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European Journal of Heart Failure 2003 5(1):41-45; doi:10.1016/S1388-9842(02)00175-7
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© 2002 European Society of Cardiology

The frequency of systolic versus diastolic heart failure in an Egyptian cohort

Bassem S. Ibrahim*

National Heart Institute Cairo, Egypt

* 127 Ramses Street, Ramses Square, Cairo, Egypt. Tel.: +20-2-2718835; fax: +20-2-2902412 E-mail address: bassemibrahim{at}hotmail.com


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Background: All factors predisposing for congestive heart failure (CHF), such as coronary artery disease (CAD), hypertension and diabetes are increasing in prevalence in Egypt. Despite this, no data about CHF in our country are available.

Aims: To study the relative contribution of systolic vs. diastolic heart failure in Egyptians and the prevalence of risk factors in this population, as well as their prognosis.

Methods: This was a retrospective study of patients with a diagnosis of CHF over a 3.5-year period in a general cardiology clinic. Demographic, ECG and echocardiographic data for left ventricular systolic and diastolic function were collected. The differential effect of systolic versus diastolic CHF was analyzed regarding hospitalization and mortality.

Results: After exclusion of valvular diseases, we found 155 patients diagnosed with heart failure, 102 patients (66%) had systolic heart failure, and 53 (34%) had diastolic heart failure. Mean age was 60±10 and 63±11 years, respectively (P=0.13). Systolic CHF patients had significantly more CAD, while those with diastolic failure were mostly hypertensives (P<0.01) for both. There was no significant difference in the incidence of diabetes mellitus, cerebrovascular accidents or atrial fibrillation between the two groups. Patients with systolic failure required more hospitalization, P<0.05, and had a mortality rate of 17.6% vs. 11.3% for patients with diastolic heart failure (P=0.3).

Conclusion: Diastolic heart failure is present in one-third of cases of CHF in Egyptians. Hypertension is very common in this group. These patients require less hospitalization but have a similar mortality rate.

Key Words: Heart failure • Systolic • Diastolic • Egypt

Received January 10, 2002; Revised June 14, 2002; Accepted June 20, 2002


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Congestive heart failure (CHF) is rapidly becoming a major public health problem worldwide [1]. The wide-spread use of echocardiography in the diagnosis of CHF has resulted in the emergence of the new entity of diastolic heart failure [2]. This entity is reported to include a significant proportion of patients with a clinical diagnosis of heart failure. There have been several studies from different parts of the world reporting on the epidemiology of CHF, the relative frequencies of systolic and diastolic heart failure, as well as the profile of risk factors contributing to the emergence of this epidemic in various regions of the world [3–6]. Egypt is experiencing a tidal rise in coronary artery disease (CAD), hypertension [7], and diabetes [8] as well as aging of the population. This is inevitably reflected in the prevalence of cardiovascular diseases in the community. According to official statistics cardiovascular disease accounted for 12.4% of all deaths in Egyptians in 1970, whereas in 1998 it was responsible for 47% of the nation's mortality [9]. However, there are no data published about heart failure in Egypt. We here report the relative frequency of systolic versus diastolic heart failure in a tertiary hospital, as well as the characteristic profile of Egyptian heart failure patients.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusion
 References
 
We conducted a retrospective search through all patient files in a general cardiology clinic. This is a weekly outpatient clinic (every Saturday) in the National Heart Institute (NHI), which is a tertiary referral center. Average attendance is 15–20 patients per clinic. New referrals who have chronic cardiac conditions, have regular follow-up arranged for them, while those who are deemed free of significant cardiac problem are discharged. Heart failure patients constitute approximately 10% of the clinic load. We studied the files of all patients with the diagnosis of CHF starting from June 2001 and going back until we had collected 200 consecutive cases. This encompassed a period of approximately 4 years. We excluded patients with significant valvular heart disease. We included all patients provided they had more than one visit to the OP clinic and had an echocardiographic report recorded in their files. The records of the patients were scrutinized for simple demographic data, e.g. age, gender, etc. All patients routinely had a detailed history, a thorough clinical examination, an ECG and a chest X-ray. Echocardiographic study of left ventricular function was performed in approximately 90% of cases within 1 week before or after making the diagnosis of heart failure. Echocardiographic data were obtained using standard 2.5–3.5 MHz transducers using either of two echocardiographs—the Hewlett Packard HP SONOS 2500 or 5500. Echocardiographic examination in the NHI entails routine left ventricular ejection fraction (LVEF) estimation by M-mode, two dimensional Simpson's method or both. Doppler indices of LV diastolic function were derived by the placement of the pulsed-wave Doppler sample volume between the leaflet tips of the mitral valve in the 4-chamber view. Mitral inflow interrogation allowed measurement of early diastolic filling (E wave), atrial contribution to LV filling (A wave), and the rapidity of pressure equalization between left ventricle and left atrium during early filling (deceleration time). The diastolic mitral flow pattern was classified into normal, abnormal relaxation pattern, pseudo-normalization, and restrictive pattern. In terms of processing our results, patients were analyzed according to one of two mitral flow patterns: (1) a restrictive pattern when E/A was >1 and deceleration time was <140 ms, and (2) a non-restrictive pattern when E/A<=1 or E/A was >1 and deceleration time was >=140 ms.

The diagnosis of CHF was made according to the Framingham criteria [10]. Major criteria were paroxysmal nocturnal dyspnoea, orthopnoea, raised jugular venous pulse, lung crepitations, cardiomegaly and gallop sounds. Minor criteria were ankle edema, night cough, dyspnoea on exertion, hepatomegaly, pleural effusion and tachycardia. The diagnosis of predominantly systolic heart failure required a minimum of two major criteria or one major plus two minor criteria and LVEF<50%. The diagnosis of predominantly diastolic heart failure required the following three conditions to be present simultaneously, i.e. (1) the aforementioned clinical criteria; (2) a LVEF equal to or more than 50%; (3) evidence of abnormal LV diastolic function as depicted by mitral inflow Doppler examination.

Risk factors for heart failure were sought. Hypertension was defined as the presence of systolic BP>140 mmHg and/or diastolic BP>90 mmHg on at least two occasions, or if the patient was receiving antihypertensive drug treatment. The diagnosis of diabetes mellitus was made if the patient was receiving insulin or an oral hypoglycemic agent. Smoking status was classified as current smoker, ex-smoker or life-long non-smoker. CAD was considered to be present and a cause for heart failure if there was evidence of a definite myocardial infarction from history, ECG or echocardiogram, or there was a long history of stable angina pectoris, or there was significant disease on coronary angiography. Valvular heart disease was considered to be a primary cause for heart failure if there was echocardiographic evidence of valvular disease of more than moderate severity. The patients’ medication was reviewed. Data about mortality were collected from hospital files or via telephone contact with the patient's relatives.

2.1. Statistical analysis
The results are expressed as percentages with mean±S.D. Comparisons between the heart failure groups in relation to age, sex, cardiovascular risk factors, and echocardiographic parameters were performed using {chi}2 unpaired t-tests. P values <0.05 were used to indicate differences between the groups that could not attributed to chance and was regarded as statistically significant, and P<0.01 as highly significant. All data analyses were performed with a commercially available statistical analysis software package (SPSS 10 for Windows, SPSS Inc., Chicago, Illinois).


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
Out of the 200 patients, there were 45 (22.5%) with significant valvular disease, mostly rheumatic, mitral and aortic valve diseases. About half of these had severe mitral stenosis, a quarter neglected severe aortic regurgitation and the rest combined valvular disease. They were excluded from further analysis. This left us with 155 patients. Of these, 102 (65.8%) had a LVEF less than 50% and the remaining 53 (34.2%) patients had a LVEF of 50% or more. Thus, two-thirds of the CHF population had systolic heart failure while one-third satisfied the criteria for diastolic heart failure.

3.1. Age and gender distribution
The mean age for the systolic CHF group was 60±10 years, while for diastolic CHF it was 63±11 years (P=0.13). In the diastolic CHF group there were 25 males out of the 53 patients (47.2%), while in systolic CHF males represented a significant majority; 78 out of 102 patients (76.5%); P<0.01. Of 103 males in the two heart failure groups, 76% had CHF with reduced LVEF. In contrast, the 52 women in the whole of the study with CHF, were more evenly distributed, 24 (46%) had systolic CHF and 28 (54%) had diastolic CHF. The women in the whole study group were slightly older than the men; 63.4±10 vs. 60.4±10 years, but this was not statistically significant (P=0.9) (Table 1).


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  		Table 1 Clinical characteristics of CHF patients

 
3.2. Risk factors for heart failure
Distribution of the three major risk factors among both groups of heart failure patients is shown in Fig. 1. Evidence of CAD or previous myocardial infarction was present in 72% of patients with systolic CHF, and the rest of this group was treated as heart failure of non-ischemic origin. In the diastolic CHF group evidence of coronary disease was present in only 25% of the patients (P<0.01). Systemic hypertension was present in 60% of the systolic CHF patients, while almost all patients (94%) with diastolic CHF had hypertension i.e. only 3 out of the 53 patients in this group were normotensives (P<0.01). Diabetes mellitus was present with equal frequency in both groups (35%). Current or past smoking was reported in 60% of systolic CHF patients and in 42% of patients with preserved LVEF. End-stage renal failure was present in 1 (1%) patient in the systolic CHF and 4 (8%) patients with diastolic failure (Table 1).


Figure 1
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  		Fig. 1 Distribution of risk factors in both groups of CHF. CAD, coronary artery disease; HT, hypertension; DM, diabetes mellitus.

 
Gender distribution of risk factors is shown in Fig. 2. CAD was diagnosed in 17 females (33%) and 65 males (63%), which was highly significant (P<0.01). Hypertension was more common in women 82% vs. 68% of males; this was only of borderline statistical significance (P=0.06). Fifteen females (29%) had diabetes mellitus in contrast with 38 (37%) of males (P=0.28). All those with current or past smoking status were males, 83 out of 103 (81%), none of the women had a history of smoking.


Figure 2
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  		Fig. 2 Gender distribution of risk factors. CAD, coronary artery disease; HT, hypertension; DM, diabetes mellitus.

 
3.3. ECG and echocardiographic features
Left ventricular hypertrophy criteria on ECG [11] were identified in 12% of patients with systolic CHF and in 34% of patients with diastolic CHF (P<0.05) (Table 1). Atrial fibrillation whether chronic or paroxysmal was detected in 15 (15%) patients with systolic CHF and in 3 (6%) patients with diastolic failure. This was not statistically significant.

Diastolic parameters on echocardiography showed that 89% patients with normal LVEF had either abnormal relaxation pattern or normal/pseudo-normalization pattern (non-restrictive). In contrast, the restrictive pattern was more common in the systolic LV failure group (45% vs. 11%; P<0.01). Regarding associated valvular disease of moderate severity this was present in 4 patients (8%) in the diastolic CHF group, one with aortic stenosis and 3 with mitral regurgitation. In the systolic CHF group there were 12 patients (12%), all lesions of regurgitant nature.

3.4. Prognosis
During follow-up, cerebrovascular accident or transient ischemic attacks developed in 10 patients (10%) with systolic CHF and in 8 patients (15%) suffering from diastolic CHF (not significant) (Table 1).

Patients were receiving standard therapy for heart failure. For example, in the systolic CHF group, diuretics were used in 99% of patients, ACE inhibitors in 93%, digoxin in 52% and beta-blockers in 37%. In the diastolic CHF group, diuretics were used in 92%, ACE inhibitors in 81%, calcium channel blockers in 51% and beta-blockers in 47%.

During the mean follow-up of 18.8 months the average hospitalization rate per patient in the systolic heart failure group was 1.01±1.38 (range 0–7), while in the diastolic CHF group the rate was 0.52±0.82 (range 0–3). This was statistically significant (P<0.05). During the same follow-up period, 18 patients (17.6%) with systolic heart failure died compared with 6 patients (11.3%) in the diastolic CHF group. However, this difference was not statistically significant (P=0.3).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
Egypt has undergone dramatic socio-economic changes in the second half of the 20th century, which has resulted from a great tide of urbanization and a rise in living standards. This is reflected by a rise in the average age for both men and women and a change in the pattern of diseases. While there is a decline in infectious and rheumatic heart disease prevalence there is an epidemic of CAD and its risk factors such as hypertension, diabetes and smoking. According to the National Hypertension Project (NHP) the estimated prevalence of hypertension in adult Egyptians is 26.3% [6]. Another study found the prevalence of diabetes in the population to be estimated at 9.3%, and this figure rises to 20% in high socio-economic sections in the cities [7]. Approximately 40% of adult males are smokers.

As a result, cardiovascular diseases have almost quadrupled in less than 3 decades [9]. No doubt heart failure is a frequent diagnosis. However, to date no data are available about heart failure in Egypt, nor of the relative contribution of systolic vs. diastolic CHF. This is the first report to study this disease pattern and the demographic and clinical characteristics of patients suffering from this syndrome.

We found that one-third of clinical CHF patients presenting to the NHI, have predominantly diastolic heart failure, while the other two-thirds have systolic CHF. Higher prevalence of diastolic heart failure is found in older populations [4,6]. But our figure of 34.2% is close to that in patients with similar age distribution [12–14]. The younger age of our patients may reflect the younger life expectancy in Egypt (62.8 years for men and 66.4 years for women) [9] compared to their counterparts in America and Western Europe. Beside age a higher percentage of our patients would have been classified as ‘predominantly diastolic heart failure’ if we had opted for a lower LVEF as recommended by the European Study Group on Diastolic Heart Failure [15]. With respect to sex distribution, women seem to suffer more from hypertension and less from coronary disease, and thus they were more represented in the diastolic heart failure group. Also, as women survive longer they approach the mean age where diastolic CHF predominates and thus their proportion tends to be higher in this heart failure entity.

Regarding risk factors for heart failure, the majority of patients (72%) with systolic CHF had evidence of CAD, while in diastolic CHF the picture is dominated by hypertension. The National Hypertension Project has demonstrated that rates of awareness, treatment and control among hypertensive individuals in Egypt to be relatively low [7]. These factors exacerbate the burden of hypertension and pave the way to heart failure. More than one-third in both groups of heart failure have diabetes mellitus. This is a much higher percentage than in studies conducted in Western Societies and is a reflection that Egypt has one of the highest national prevalences of diabetes in the world [8]. A notable feature in our CHF patients is the aggregation of risk factors, leaving only 10% of the study group with neither CAD, hypertension nor diabetes. Out of the three risk factors, hypertension stands out as the most common predisposing risk factor for CHF in Egypt. These results are in agreement with the Framingham study [16] and reports from Hong Kong [6].

Patients with predominantly systolic heart failure had a statistically higher hospitalization rate than those suffering from diastolic CHF. This is in agreement with the findings of other researchers [17]. Mortality rate was higher in our patients with reduced LV systolic function but this was not of statistical significance. Studies diverge regarding the natural history of CHF with preserved systolic function, while many report a better prognosis compared to systolic CHF [14,18]; others report a similar mortality rate [4,17]. At least two publications of patients in their sixties reach a similar conclusion [13,19]. Factors like age and perhaps the cut-off point of LVEF selected to separate both groups of heart failure, may explain the disagreement between the different studies.

This study is inherently limited by its retrospective nature. However, the completeness of data collected testifies to the accuracy of our results. The 155 study subjects contributed 243 patient years of observation. Every effort was made to confirm our findings, with phone calls to the patient or his/her relatives whenever necessary.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
In Egypt, one-third of patients with a clinical diagnosis of heart failure in a general cardiology clinic have predominantly diastolic heart failure. Hypertension is quite common in this group of patients, while CAD is more common in patients with systolic cardiac failure. Patients with systolic failure required more frequent hospitalization and had a non-significant higher mortality rate over the mid-term.


   Acknowledgements
 
We would like to thank Prof. Sherif A. Hady, Dean of the NHI for his invaluable support to our research and the heart failure patients.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 

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