Gender, age, and heart failure with preserved left ventricular systolic function

having preclinical diastolic or systolic dysfunction. The prevalence of validated CHF was 2.2% (95% confidence interval [CI], 1.6 –2.8%) with 44% having an EF higher than 50%. Overall, 20.8% (95% CI, 19.0 –22.7%) of the population had mild diastolic dysfunction, 6.6% (95% CI, 5.5–7.8%) had moderate diastolic dysfunction and 0.7% (95% CI, 0.3–1.1%) had severe diastolic dysfunction with 5.6% (95% CI, 4.5– 6.7%) of the population having moderate or severe diastolic dysfunction with normal EF. The prevalence of any systolic dysfunction (EF 50%) was 6.0% (95% CI, 5.0 –7.1%) with moderate or severe systolic dysfunction (EF 40%) being present in 2.0% (95% CI, 1.4 – 2.5%). CHF was much more common among those with systolic or diastolic dysfunction than in those with normal ventricular function. However, even among those with moderate or severe diastolic or systolic dysfunction, less than half had recognized CHF. In multivariate analysis, controlling for age, sex and EF, mild diastolic dysfunction (hazard ratio, 8.31 [95% CI, 3.00 –23.1], p⬍0.001) and moderate or severe diastolic dysfunction (hazard ratio, 10.17 [95% CI, 3.28 –31.0], p⬍0.001) were predictive of all-cause mortality. Conclusions: In the community, systolic dysfunction is frequently present in individuals without recognized CHF. Furthermore, diastolic dysfunction as rigorously defined by comprehensive Doppler techniques is common, often not accompanied by recognized CHF and associated with marked increases in all-cause mortality. Perspective: The revelatory aspect of this study is the graded association of diastolic dysfunction with the risk of dying, even among patients without clinical evidence of heart failure at the time of the Doppler study. The high prevalence of diastolic filling abnormalities and the lack of uniform criteria for determining what constitutes pathological filling in the elderly has made many echocardiographers reluctant to include its assessment in the evaluation of such patients, unless they are known to have symptomatic heart failure. This study should lead to a rethinking of that practice and should spur further efforts to understand, prevent and treat preclinical and clinical diastolic dysfunction. As the racial demographics of Olmsted County (96% white) are hardly representative of the US, these findings may actually underestimate the burden of systolic and diastolic dysfunction in the wider population, for which hypertension and diabetes are more prevalent. KA

in patients with preserved left ventricular systolic function (LVSF)? Methods: The authors studied a cohort of patients derived from the National Heart Failure (NHF) Project, sponsored by the Centers for Medicare and Medicaid Services (CMS). This project includes a database containing clinical and demographic information on 37,500 fee-for-service Medicare beneficiaries hospitalized with the principal discharge diagnosis of heart failure (HF). Only patients aged 65 years or older were included in the analysis. Patients transferred to another acute care facility, leaving against medical advice or receiving chronic dialysis were excluded. Bivariate comparisons between the demographic and clinical variables and the presence of preserved LVSF. Multivariable logistic models to identify variables independently associated with preserved LVSF were then performed. Results: Of the 37,500 patients in the NHF cohort, 12,956 (66%) had impaired LVSF and 6754 (34%) had normal LVSF or a quantitative LVEF ⱖ0.50. Of the patients with documentation of LVSF, 43% of women and 23% of men had normal systolic function. Compared to patients with impaired LVSF, patients with preserved LVSF were older (79.7⫾7.6 vs. 78.2⫾7.4, p⬍0.001), more likely to be female (71% vs. 49%, p⬍0.001), less likely to have coronary disease (46% vs. 65%, p⬍0.001), more likely to have hypertension (69% vs. 61%, p⬍0.001), atrial fibrillation (36% vs. 30%, p⬍0.001) and aortic stenosis (11% vs. 8%, p⬍0.001). Patients with preserved LVSF were also more likely to have high admission blood pressure and less likely to have high heart rate, elevated creatinine or left bundlebranch block. The multivariable logistic model revealed that female gender (relative risk 1.71 [1.63–1.78]), age (ages 85– 89 —1.24) and race (African-American— 0.79) maintained strong associations with HF and preserved LVSF. Females were found to be the predominant gender in all subgroups of preserved LVSF based on age, race, coronary artery disease, atrial fibrillation, hypertension, aortic stenosis, diabetes, renal function and chronic obstructive lung disease. Conclusions: In this study of a large national cohort of older fee-for-service Medicare beneficiaries with HF, preserved LVSF represented approximately one third of the population and occurred more frequently in women. Even after adjustment for differences in age and a wide range of coexisting conditions, female gender remained highly correlated with preserved LVSF. HF in the setting of preserved LVSF, whether it be due to hypertension, aortic stenosis or atrial fibrillation, is more common in women. Perspective: Currently, most research in HF has focused on patients with impaired LVSF and largely has studied more men than women. This study shows that HF with preserved LVSF is predominantly a disease of women. Future efforts to understand the cause for HF with preserved LVSF in women are needed. Studies to identify treatments for and ways to prevent HF with preserved LVSF (particularly in women) are warranted. TK

Gender, Age, and Heart Failure with Preserved Left Ventricular Systolic Function Masoudi FA, Havranek EP, Smith G, et al. J Am Coll Cardiol 2003;41:217–23. Study Question: What are the relative contributions of gender, age and comorbidity to the prevalence of heart failure

ACC CURRENT JOURNAL REVIEW May/Jun 2003

51