Articles15 October 2002
    Author, Article, and Disclosure Information
    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 DDArrieta MILeaverton PERoss EAPrevalence and mortality rate of congestive heart failure in the United States. J Am Coll Cardiol1992;20:301-6. [PMID: 1634664] CrossrefMedlineGoogle Scholar
    • 2. Levy DLarson MGVasan RSKannel WBHo KKThe progression from hypertension to congestive heart failure. JAMA1996;275:1557-62. [PMID: 8622246] CrossrefMedlineGoogle Scholar
    • 3. Rich MWEpidemiology, pathophysiology, and etiology of congestive heart failure in older adults. J Am Geriatr Soc1997;45:968-74. [PMID: 9256850] CrossrefMedlineGoogle Scholar
    • 4. Braunwald EShattuck lecture—cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities. N Engl J Med1997;337:1360-9. [PMID: 9358131] CrossrefMedlineGoogle Scholar
    • 5. Vasan RSBenjamin EJLevy DPrevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol1995;26:1565-74. [PMID: 7594087] CrossrefMedlineGoogle Scholar
    • 6. Bonow ROUdelson JELeft ventricular diastolic dysfunction as a cause of congestive heart failure. Mechanisms and management. Ann Intern Med1992;117:502-10. [PMID: 1503353] LinkGoogle Scholar
    • 7. Kitzman DWHigginbotham MBCobb FRSheikh KHSullivan MJExercise intolerance in patients with heart failure and preserved left ventricular systolic function: failure of the Frank-Starling mechanism. J Am Coll Cardiol1991;17:1065-72. [PMID: 2007704] CrossrefMedlineGoogle Scholar
    • 8. Senni MRedfield MMCongestive heart failure in elderly patients. Mayo Clin Proc1997;72:453-60. [PMID: 9146689] CrossrefMedlineGoogle Scholar
    • 9. Kitzman DWSullivan MJExercise 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 ESobel BECoronary 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 JBraunwald EThe 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 JMArnold AGottdiener JSWong NDFried LPKlopfenstein HSet al Left ventricular mass in the elderly. The Cardiovascular Health Study. Hypertension1997;29:1095-103. [PMID: 9149672] CrossrefMedlineGoogle Scholar
    • 13. Wei JYAge and the cardiovascular system. N Engl J Med1992;327:1735-9. [PMID: 1304738] CrossrefMedlineGoogle Scholar
    • 14. Kitzman DWSheikh KHBeere PAPhilips JLHigginbotham MBAge-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 Cardiol1991;18:1243-50. [PMID: 1918701] CrossrefMedlineGoogle Scholar
    • 15. Ho KKAnderson KMKannel WBGrossman WLevy DSurvival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation1993;88:107-15. [PMID: 8319323] CrossrefMedlineGoogle Scholar
    • 16. Andersson BWaagstein FSpectrum and outcome of congestive heart failure in a hospitalized population. Am Heart J1993;126:632-40. [PMID: 8362719] CrossrefMedlineGoogle Scholar
    • 17. Carson PJohnson GFletcher RCohn JMild 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 Cardiol1996;27:642-9. [PMID: 8606276] CrossrefMedlineGoogle Scholar
    • 18. Gaasch WHDiagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction. JAMA1994;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 JNRector TSPrognosis of congestive heart failure and predictors of mortality. Am J Cardiol1988;62:25A-30A. [PMID: 3389302] CrossrefMedlineGoogle Scholar
    • 21. Pernenkil RVinson JMShah ASBeckham VWittenberg CRich MWCourse and prognosis in patients > or =70 years of age with congestive heart failure and normal versus abnormal left ventricular ejection fraction. Am J Cardiol1997;79:216-9. [PMID: 9193031] CrossrefMedlineGoogle Scholar
    • 22. Senni MTribouilloy CMRodeheffer RJJacobsen SJEvans JMBailey KRet al Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation1998;98:2282-9. [PMID: 9826315] CrossrefMedlineGoogle Scholar
    • 23. Vasan RSLarson MGBenjamin EJEvans JCReiss CKLevy DCongestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol1999;33:1948-55. [PMID: 10362198] CrossrefMedlineGoogle Scholar
    • 24. Fried LPBorhani NOEnright PFurberg CDGardin JMKronmal RAet al The Cardiovascular Health Study: design and rationale. Ann Epidemiol1991;1:263-76. [PMID: 1669507] CrossrefMedlineGoogle Scholar
    • 25. Mittelmark MBPsaty BMRautaharju PMFried LPBorhani NOTracy RPet al Prevalence of cardiovascular diseases among older adults. The Cardiovascular Health Study. Am J Epidemiol1993;137:311-7. [PMID: 8452139] CrossrefMedlineGoogle Scholar
    • 26. Psaty BMKuller LHBild DBurke GLKittner SJMittelmark Met al Methods of assessing prevalent cardiovascular disease in the Cardiovascular Health Study. Ann Epidemiol1995;5:270-7. [PMID: 8520708] CrossrefMedlineGoogle Scholar
    • 27. Ives DGFitzpatrick ALBild DEPsaty BMKuller LHCrowley PMet al Surveillance and ascertainment of cardiovascular events. The Cardiovascular Health Study. Ann Epidemiol1995;5:278-85. [PMID: 8520709] CrossrefMedlineGoogle Scholar
    • 28. Gardin JMWong NDBommer WKlopfenstein HSSmith VETabatznik Bet al Echocardiographic design of a multicenter investigation of free-living elderly subjects: the Cardiovascular Health Study. J Am Soc Echocardiogr1992;5:63-72. [PMID: 1739473] CrossrefMedlineGoogle Scholar
    • 29. Rautaharju PMManolio TASiscovick DZhou SHGardin JMKronmal Ret al Utility of new electrocardiographic models for left ventricular mass in older adults. The Cardiovascular Health Study Collaborative Research Group. Hypertension1996;28:8-15. [PMID: 8675268] CrossrefMedlineGoogle Scholar
    • 30. Gardin JMSiscovick DAnton-Culver HLynch JCSmith VEKlopfenstein HSet al Sex, age, and disease affect echocardiographic left ventricular mass and systolic function in the free-living elderly. The Cardiovascular Health Study. Circulation1995;91:1739-48. [PMID: 7882482] CrossrefMedlineGoogle Scholar
    • 31. Newman ABSiscovick DSManolio TAPolak JFried LPBorhani NOet al Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation1993;88:837-45. [PMID: 8353913] CrossrefMedlineGoogle Scholar
    • 32. Lilienfeld AMLilienfeld DEFoundations of Epidemiology. 2nd ed. New York: Oxford Univ Pr; 1980:217. Google Scholar
    • 33. Kalbfleisch JDPrentice RLThe Statistical Analysis of Failure Time Data. New York: J Wiley; 1980. Google Scholar
    • 34. Kitzman DWGardin JMGottdiener JSArnold ABoineau RAurigemma Get al Importance of heart failure with preserved systolic function in patients > or =65 years of age. CHS Research Group. Cardiovascular Health Study. Am J Cardiol2001;87:413-9. [PMID: 11179524] CrossrefMedlineGoogle Scholar
    • 35. Gottdiener JSArnold AMAurigemma GPPolak JFTracy RPKitzman DWet al Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study. J Am Coll Cardiol2000;35:1628-37. [PMID: 10807470] CrossrefMedlineGoogle Scholar
    • 36. Aurigemma GPGottdiener JSShemanski LGardin JKitzman DPredictive value of systolic and diastolic function for incident congestive heart failure in the elderly: the cardiovascular health study. J Am Coll Cardiol2001;37:1042-8. [PMID: 11263606] CrossrefMedlineGoogle Scholar
    • 37. Vasan RSLevy DDefining diastolic heart failure: a call for standardized diagnostic criteria. Circulation2000;101:2118-21. [PMID: 10790356] CrossrefMedlineGoogle Scholar
    • 38. Risk stratification and survival after myocardial infarction. N Engl J Med1983;309:331-6. [PMID: 6866068] CrossrefMedlineGoogle Scholar
    • 39. Kambara HNakagawa MKinoshita MKawai CLong-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 Cardiol1993;16:872-8. [PMID: 8168271] CrossrefMedlineGoogle Scholar
    • 40. Wilber DJGaran HFinkelstein DKelly ENewell JMcGovern Bet al Out-of-hospital cardiac arrest. Use of electrophysiologic testing in the prediction of long-term outcome. N Engl J Med1988;318:19-24. [PMID: 3336381] CrossrefMedlineGoogle Scholar
    • 41. Powell ACFuchs TFinkelstein DMGaran HCannom DSMcGovern BAet al Influence of implantable cardioverter-defibrillators on the long-term prognosis of survivors of out-of-hospital cardiac arrest. Circulation1993;88:1083-92. [PMID: 8353870] CrossrefMedlineGoogle Scholar
    • 42. Cohn JNJohnson GHeart failure with normal ejection fraction. The V-HeFT Study. Veterans Administration Cooperative Study Group. Circulation1990;81:III48-53. [PMID: 2404638] MedlineGoogle Scholar
    • 43. Setaro JFSoufer RRemetz MSPerlmutter RAZaret BLLong-term outcome in patients with congestive heart failure and intact systolic left ventricular performance. Am J Cardiol1992;69:1212-6. [PMID: 1575193] CrossrefMedlineGoogle Scholar
    • 44. Opasich CTavazzi LLucci DGorini MAlbanese MCCacciatore Get al Comparison of one-year outcome in women versus men with chronic congestive heart failure. Am J Cardiol2000;86:353-7. [PMID: 10922453] CrossrefMedlineGoogle Scholar
    • 45. Gandhi SKPowers JCNomeir AMFowle KKitzman DWRankin KMet al The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med2001;344:17-22. [PMID: 11136955] CrossrefMedlineGoogle Scholar
    • 46. Kramer KKirkman PKitzman DLittle WCFlash pulmonary edema: association with hypertension and reoccurrence despite coronary revascularization. Am Heart J2000;140:451-5. [PMID: 10966547] CrossrefMedlineGoogle Scholar
    • 47. Mosterd AHoes AWde Bruyne MCDeckers JWLinker DTHofman Aet al Prevalence of heart failure and left ventricular dysfunction in the general population; The Rotterdam Study. Eur Heart J1999;20:447-55. [PMID: 10213348] CrossrefMedlineGoogle Scholar
    • 48. Mortality from congestive heart failure—United States, 1980-1990. MMWR Morb Mortal Wkly Rep1994;43:77-81. [PMID: 8295629] MedlineGoogle Scholar
    • 49. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. N Engl J Med1987;316:1429-35. [PMID: 2883575] CrossrefMedlineGoogle Scholar
    • 50. Pfeffer MABraunwald EMoyé LABasta LBrown EJCuddy TEet 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 Med1992;327:669-77. [PMID: 1386652] CrossrefMedlineGoogle Scholar
    • 51. Cohn JNArchibald DGZiesche SFranciosa JAHarston WETristani FEet al Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med1986;314:1547-52. [PMID: 3520315] CrossrefMedlineGoogle Scholar
    • 52. Cohn JNJohnson GZiesche SCobb FFrancis GTristani Fet al A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med1991;325:303-10. [PMID: 2057035] CrossrefMedlineGoogle Scholar
    • 53. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med1991;325:293-302. [PMID: 2057034] CrossrefMedlineGoogle Scholar
    • 54. Packer MBristow MRCohn JNColucci WSFowler MBGilbert EMet 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 Med1996;334:1349-55. [PMID: 8614419] CrossrefMedlineGoogle Scholar