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Congestive heart failure with preserved systolic function in patients hospitalized for congestive heart failure
66
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
244
245
Congestive Heart Failure with Preserved Systolic Function in Patients Hospitalized for Congestive Heart Failure S. Lepage, C. Therianlt; Centre universitaire de sante de I'Estrie, Sherbrooke, Quebec, Canada
Congestive Heart Failure - Prevalence and Mortality from the N H A N E S - I I United States Survey and Follow-Up Kshitij Sharma, Skai Schwartz, Douglas Schocken; University of South Florida, Tampa, FL
To evaluate the occurrence of congestive heart failure (CHF) in the setting of a preserved systolic function (PSF), we retrospectively evaluated over a 1-year period (04/94-05/95) all patients with a discharge summary of CHF in our hospital. These patients were followed for a mean period of I3 months. O f the 162 consecutive patients hospitalized for CHF, 119 underwent radionuclide angiogram during or within a 2-year period of their hospitalization. Preserved systolic function was defined as an ejection fraction -> to 40%. Using this criteria, 84 patients (70.6%) had systolic dysfunction (SD) and 35 patients (29.4%) had a preserved systolic function. These patients are compared in the following table:
Congestive heart failure (CHF) continues to be a major public health problem. Estimates of its prevalence are difficult to determine due to a general lack of population-based data. W e utilized the NHANES-II database to determine the prevalence and mortality of CHF in the non-institutionalized U.S. population.
Ejection fraction Number of patients Mean age Sex (ratio) Hospitalization (days)
-< 40
> 40
84 68-- 13 62 6 - 2 2 9 (2,8:1) 15
35 68-+ 13 11 d-24 9 (l:2,2) 18
After 13 months, rehospitalization occurred in 27 SD patients (32%) and 9 PSF patients (26%). Mortality was identical in both groups (25%). Conclusion: These data demonstrate that a significant proportion (29%) of patients hospitalized for CHF have preserved systolic function. This group is composed at 69% of female patients. Their evolution outside the hospital is very similar with a significant proportion of rehospitalization and mortality.
NHANES-II was a population-based survey conducted between 1976 and 1980. O f 20,322 evaluated individuals, 10450 had historical data, physical examination and laboratory data including chest X-ray collected. Based on self-report of a history of CHF, approximately 1.04% of the population between the ages of 25 and 75 or roughly 1,191,961 individuals were affected. Utilizing clinical criteria for CHF derived from a prior NHANES-I survey modified to include all relevant subjective and objective data from NHANES-II participants, 1.78% were diagnosed with CHF. As noted previously, the prevalence of CHF rises with age, affecting 2.48% of men and 2.65% of women aged 55-64 and 5.08% of men and 5.28% of women aged 65-75 based on clinical criteria. At follow-up in 1992 (12-16 yr. after initial NHANES-II evaluation), all-cause mortality for those affected by heart failure was 50% for those with self-reported CHF and 48% for those with clinical criteria for CHF, compared with 16% and 15% without these findings, respectively. In the oldest age-group, individuals aged 65-75 yr. with self-reported CHF had a 12-16 yr. mortality of 73 % compared to 45% for those not reporting CHF, while for those with and without CHF by clinical criteria, the mortalities were 58% and 45% respectively. The findings of this data analysis provide further evidence for the significant prevalence and mortality for CHF in the United States.
246
247
Undertreatmeut of Older Patients with Congestive Heart Failure Carla A. Sueta, Mark W. Massing, Ross J. Simpson, Jr; Medical Review of North Carolina, Raleigh, NC, Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
Thoracic Electrical Bioimpedance Measurement of Cardiac Performance is Highly Reproducible in Heart Failure Patients Barry H. Greenberg, Lucia V. Lazio, David Clontier, Denise D. Hernmnn; Cardiology, University of California, San Diego, San Diego, C A
Despite clinical trial data, prescription of ACE-Inhibitor therapy(rx) and titration to the recommended target dose is suboptimal in patients(pts) with congestive heart failure(CHF). Our hypothesis was that older age was associated with less aggressive therapy. Methods: We examined a Merck sponsored administrative data set containing chart audits on 20,371 US outpatients with CHF(ICD9 code 428 or chart documentation of CHF) from 296 US practices to determine the predictors of ACE-I utilization and titration to a recommended target dose. Recommended daily target doses included: captopril 150 rag, enalapril 20 mg, fosinopril 20 nag, Iisinopril 20 mg, ramipril 10 rag, and quinapril 40 rag. The sample analyzed included 17,073 patients > 21 yrs, whose last visit occurred between 1/97 and 4/98. Results: The mean age of the cohort was 72 -+ 0.1 yrs and 45% were women. Coronary artery disease was documented in 76% of pts. Documentation of left ventricular function was available in 73% of pts. Overall, 53% of pts received an ACE-Inhibitor, 70% with systolic dysfunction. Target dose was achieved in only 34% of patients overall. ACE-I Rx
Age > 65 yrs Male Systolic dysfunction Histm3, of coronary artet2¢ bypass grafting History of myocardial infarction History of diabetes History of hypertension South
OR 0.73 1.17 2.62 0.83 1.12 1.17 1.3 l 1.01
Target ACE-I 95%CI 0.67-0.80 1.08-1.26 2.42-2.83 0.76-0.90 [.03-1.21 1.08-1.28 1.22-i.42 0.92-1.11
OR 0.59 1.14 1.13 0.87 0.75 I.I9 1.83 0.84
95%CI 0.52-0.66 1.02-1.28 t.01-I.26 0.77-0.98 0.67-0.84 1.06-1.34 1.63-2.05 0.71-0.93
Conclusion: Our data suggests that age is an impoltant predictor of both ACE-Inhibitor rx and titration to target dose. Diagnostic testing is a predictor of ACE-Inhibitor prescription. A history of hypertension, diabetes, and male gender predict more aggressive therapy. CHF is the most common reason for hospitalization in patients --> 65 years. Interventions should be developed to focus on this target population.
Background: Since the clinical course of heart failure (HF) varies considerably, sequential assessment of cardiac performance over time would be of value in the management of HF patients. Consequently, we evaluated the reproducibility of non-invasive thoracic electrical bioimpedance (TEB) cardiac performance measurements in 62 stable patients with systolic dysfunction and N Y H A Class 11-111 symptoms. Methods: Heart rate (HR), blood pressure (BP), cardiac index (CI), and stroke volume index (SVI) were measured at rest 2,10, and 60 minutes (week 1), and after 2 and 10 minutes 1 week later (week 2). Results: At week 1, an average 2.8 bpm reduction in HR (p<0.001) between 2 to 60 minutes resulted in a reduction in CI from 2.82 to 2.66 l/min/mZ(p<0.001). SVI, however, remained essentially unchanged going from 37.0 ml/m a at 2 minutes to 36.2 ml/m 2 at 60 minutes (p = N S ) with a confidence interval extending from -0.04 to 1.8. A comparison of measurements at 2 minutes between week 1 and 2 is summarized below:
W E E K 1 (mean) W E E K 2 (mean) Difference 95% Confidence Interval p value
HR (bpm)
BP(mmHG)
79.1 77.4 1.7 -0.5 to 3.9 NS
85.9 86.0 -0.1 -2.1 to 1.8 NS
CI(I/min/m 2) SVI(ml/m 2) 2.8 2.7 0.1 0.002 to 0.2 p < 0.05
36.8 36.5 0.7 -1.0 to 2.4 NS
Conclusion: I) There is little variability in cardiac performance in stable HF patients over 1 week; 2) SVI is better suited than CI for following H F patients over time; and 3) TEB measurements are highly reproducible with small confidence intervals. TEB provides a rapid, inexpensive method for detecting changes in H F patients over time.
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
244
245
Congestive Heart Failure with Preserved Systolic Function in Patients Hospitalized for Congestive Heart Failure S. Lepage, C. Therianlt; Centre universitaire de sante de I'Estrie, Sherbrooke, Quebec, Canada
Congestive Heart Failure - Prevalence and Mortality from the N H A N E S - I I United States Survey and Follow-Up Kshitij Sharma, Skai Schwartz, Douglas Schocken; University of South Florida, Tampa, FL
To evaluate the occurrence of congestive heart failure (CHF) in the setting of a preserved systolic function (PSF), we retrospectively evaluated over a 1-year period (04/94-05/95) all patients with a discharge summary of CHF in our hospital. These patients were followed for a mean period of I3 months. O f the 162 consecutive patients hospitalized for CHF, 119 underwent radionuclide angiogram during or within a 2-year period of their hospitalization. Preserved systolic function was defined as an ejection fraction -> to 40%. Using this criteria, 84 patients (70.6%) had systolic dysfunction (SD) and 35 patients (29.4%) had a preserved systolic function. These patients are compared in the following table:
Congestive heart failure (CHF) continues to be a major public health problem. Estimates of its prevalence are difficult to determine due to a general lack of population-based data. W e utilized the NHANES-II database to determine the prevalence and mortality of CHF in the non-institutionalized U.S. population.
Ejection fraction Number of patients Mean age Sex (ratio) Hospitalization (days)
-< 40
> 40
84 68-- 13 62 6 - 2 2 9 (2,8:1) 15
35 68-+ 13 11 d-24 9 (l:2,2) 18
After 13 months, rehospitalization occurred in 27 SD patients (32%) and 9 PSF patients (26%). Mortality was identical in both groups (25%). Conclusion: These data demonstrate that a significant proportion (29%) of patients hospitalized for CHF have preserved systolic function. This group is composed at 69% of female patients. Their evolution outside the hospital is very similar with a significant proportion of rehospitalization and mortality.
NHANES-II was a population-based survey conducted between 1976 and 1980. O f 20,322 evaluated individuals, 10450 had historical data, physical examination and laboratory data including chest X-ray collected. Based on self-report of a history of CHF, approximately 1.04% of the population between the ages of 25 and 75 or roughly 1,191,961 individuals were affected. Utilizing clinical criteria for CHF derived from a prior NHANES-I survey modified to include all relevant subjective and objective data from NHANES-II participants, 1.78% were diagnosed with CHF. As noted previously, the prevalence of CHF rises with age, affecting 2.48% of men and 2.65% of women aged 55-64 and 5.08% of men and 5.28% of women aged 65-75 based on clinical criteria. At follow-up in 1992 (12-16 yr. after initial NHANES-II evaluation), all-cause mortality for those affected by heart failure was 50% for those with self-reported CHF and 48% for those with clinical criteria for CHF, compared with 16% and 15% without these findings, respectively. In the oldest age-group, individuals aged 65-75 yr. with self-reported CHF had a 12-16 yr. mortality of 73 % compared to 45% for those not reporting CHF, while for those with and without CHF by clinical criteria, the mortalities were 58% and 45% respectively. The findings of this data analysis provide further evidence for the significant prevalence and mortality for CHF in the United States.
246
247
Undertreatmeut of Older Patients with Congestive Heart Failure Carla A. Sueta, Mark W. Massing, Ross J. Simpson, Jr; Medical Review of North Carolina, Raleigh, NC, Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
Thoracic Electrical Bioimpedance Measurement of Cardiac Performance is Highly Reproducible in Heart Failure Patients Barry H. Greenberg, Lucia V. Lazio, David Clontier, Denise D. Hernmnn; Cardiology, University of California, San Diego, San Diego, C A
Despite clinical trial data, prescription of ACE-Inhibitor therapy(rx) and titration to the recommended target dose is suboptimal in patients(pts) with congestive heart failure(CHF). Our hypothesis was that older age was associated with less aggressive therapy. Methods: We examined a Merck sponsored administrative data set containing chart audits on 20,371 US outpatients with CHF(ICD9 code 428 or chart documentation of CHF) from 296 US practices to determine the predictors of ACE-I utilization and titration to a recommended target dose. Recommended daily target doses included: captopril 150 rag, enalapril 20 mg, fosinopril 20 nag, Iisinopril 20 mg, ramipril 10 rag, and quinapril 40 rag. The sample analyzed included 17,073 patients > 21 yrs, whose last visit occurred between 1/97 and 4/98. Results: The mean age of the cohort was 72 -+ 0.1 yrs and 45% were women. Coronary artery disease was documented in 76% of pts. Documentation of left ventricular function was available in 73% of pts. Overall, 53% of pts received an ACE-Inhibitor, 70% with systolic dysfunction. Target dose was achieved in only 34% of patients overall. ACE-I Rx
Age > 65 yrs Male Systolic dysfunction Histm3, of coronary artet2¢ bypass grafting History of myocardial infarction History of diabetes History of hypertension South
OR 0.73 1.17 2.62 0.83 1.12 1.17 1.3 l 1.01
Target ACE-I 95%CI 0.67-0.80 1.08-1.26 2.42-2.83 0.76-0.90 [.03-1.21 1.08-1.28 1.22-i.42 0.92-1.11
OR 0.59 1.14 1.13 0.87 0.75 I.I9 1.83 0.84
95%CI 0.52-0.66 1.02-1.28 t.01-I.26 0.77-0.98 0.67-0.84 1.06-1.34 1.63-2.05 0.71-0.93
Conclusion: Our data suggests that age is an impoltant predictor of both ACE-Inhibitor rx and titration to target dose. Diagnostic testing is a predictor of ACE-Inhibitor prescription. A history of hypertension, diabetes, and male gender predict more aggressive therapy. CHF is the most common reason for hospitalization in patients --> 65 years. Interventions should be developed to focus on this target population.
Background: Since the clinical course of heart failure (HF) varies considerably, sequential assessment of cardiac performance over time would be of value in the management of HF patients. Consequently, we evaluated the reproducibility of non-invasive thoracic electrical bioimpedance (TEB) cardiac performance measurements in 62 stable patients with systolic dysfunction and N Y H A Class 11-111 symptoms. Methods: Heart rate (HR), blood pressure (BP), cardiac index (CI), and stroke volume index (SVI) were measured at rest 2,10, and 60 minutes (week 1), and after 2 and 10 minutes 1 week later (week 2). Results: At week 1, an average 2.8 bpm reduction in HR (p<0.001) between 2 to 60 minutes resulted in a reduction in CI from 2.82 to 2.66 l/min/mZ(p<0.001). SVI, however, remained essentially unchanged going from 37.0 ml/m a at 2 minutes to 36.2 ml/m 2 at 60 minutes (p = N S ) with a confidence interval extending from -0.04 to 1.8. A comparison of measurements at 2 minutes between week 1 and 2 is summarized below:
W E E K 1 (mean) W E E K 2 (mean) Difference 95% Confidence Interval p value
HR (bpm)
BP(mmHG)
79.1 77.4 1.7 -0.5 to 3.9 NS
85.9 86.0 -0.1 -2.1 to 1.8 NS
CI(I/min/m 2) SVI(ml/m 2) 2.8 2.7 0.1 0.002 to 0.2 p < 0.05
36.8 36.5 0.7 -1.0 to 2.4 NS
Conclusion: I) There is little variability in cardiac performance in stable HF patients over 1 week; 2) SVI is better suited than CI for following H F patients over time; and 3) TEB measurements are highly reproducible with small confidence intervals. TEB provides a rapid, inexpensive method for detecting changes in H F patients over time.