] CrossrefMedlineGoogle Scholar - 2.
Levy D ,Larson MG ,Vasan RS ,Kannel WB ,Ho KK . The progression from hypertension to congestive heart failure. JAMA. 1996;275:1557-62. [PMID: 8622246] CrossrefMedlineGoogle Scholar - 3.
Rich MW . Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults. J Am Geriatr Soc. 1997;45:968-74. [PMID: 9256850] CrossrefMedlineGoogle Scholar - 4.
Braunwald E . Shattuck lecture—cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities. N Engl J Med. 1997;337:1360-9. [PMID: 9358131] CrossrefMedlineGoogle Scholar - 5.
Vasan RS ,Benjamin EJ ,Levy D . Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol. 1995;26:1565-74. [PMID: 7594087] CrossrefMedlineGoogle Scholar - 6.
Bonow RO ,Udelson JE . Left ventricular diastolic dysfunction as a cause of congestive heart failure. Mechanisms and management. Ann Intern Med. 1992;117:502-10. [PMID: 1503353] LinkGoogle Scholar - 7.
Kitzman DW ,Higginbotham MB ,Cobb FR ,Sheikh KH ,Sullivan MJ . Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: failure of the Frank-Starling mechanism. J Am Coll Cardiol. 1991;17:1065-72. [PMID: 2007704] CrossrefMedlineGoogle Scholar - 8.
Senni M ,Redfield MM . Congestive heart failure in elderly patients. Mayo Clin Proc. 1997;72:453-60. [PMID: 9146689] CrossrefMedlineGoogle Scholar - 9.
Kitzman DW ,Sullivan MJ . Exercise intolerance in patients with heart failure: role of diastolic dysfunction.. In: Grossman W, eds. Diastolic Relaxation of the Heart. Boston: Kluwer Academic Publishers; 1994:295-302. Google Scholar - 10.
Braunwald E ,Sobel BE . Coronary blood flow and ischemia.. In: Braunwald E, eds. Heart Disease: A Textbook of Cardiovascular Medicine. 4th ed. Philadelphia: WB Saunders; 1992:1179. Google Scholar - 11.
Wynne J ,Braunwald E . The cardiomyopathies and myocardities: toxic, chemical, and physical damage to the heart.. In: Braunwald E, eds. Heart Disease: A Textbook of Cardiovascular Medicine. 4th ed. Philadelphia: WB Saunders; 1992:1415-6. Google Scholar - 12.
Gardin JM ,Arnold A ,Gottdiener JS ,Wong ND ,Fried LP ,Klopfenstein HS ,et al . Left ventricular mass in the elderly. The Cardiovascular Health Study. Hypertension. 1997;29:1095-103. [PMID: 9149672] CrossrefMedlineGoogle Scholar - 13.
Wei JY . Age and the cardiovascular system. N Engl J Med. 1992;327:1735-9. [PMID: 1304738] CrossrefMedlineGoogle Scholar - 14.
Kitzman DW ,Sheikh KH ,Beere PA ,Philips JL ,Higginbotham MB . Age-related alterations of Doppler left ventricular filling indexes in normal subjects are independent of left ventricular mass, heart rate, contractility and loading conditions. J Am Coll Cardiol. 1991;18:1243-50. [PMID: 1918701] CrossrefMedlineGoogle Scholar - 15.
Ho KK ,Anderson KM ,Kannel WB ,Grossman W ,Levy D . Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation. 1993;88:107-15. [PMID: 8319323] CrossrefMedlineGoogle Scholar - 16.
Andersson B ,Waagstein F . Spectrum and outcome of congestive heart failure in a hospitalized population. Am Heart J. 1993;126:632-40. [PMID: 8362719] CrossrefMedlineGoogle Scholar - 17.
Carson P ,Johnson G ,Fletcher R ,Cohn J . Mild systolic dysfunction in heart failure (left ventricular ejection fraction >35%): baseline characteristics, prognosis and response to therapy in the Vasodilator in Heart Failure Trials (V-HeFT). J Am Coll Cardiol. 1996;27:642-9. [PMID: 8606276] CrossrefMedlineGoogle Scholar - 18.
Gaasch WH . Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction. JAMA. 1994;271:1276-80. [PMID: 8151903] CrossrefMedlineGoogle Scholar - 19. Gradman A, Deedwania P, Cody R, Massie B, Packer M, Pitt B, et al. Predictors of total mortality and sudden death in mild to moderate heart failure. Captopril-Digoxin Study Group. J Am Coll Cardiol. 1989; 14:564-70; discussion 571-2. [PMID: 2768707] Google Scholar
- 20.
Cohn JN ,Rector TS . Prognosis of congestive heart failure and predictors of mortality. Am J Cardiol. 1988;62:25A-30A. [PMID: 3389302] CrossrefMedlineGoogle Scholar - 21.
Pernenkil R ,Vinson JM ,Shah AS ,Beckham V ,Wittenberg C ,Rich MW . Course and prognosis in patients > or =70 years of age with congestive heart failure and normal versus abnormal left ventricular ejection fraction. Am J Cardiol. 1997;79:216-9. [PMID: 9193031] CrossrefMedlineGoogle Scholar - 22.
Senni M ,Tribouilloy CM ,Rodeheffer RJ ,Jacobsen SJ ,Evans JM ,Bailey KR ,et al . Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation. 1998;98:2282-9. [PMID: 9826315] CrossrefMedlineGoogle Scholar - 23.
Vasan RS ,Larson MG ,Benjamin EJ ,Evans JC ,Reiss CK ,Levy D . Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol. 1999;33:1948-55. [PMID: 10362198] CrossrefMedlineGoogle Scholar - 24.
Fried LP ,Borhani NO ,Enright P ,Furberg CD ,Gardin JM ,Kronmal RA ,et al . The Cardiovascular Health Study: design and rationale. Ann Epidemiol. 1991;1:263-76. [PMID: 1669507] CrossrefMedlineGoogle Scholar - 25.
Mittelmark MB ,Psaty BM ,Rautaharju PM ,Fried LP ,Borhani NO ,Tracy RP ,et al . Prevalence of cardiovascular diseases among older adults. The Cardiovascular Health Study. Am J Epidemiol. 1993;137:311-7. [PMID: 8452139] CrossrefMedlineGoogle Scholar - 26.
Psaty BM ,Kuller LH ,Bild D ,Burke GL ,Kittner SJ ,Mittelmark M ,et al . Methods of assessing prevalent cardiovascular disease in the Cardiovascular Health Study. Ann Epidemiol. 1995;5:270-7. [PMID: 8520708] CrossrefMedlineGoogle Scholar - 27.
Ives DG ,Fitzpatrick AL ,Bild DE ,Psaty BM ,Kuller LH ,Crowley PM ,et al . Surveillance and ascertainment of cardiovascular events. The Cardiovascular Health Study. Ann Epidemiol. 1995;5:278-85. [PMID: 8520709] CrossrefMedlineGoogle Scholar - 28.
Gardin JM ,Wong ND ,Bommer W ,Klopfenstein HS ,Smith VE ,Tabatznik B ,et al . Echocardiographic design of a multicenter investigation of free-living elderly subjects: the Cardiovascular Health Study. J Am Soc Echocardiogr. 1992;5:63-72. [PMID: 1739473] CrossrefMedlineGoogle Scholar - 29.
Rautaharju PM ,Manolio TA ,Siscovick D ,Zhou SH ,Gardin JM ,Kronmal R ,et al . Utility of new electrocardiographic models for left ventricular mass in older adults. The Cardiovascular Health Study Collaborative Research Group. Hypertension. 1996;28:8-15. [PMID: 8675268] CrossrefMedlineGoogle Scholar - 30.
Gardin JM ,Siscovick D ,Anton-Culver H ,Lynch JC ,Smith VE ,Klopfenstein HS ,et al . Sex, age, and disease affect echocardiographic left ventricular mass and systolic function in the free-living elderly. The Cardiovascular Health Study. Circulation. 1995;91:1739-48. [PMID: 7882482] CrossrefMedlineGoogle Scholar - 31.
Newman AB ,Siscovick DS ,Manolio TA ,Polak J ,Fried LP ,Borhani NO ,et al . Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation. 1993;88:837-45. [PMID: 8353913] CrossrefMedlineGoogle Scholar - 32.
Lilienfeld AM ,Lilienfeld DE . Foundations of Epidemiology. 2nd ed. New York: Oxford Univ Pr; 1980:217. Google Scholar - 33.
Kalbfleisch JD ,Prentice RL . The Statistical Analysis of Failure Time Data. New York: J Wiley; 1980. Google Scholar - 34.
Kitzman DW ,Gardin JM ,Gottdiener JS ,Arnold A ,Boineau R ,Aurigemma G ,et al . Importance of heart failure with preserved systolic function in patients > or =65 years of age. CHS Research Group. Cardiovascular Health Study. Am J Cardiol. 2001;87:413-9. [PMID: 11179524] CrossrefMedlineGoogle Scholar - 35.
Gottdiener JS ,Arnold AM ,Aurigemma GP ,Polak JF ,Tracy RP ,Kitzman DW ,et al . Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study. J Am Coll Cardiol. 2000;35:1628-37. [PMID: 10807470] CrossrefMedlineGoogle Scholar - 36.
Aurigemma GP ,Gottdiener JS ,Shemanski L ,Gardin J ,Kitzman D . Predictive value of systolic and diastolic function for incident congestive heart failure in the elderly: the cardiovascular health study. J Am Coll Cardiol. 2001;37:1042-8. [PMID: 11263606] CrossrefMedlineGoogle Scholar - 37.
Vasan RS ,Levy D . Defining diastolic heart failure: a call for standardized diagnostic criteria. Circulation. 2000;101:2118-21. [PMID: 10790356] CrossrefMedlineGoogle Scholar - 38.
- 39.
Kambara H ,Nakagawa M ,Kinoshita M ,Kawai C . Long-term prognosis after myocardial infarction: univariate and multivariate analysis of clinical characteristics in 1,000 patients. Kyoto and Shiga Myocardial Infarction (KYSMI) Study Group. Clin Cardiol. 1993;16:872-8. [PMID: 8168271] CrossrefMedlineGoogle Scholar - 40.
Wilber DJ ,Garan H ,Finkelstein D ,Kelly E ,Newell J ,McGovern B ,et al . Out-of-hospital cardiac arrest. Use of electrophysiologic testing in the prediction of long-term outcome. N Engl J Med. 1988;318:19-24. [PMID: 3336381] CrossrefMedlineGoogle Scholar - 41.
Powell AC ,Fuchs T ,Finkelstein DM ,Garan H ,Cannom DS ,McGovern BA ,et al . Influence of implantable cardioverter-defibrillators on the long-term prognosis of survivors of out-of-hospital cardiac arrest. Circulation. 1993;88:1083-92. [PMID: 8353870] CrossrefMedlineGoogle Scholar - 42.
Cohn JN ,Johnson G . Heart failure with normal ejection fraction. The V-HeFT Study. Veterans Administration Cooperative Study Group. Circulation. 1990;81:III48-53. [PMID: 2404638] MedlineGoogle Scholar - 43.
Setaro JF ,Soufer R ,Remetz MS ,Perlmutter RA ,Zaret BL . Long-term outcome in patients with congestive heart failure and intact systolic left ventricular performance. Am J Cardiol. 1992;69:1212-6. [PMID: 1575193] CrossrefMedlineGoogle Scholar - 44.
Opasich C ,Tavazzi L ,Lucci D ,Gorini M ,Albanese MC ,Cacciatore G ,et al . Comparison of one-year outcome in women versus men with chronic congestive heart failure. Am J Cardiol. 2000;86:353-7. [PMID: 10922453] CrossrefMedlineGoogle Scholar - 45.
Gandhi SK ,Powers JC ,Nomeir AM ,Fowle K ,Kitzman DW ,Rankin KM ,et al . The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med. 2001;344:17-22. [PMID: 11136955] CrossrefMedlineGoogle Scholar - 46.
Kramer K ,Kirkman P ,Kitzman D ,Little WC . Flash pulmonary edema: association with hypertension and reoccurrence despite coronary revascularization. Am Heart J. 2000;140:451-5. [PMID: 10966547] CrossrefMedlineGoogle Scholar - 47.
Mosterd A ,Hoes AW ,de Bruyne MC ,Deckers JW ,Linker DT ,Hofman A ,et al . Prevalence of heart failure and left ventricular dysfunction in the general population; The Rotterdam Study. Eur Heart J. 1999;20:447-55. [PMID: 10213348] CrossrefMedlineGoogle Scholar - 48.
- 49.
- 50.
Pfeffer MA ,Braunwald E ,Moyé LA ,Basta L ,Brown EJ ,Cuddy TE ,et al . Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med. 1992;327:669-77. [PMID: 1386652] CrossrefMedlineGoogle Scholar - 51.
Cohn JN ,Archibald DG ,Ziesche S ,Franciosa JA ,Harston WE ,Tristani FE ,et al . Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med. 1986;314:1547-52. [PMID: 3520315] CrossrefMedlineGoogle Scholar - 52.
Cohn JN ,Johnson G ,Ziesche S ,Cobb F ,Francis G ,Tristani F ,et al . A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991;325:303-10. [PMID: 2057035] CrossrefMedlineGoogle Scholar - 53.
- 54.
Packer M ,Bristow MR ,Cohn JN ,Colucci WS ,Fowler MB ,Gilbert EM ,et al . The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med. 1996;334:1349-55. [PMID: 8614419] CrossrefMedlineGoogle Scholar
Author, Article, and Disclosure Information
From St. Francis Hospital, Roslyn, New York; Mayo Clinic, Rochester, Minnesota; Georgetown University Hospital, Washington, D.C.; University of Washington, Seattle, Washington; Wake Forest University, Winston-Salem, North Carolina; University of Vermont, Burlington, Vermont; Tufts–New England Medical Center, Boston, Massachusetts; St. John Hospital and Medical Center, Detroit, Michigan; University of Massachusetts Medical Center, Worcester, Massachusetts;
and National Heart, Lung, and Blood Institute, Bethesda, Maryland.
Grant Support: By the National Heart, Lung, and Blood Institute (contracts NO1-HC-85079-85086 and NO1-HC-15103).
Corresponding Author: John S. Gottdiener, MD, Cardiology Division, St. Francis Hospital, 100 Port Washington Boulevard, Roslyn, NY 11576-1353; e-mail, [email protected]
Current Author Addresses: Dr. Gottdiener: Cardiology Division, St. Francis Hospital, 100 Port Washington Boulevard, Roslyn, NY 11576-1353.
Dr. McClelland: Mayo Clinic, 200 First Street SW, Harwick 706, Rochester, MN 55905.
Dr. Marshall: Division of Cardiology, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007.
Dr. Shemanski: University of Washington, 201 Elliott Avenue West, Suite 400, Seattle, WA 98119.
Drs. Furberg and Kitzman: Department of Public Health, Wake Forest University, Bowman Gray School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157.
Dr. Cushman: University of Vermont, 208 South Park Drive, Suite 2, Colchester, VT 05446.
Dr. Polak: Department of Radiology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115.
Dr. Gardin: Division of Cardiology, St. John Hospital and Medical Center, 22191 Moross Road, PB 1, Suite 105, Detroit, MI 48226.
Dr. Gersh: Mayo Clinic, Division of Cardiology, 200 First Street SW, Rochester, MN 55905.
Dr. Aurigemma: Division of Cardiovascular Medicine, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655.
Dr. Manolio: Division of Epidemiology and Clinical Applications, National Institutes of Health, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, MSC 7934, Bethesda, MD 20892-7934.
Author Contributions: Conception and design: J.S. Gottdiener, R. Marshall, D.W. Kitzman, J.M. Gardin, B.J. Gersh, T.A. Manolio.
Analysis and interpretation of the data: J.S. Gottdiener, R.L. McClelland, R. Marshall, L. Shemanski, C.D. Furberg, D.W. Kitzman, M. Cushman, J.M. Gardin, B.J. Gersh.
Drafting of the article: J.S. Gottdiener, R. Marshall, D.W. Kitzman, J. Polak, J.M. Gardin, B.J. Gersh, G.P. Aurigemma.
Critical revision of the article for important intellectual content: J.S. Gottdiener, R. Marshall, C.D. Furberg, D.W. Kitzman, M. Cushman, J.M. Gardin, B.J. Gersh, G.P. Aurigemma, T.A. Manolio.
Final approval of the article: J.S. Gottdiener, C.D. Furberg, D.W. Kitzman, M. Cushman, J. Polak, B.J. Gersh, G.P. Aurigemma, T.A. Manolio.
Provision of study materials or patients: D.W. Kitzman.
Statistical expertise: R.L. McClelland, L. Shemanski.
Obtaining of funding: J.M. Gardin.
Administrative, technical, or logistic support: C.D. Furberg, M. Cushman.
Collection and assembly of data: J.S. Gottdiener, L. Shemanski, M. Cushman, J. Polak, J.M. Gardin.
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