Skip Navigation

European Journal of Heart Failure 2004 6(5):653-661; doi:10.1016/j.ejheart.2003.11.007
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Raymond, I.
Right arrow Articles by Hildebrandt, P. R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Raymond, I.
Right arrow Articles by Hildebrandt, P. R.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© 2004 European Society of Cardiology

The prognosis of impaired left ventricular systolic function and heart failure in a middle-aged and elderly population in an urban population segment of Copenhagen

Ilan Raymonda,*, Jesper Mehlsenb, Frants Pedersena, Jeannett Dimsitsa, Jørgen Jacobsenc and Per Rossen Hildebrandt

a Department of Cardiology and Endocrinology, H:S Frederiksberg Hospital, University of Copenhagen Ndr. Fasanvej 57-59, DK-2000 Frederiksberg, Denmark
b Department of Clinical Physiology and Nuclear Medicine, H:S Frederiksberg Hospital University of Copenhagen, Denmark
c Private practice, Frederiksberg Denmark

* Corresponding author. Present address: University Hospital of Copenhagen Rigshospitalet, Department of Cardiology, Blegdamsvej 9, DK-2100 Ø Copenhagen, Denmark Tel.: +45-38164350; Fax: +45-38164359. E-mail address: ilan.raymond{at}dadlnet.dk


   Abstract
Top
 Abstract
1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 
Aims: To determine the prognosis, total mortality and cardiac morbidity, of patients with left ventricular systolic dysfunction and heart failure (HF) in a general population sample.

Methods and results: A total of 764 subjects, 432 females and 332 males, median age (range) 66 years (50–89), participated in this cross sectional survey. The study population was recruited from randomly selected general practitioners and stratified to include a minimum of 150 persons in each age decade stratum. Each participant filled in a heart failure questionnaire and ECG, blood tests and echocardiography were performed. Median (range) follow-up was 1145 (51–1197) days. Subjects with LVEF≤0.40 had a significantly higher all-cause mortality (27.8% vs. 5.6%, P<0.0001), admission rate for HF (25.0% vs. 1.9%, P<0.0001) and for other cardiac causes (25.0% vs. 6.3%, P<0.0001) than in subjects with LVEF>0.40. The age and gender adjusted 2-year relative risk of death was 4.6 (95% C.I.=1.6–13.2). No significant difference in mortality was found between subjects with or without heart failure symptoms.

Conclusion: Significantly higher mortality as well as cardiac morbidity was found in subjects with symptomatic and asymptomatic LV systolic dysfunction compared to those with normal systolic function. These conditions were among the strongest predictors of all-cause mortality and cardiac morbidity.

Key Words: Epidemiology • Prognosis • Systolic function • Heart failure • Echocardiography • Human

Received June 11, 2003; Revised September 19, 2003; Accepted November 19, 2003


   1. Introduction
Top
 Abstract
 1. Introduction
2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 
Despite advances in medical management, data from hospital-based studies and clinical trials show that the prognosis of heart failure (HF) and left ventricular (LV) systolic dysfunction remains poor. Few data on the prognosis of HF, based on echocardiography, and LV systolic dysfunction are available from the general population. The mortality rate of HF and LV systolic dysfunction is excessive whether regarded from the time of first signs and symptoms, from the first hospital admission or from the entry into a clinical trial and the prognosis is similar to many malignant diseases [1]. Poor prognosis has been found even for asymptomatic LV systolic dysfunction [2,3]. HF is one of the most common causes of morbidity and mortality among the middle-aged and elderly populations in Western society and it accounts for approximately four hospitalisations per year per 1000 inhabitants in Western countries [4,5]. Furthermore, the disease is associated with poor quality of life.

Most population studies, evaluating mortality and morbidity due to HF, rely on HF defined by clinical criteria, a few use echocardiography [2,6,7] and only one has examined the importance of asymptomatic LV dysfunction [8].

A high proportion (25–40%) of HF patients do not have marked LV systolic dysfunction [9] and are thus classified as having HF with preserved systolic function. Data on the prognosis of these patients are scarce and inconsistent, with annual mortality rates varying from 1.3–17.5% [9]. The variability in the prevalence as well as the prognosis is mainly a consequence of disagreement on the definition of HF with preserved systolic function and/or diastolic HF.

A precise classification is very important when analysing HF prognosis, especially with respect to whether the diagnosis is based on clinical criteria or objective evidence including measures of LV systolic function. Thus, the aim of the present study was primarily to evaluate the mortality and morbidity HF due to systolic dysfunction and LV systolic dysfunction in a large middle-aged and elderly population and secondarily to find risk factors with a possible impact on prognosis.


   2. Method
Top
 Abstract
 1. Introduction
 2. Method
3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 
A more thorough description of the methods and study population has been published in a previous paper [10].


   3. Study population
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 
Every Danish resident is registered with a GP, there is a fairly equal distribution of patients for each GP. The study population, aged 50–89 years, was recruited from randomly selected GP's situated in the same local area. The population was stratified into four age groups, with at least 150 subjects in each age decade. The only inclusion criterion was age between 50 and 89 years. Exclusion criteria were inability to co-operate in the examinations (e.g., due to dementia), permanent residency in a nursing home, or lack of response to two written invitations. An invitation to participate in the study was sent to all persons between the age of 50 and 89 years, registered with the first two GP practices (n=702). From the third practice, persons aged 60–89 years (n=308) and from the last practice only persons aged 80–89 years (n=78) were invited. A total of 1088 subjects were invited and 764 participated, corresponding to an overall response rate of 70.2%. In supplementary analyses, we found that the study population was comparable to the background population in terms of age and gender distribution but participants had a lower mortality and cardiac morbidity compared to the non-responders [10].

The study was conducted between September 1997 and February 2000. The study was performed according to the Helsinki-declaration and approved by the local ethics committee. All participants gave written informed consent.

3.1. Study design
The design of the study has been described in detail in a previous paper [10].

3.1.1. Questionnaire
At study entry, participants completed a heart failure questionnaire, which recorded: (a) known cardiac diseases and other major diseases with a high prevalence of cardiac complications (e.g., hypertension, diabetes, pulmonary disease); (b) hospital admissions for major cardiovascular disease or pulmonary embolism; (c) symptoms of HF including the degree of dyspnoea (modified WHO classification), ankle oedema, angina, and cough; and (d) medication.

Blood pressure and heart rate: blood pressure (BP) and heart rate were measured twice after at least 15 min rest in a sitting position, using an automatic device.

3.1.2. Laboratory analyses
Blood samples were collected for analysis of haematology, sodium, potassium, creatinine, random blood-glucose, plasma-glycosylated haemoglobin A1c (HbA1C). Fresh-voided urine samples were used for analysis of albumin/creatinine ratio.

3.1.3. Electrocardiogram
A 12 lead ECG was obtained using standard procedures and evaluated according to the Minnesota code [11]. The following abnormal findings were recorded: presence of pathological Q waves, left bundle-branch block (LBBB), significant ST segment abnormalities (ST elevation or depression >1 mm), T wave abnormalities (T wave inversion ≥3 mm in ≥2 contiguous leads or flattening of T waves in ≥2 contiguous leads), Left ventricular hypertrophy (LVH) (SV1+RV5/6>35 mm or RaVL+SV3>20 mm), atrial fibrillation/flutter, heart rate <50 or >100 bpm and the appearance of ≥3 premature ventricular beats (PVBs) per 10 s. Normal ECG was characterised by sinus rhythm without any of the pathological signs.

3.1.4. Echocardiography
A transthoracic echocardiographic examination was performed on each participant using standard protocols and state-of-the-art equipment (either HPTM Sonos 5500, AcusonTM 128/10c, or VingmedTM 750). Systolic function was evaluated twice, by the 16-segment and the 9-segment wall motion index score (WMI), and expressed as LV ejection fraction (LVEF), by multiplying the WMI score by 30 [12]. Normality was defined as a WMI value of 2.0. All echocardiograms were evaluated off-line in a blinded fashion by two experienced cardiologists. LVEF was determined as the average value of the two observers as previously described [10].

Mortality data were obtained from the Danish Central Personal Register, which registers all deaths in Denmark within 2 weeks. Data on admissions for HF and/or other major cardiovascular diseases were extracted from the National Registry of Patients based on discharge diagnosis classified according to the 10th revision of the International Classification of Disease (ICD-10) [13]. HF admissions were defined as primary discharge diagnosis ICD-10: I50, and other major cardiovascular diseases were defined as ICD-10: I10-I15; I20-I25; I34-I36; I42.1-2, 6-9; I46; I49.9.

3.1.5. Definition of heart failure
HF due to systolic dysfunction was defined using the ESC criteria [14] as a model: symptoms of HF (dyspnoea and/or ankle swelling) and objective evidence of LV systolic dysfunction (LVEF≤0.40).

3.1.6. Statistics
Variables potentially associated with 1-year and 2-year mortality rates in subjects with symptomatic and asymptomatic LV dysfunction were analysed by logistic regression analysis with backward elimination.

Kaplan–Meier curves on total mortality were computed to evaluate possible difference between subjects with (a) LV systolic dysfunction (b) LV systolic dysfunction with and without symptoms of HF, compared to subjects with LVEF>0.40 (log rank test). Potentially, independent prognostic factors for mortality, HF-admissions, and admissions for other major cardiovascular diseases were evaluated by the Cox proportional hazards analysis with backward stepwise elimination. All variables in the equations were tested for interaction by comparison of models with and without interaction parameters. All tests were two sided and P-values<0.05 were considered significant. All tests were computed using the SPSS-software (SPSS 9.0 Inc. Chicago, USA).


   4. Results
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 
A total of 764 subjects (432 females and 332 males) participated in the investigation and were stratified into four age decades (50–59 [n=239]; 60–69 [n=205]; 70–79 [n=191] and 80–89 years [n=129]). Echocardiograms were readable in 762 subjects and of these, 36 (11 females and 25 males) had a LVEF≤0.40. The inter-observer variation of WMI was 2.9% when expressed as a median percentage error, and the coefficient of variation was 4.9%. In a random sample of 198 echocardiograms, 22 (11.1%) had a low quality and in these the inter-observer coefficient of variation was 6.8%.

The main demographics of the study population are shown in Table 1. All subjects were followed for a median period of 1145 days (range: 51–1197). In the follow up period, 61 deaths, 23 HF admissions and 55 admissions for other major cardiovascular (CV) disease were registered. Four subjects were lost to follow up.


View this table:
[in this window]
[in a new window]

  		Table 1 Basic demographics of the study population

 

   5. Survival rates
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 
In subjects with LV systolic dysfunction (LVEF≤0.40) the survival rate during the first and second year following the examination was 91.7%, and 76.5%, respectively, compared to 97.9% and 96.8%, respectively, in participants with LVEF>0.40. The relative risk of death in patients with LV systolic dysfunction was 2.1 (95% CI=0.5–8.5) and 4.6 (95% CI=1.6–13.2) in the first and second year when adjusted for age and gender.


   6. Mortality
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 
In the follow up period, all-cause mortality was significantly higher in subjects with LVEF≤0.40 compared to subjects with LVEF>0.40 (27.8% vs. 5.6%, P<0.0001). A Kaplan–Meier plot (Fig. 1) of subjects with LVEF≤0.40 vs. subjects with LVEF>0.40 showed significant differences in cumulative survival (Log Rank 33.9, P<0.00001).


Figure 1
View larger version (6K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Fig. 1 Kaplan–Meier Plot of cumulative survival of subjects with LVEF≤0.40 (----) vs. subjects with LVEF>0.40(____).

 
Two different models of Cox proportional hazards analysis were used to evaluate potential independent prognostic factors for total mortality. The first model included 762 subjects, while the second model only included the 634 participants in whom all data were available.

In the first model, analysis of self-reported medical history was performed. LV systolic dysfunction, male gender, age and admission for ankle oedema were independent risk factors with regard to total mortality (Table 2).


View this table:
[in this window]
[in a new window]

  		Table 2 Cox proportional hazards analysis of mortality: Self-reported medical history, cardiovascular symptoms and systolic dysfunction were factors analysed in the model

 
Table 3 shows the second model, this only included patients with a full set of data, which allowed us to reach a definite diagnosis of cardiovascular and related diseases (see Appendix A). These diagnoses were included in the analysis, as were BP, ECG and blood tests. Independent risk factors for total mortality were male gender, abnormal ECG, age and heart rate. The variables of the two models are shown in Tables 2 and 3.


View this table:
[in this window]
[in a new window]

  		Table 3 Cox proportional hazards analysis of mortality: Cardiovascular and related diseases, blood pressure, ECG and blood tests were factors analysed in the model

 
The increased mortality was found in participants with depressed LV function regardless of symptoms (Fig. 2). In a Cox proportional hazards analysis of subjects with systolic dysfunction, comprising age and gender, no significant difference in total mortality (P=0.4) was found between those with and without symptoms, and both symptomatic and asymptomatic systolic dysfunction were risk factors for total mortality (hazard ratios: 3.1, P=0.01 and 5.2, P=0.002, respectively) independent of age and gender. A similar result for LVEF≤0.45 was found (HR: 2.4, P=0.04 and 3.4, P=0.02), with no significant difference between groups (P=0.4).


Figure 2
View larger version (5K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Fig. 2 Kaplan–Meier Plot of cumulative survival of subjects with symptomatic (----), asymptomatic(__ __ __) LV systolic dysfunction (LVEF≤0.40) vs. subjects with LVEF>0.40(___).

 
Mortality increased with decreasing LVEF (HR: 1.1 per unit, P=0.05) in subjects with systolic dysfunction independent of age and gender.


   7. Admission for HF and other CV diseases
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
8. Discussion
 9. Conclusion
 Appendix A
 References
 
The first year admission rate for HF was 16.7% in subjects with LV systolic dysfunction compared to 0.7% in participants with normal LV systolic function (P<0.0001) and the readmission rate for HF was 5.6% vs. 0.3% (P<0.0001). Systolic dysfunction was an independent predictor for first admission for HF irrespective of age and gender (OR=14.9, 95% CI=4.0–55.0).

Admission rates for other major CV diseases during the first year were 19.4% for subjects with LV systolic dysfunction compared to 2.6% in participants with normal systolic function (P<0.0001), and the first year readmission rate was 13.9% vs. 0.7% (P<0.0001). Systolic dysfunction was an independent predictor of admission for other major cardiovascular diseases irrespective of age and gender (OR=6.6, 95% CI=2.5–17.6).

In the follow up period, first HF admissions (25.0% vs. 1.9%, P<0.0001), and first admissions for other cardiovascular causes (25.0% vs. 6.3%, P<0.0001) were significantly higher in subjects with LVEF≤0.40 compared to subjects with LVEF>0.40.

Table 4 shows potential risk factors for admissions for HF and other CV diseases using the two reported models of Cox proportional hazards analysis.


View this table:
[in this window]
[in a new window]

  		Table 4 Cox proportional hazards analysis of cardiac morbidity: Model 1 evaluated self-reported medical history, cardiovascular symptoms and systolic dysfunction. Model 2 evaluated cardiovascular and related diseases, blood pressure, ECG and blood tests.

 

   8. Discussion
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
9. Conclusion
 Appendix A
 References
 
The main purpose of the present study was to shed light on mortality and cardiac morbidity associated with asymptomatic LV systolic dysfunction and HF due to systolic dysfunction in the general population. In a large, randomly recruited elderly urban population, we found that the age- and gender-adjusted 1-year risk of death was more than doubled and that the 2-year mortality risk was quadrupled, in those who had systolic dysfunction with and without HF symptoms, compared to those with normal or nearly normal systolic function. Intriguingly, we did not find any significant difference in total mortality when comparing patients with systolic dysfunction with or without accompanying symptoms. Both conditions predicted total mortality independently of age and gender.

The results of our study are in accordance with several previous population based studies [7,15], although both higher [8,16] and lower [2,17] mortality rates have been reported. These differences can be explained by the differences in the structure of the study populations; primarily age and gender, and the strictness of the criteria used to diagnose heart failure. The Rotterdam study [7] and the US-based Cardiovascular Health Study [15]examined populations aged 55–95 years and 65–101 years respectively, and found similar 1-year mortality rates; 11% in the HF population, 12% and 11% per year for HF and abnormal LV function, respectively, compared to 8% in our study. Although participants were younger in our population, there was a higher participation among septuagenarians and octogenarians due to the sampling procedure, which ensured a population, which was comparable to the general population with regard to age and gender [10]. In the Rotterdam study the 2-year mortality rate for the HF population was 21%, compared to 23% among those with systolic dysfunction in our study. However, the age-adjusted risk of death was considerably higher in our study, 4.6 for subjects with LV systolic dysfunction, as opposed to a two-fold in both these above mentioned studies, irrespective of whether it was patients with HF based on clinical criteria [7,15] or LV systolic dysfunction [15]. This might be due to differences in the criteria for heart failure and systolic dysfunction used in the studies.

Lower mortality rates were found in the Swedish study of men born in 1913, which included the mildest stages of HF [18] and showed a 5-year mortality of 26% in men with manifest HF diagnosed by clinical criteria, [17] and in the younger population (25–75 years) examined by McDonagh and co-workers that found a 4-year all-cause mortality of 21% in subjects with systolic dysfunction [2]. Higher rates were reported in the Helsinki Ageing Study, [8] in subjects aged 75, 80 and 85 years. Four-year mortality was 57% and 46%, respectively for HF and systolic dysfunction, which could be translated into an age- and gender-adjusted 4-year mortality risk of 2.1 for HF patients.

Highest mortality was reported in the Framingham Heart Study; with a six-fold age corrected risk of death (age range: 6–70 years at first examination) compared to the normal population. One-year mortality after the onset of HF was 43% in men and 36% in women. One-year mortality excluding subjects with recent HF onset was 21% and 12%, respectively [16]. These results reflect a cohort followed for 40 years, which consequently includes patients with the most severe stages of the disease compared to a cross-sectional study, where the weakest patients especially among the elderly tend to be among non-responders [10]. Furthermore due to the strictness of the HF criteria in the Framingham Study, the mildest stages of HF were excluded.

Studies of HF patients who had consulted a doctor or were admitted to a hospital [19] showed a 1-year mortality of 34%, new incidence cases of HF had a 1-year mortality rate of 38% [20]. The highest mortality rates are registered for patients admitted for acute HF and for those with new onset of HF, in which the mortality within the first 3 months has been found to be as high as 15–25% [19,20]. In intervention studies 1-year mortality has been reported to be between 5–10% (NYHA II-III) [21,22] and 15–20% (NYHA III-IV) [23,24]. Patients in these studies were highly selected with less co-morbidity, younger age and predominantly male gender, compared to HF patients in the community.

We were unable to show any differences in survival between patients with or without symptoms from their systolic dysfunction. Even though the statistical power was rather limited, it was in accordance with some previous studies [3,25]. In other randomised control trials, mortality rates for patients with asymptomatic LV systolic dysfunction were reported to be intermediate between those of persons with previous myocardial infarction and preserved systolic function and those of patients with HF due to systolic dysfunction [26]. This discrepancy may be explained by the considerable differences between the study populations in a general population study and in the large intervention studies. One main difference is the number of heart failure patients and patients with LV systolic dysfunction. In the first case, the number will usually be limited while in the latter this is rarely the case.

The results of the aforementioned studies showed no substantial differences in mortality rates with respect to whether HF was diagnosed by clinical criteria or by criteria including both symptoms and objective findings according to the ESC-criteria.

We evaluated the possible risk factors of total mortality, HF admissions and admissions for other major cardiac diseases in the study population.

In the first model, significant independent predictors of total mortality were LV systolic dysfunction and prior admission for ankle oedema. In the second model, abnormal ECG overruled LV systolic dysfunction as an independent predictor of total mortality, and a high heart rate was found to be an additional predictor of total mortality. Age and gender were independent risk factors in both models. Unexpectedly, neither ischaemic heart disease, nor diabetes mellitus or chronic obstructive pulmonary diseases were found to be independent risk factors of total mortality in our population.

It was somewhat surprising that abnormal ECG was a stronger predictor of mortality than LV systolic dysfunction, though there is a very strong association between the two conditions. In this study, we found that 93% of the individuals with LV systolic dysfunction had an abnormal ECG, [27] which was in line with the study of Nielsen and associates [28]. In addition subjects with an abnormal ECG and preserved LV systolic dysfunction may suffer from various conditions with a poor outcome: prior myocardial infarction; Q-waves, and ST-alterations, prolonged QRS-duration. Uncomplicated ventricular conduction blocks have recently been reported to be associated with increased risk of developing cardiovascular morbidity, [29] and were very often associated with coronary artery disease without prior myocardial infarction. Arrhythmias are very often due to underlying cardiac disease.

Age and male gender have been shown to be independent risk factors of total mortality in many previous studies. ECG abnormalities either as major abnormality, [15] T wave abnormalities [7] or signs of LVH [16] were risk factors in several previous studies. Two studies [2,8] found that ischaemic heart disease was an additional risk factor, whereas three other previous studies [7,15,16] were unable to demonstrate this, as in the present report. Other inconsistent risk factors of total mortality in previous studies were heart valve disease, impaired renal function, diabetes mellitus, atrial fibrillation and reduced pulmonary function. The differences in risk factors may be explained by differences in population sizes, age groups, time of follow-up, variables in the models and geographical locations.

LV systolic dysfunction was not only an important independent risk factor for HF admissions but also for other major cardiovascular admissions. In addition, ischaemic heart disease, diabetes, elevated urine-albumin and elevated plasma-creatinine were independent risk factors for hospital admissions due to cardiovascular diseases including HF. These factors are known to be associated with the prognosis of HF [7,20].

There was a considerable difference in hazard ratios between the two models, which is explained by the impact of a history of admissions for pulmonary congestion in the first model, not surprisingly a very strong predictor of HF admissions.

Dyspnoea was not found to be an independent explanatory factor for HF admissions. Dyspnoea was highly associated with HF due to systolic dysfunction and prior admissions for pulmonary congestion, both strong predictors of HF admissions. We cannot give any obvious reason why dyspnoea was a (weak) significant predictor of other major cardiac admissions. As for COPD this may play a role in worsening the symptoms of HF and consequently lead to more HF admissions or alternatively be misinterpreted as HF.

Intriguingly, combining the fact that history of admissions for pulmonary congestion was a very strong predictor of HF admissions with the fact that self-reported ankle oedema was a strong predictor of total mortality, both independently of systolic dysfunction, suggesting that HF with preserved systolic function (or mild impairment of LV systolic dysfunction) plays an important role in mortality and cardiac morbidity of the study population. Misreading of the WMI cannot be excluded as an alternative explanation, although the inter-observer variability in the echocardiographic readings was low.

These findings are in line with the reports from the Framingham Heart Study [30] showing that patients with clinical HF and preserved LV function had a slightly higher mortality than healthy controls. In a study from Olmsted County, Minnesota, Redfield et al. found even poorer outcome for HF patients with preserved LV systolic function [7].

A significantly higher mortality for patients with mild systolic dysfunction and a progressive increase in mortality with a decreases in LV ejection fraction clearly demonstrates the complexity in choosing cut-off values for LV systolic dysfunction and thus for the initiation of treatment in HF.


   9. Conclusion
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
Appendix A
 References
 
Our data strongly supports previous reports showing that patients suffering from systolic dysfunction and systolic heart failure have a poor prognosis with an overall mortality rate two to four times higher than in the general population. As expected, we found that these individuals had an even higher risk of admission due to heart failure and had a very strong risk for admission for any major cardiac disease.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
References
 

Dyspnoea: Grade 0–1=no dyspnoea or shortness of breath during considerable physical activity (running, climbing stairs more than second floor etc.), grade 2=during vacuum-cleaning/climbing stairs to the 2nd floor; grade 3=when walking on an even road; grade 4=at minimal exertion; grade 5=orthopnoea; grade 6=at rest.
Definitions of IHD:
Definite IHD was (1) a discharge diagnosis of myocardial infarction (MI) or (2) self-reported MI and the following ECG changes: Q waves in two or more contiguous leads or T wave inversion ≥3 mm in two or more contiguous leads or left bundle branch block or (3) angina pectoris (AP) discharge diagnosis/coronary artery disease (CAD) discharge diagnosis/self-reported exertional chest pain and ST depressions ≥1 mm in two or more contiguous leads.

3 Definition of hypertension:
Definite hypertension was (1) self-reported hypertension and (a) systolic BP>140 mmHg or (b) diastolic BP>90 mmHg or (c) antihypertensive medication or (2) BP>140/90 mmHg on antihypertensive treatment or (3) BP>161 mmHg systolic or >112 mmHg diastolic.

4 Diabetes:
Definite diabetes was (a) self-reported diabetes and anti-diabetic treatment or (b) random blood glucose>11.1 mmol/l or (c) HgbA1c>7.5%.

5 Chronic obstructive pulmonary disease (COPD):
Definite COPD was self-reported COPD and (a) cough or (b) treatment for asthma (ATC code r03-).


   Acknowledgements
 
This study was supported by grants from Merck Sharpe and Dohme; F. Hoffmann-La Roche Ltd.; the Research Fund of the Copenhagen Hospital Corporation; Sophus Jacobsen and Astrid Jacobsen's Fund; Arvid Nilsson's Fund; Leo Pharmaceutical's Research Fund; Svend Hansen and Ina Hansen's Fund; Lykkefeldt's Fund; Ove Villiam Buhl Olesen and Edith Buhl's Memorial Fund; Elisabeth M Schlinsog's Fund. We thank Prof. Jan Aldershvile for contributing with continuous scientific input to the present work.


   References
Top
 Abstract
 1. Introduction
 2. Method
 3. Study population
 4. Results
 5. Survival rates
 6. Mortality
 7. Admission for HF...
 8. Discussion
 9. Conclusion
 Appendix A
 References
 

  1. Stewart S., MacIntyre K., Hole D.J., Capewell S., McMurray J.J. More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail (2001) 3(3):315–322.[Abstract/Free Full Text]
  2. McDonagh T.A., Cunningham A.D., Morrison C.E., McMurray J.J., Ford I., Morton J.J., et al. Left ventricular dysfunction, natriuretic peptides, and mortality in an urban population. Heart (2001) 86(1):21–26.[Abstract/Free Full Text]
  3. Kober L., Torp-Pedersen C., Ottesen M., Burchardt H., Korup E., Lyngborg K. Influence of age on the prognostic importance of left ventricular dysfunction and congestive heart failure on long-term survival after acute myocardial infarction. TRACE Study Group. Am J Cardiol. (1996) 78(2):158–162.[Web of Science][Medline]
  4. McMurray J.J., Stewart S. Epidemiology, aetiology, and prognosis of heart failure. Heart (May 2000) 83(5):596–602.[Free Full Text]
  5. Gillum R.F. Epidemiology of heart failure in the United States. Am Heart J (1993) 126:1042–1047.[CrossRef][Web of Science][Medline]
  6. Redfield M.M., Jacobsen S.J., Burnett J.C. Jr, Mahoney D.W., Bailey K.R., Rodeheffer R.J. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. J Am Med Assoc (2003) 8(289(2)):194–202.
  7. Mosterd A., Cost B., Hoes A.W., de Bruijne M.C., Deckers J.W., Hofman A., et al. The prognosis of heart failure in the general population: the Rotterdam Study. Eur.Heart J (2001) 22(15):1318–1327.
  8. Kupari M., Lindroos M., Iivanainen A.M., Heikkila J., Tilvis R. Congestive heart failure in old age: prevalence, mechanisms and 4-year prognosis in the Helsinki Ageing Study. J Intern Med (1997) 241(5):387–394.[CrossRef][Web of Science][Medline]
  9. Vasan R.S., Benjamin E.J., Levy D. Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol (1995) 26(7):1565–1574.[Abstract]
  10. Raymond I., Green A., Busch-Sorensen M., Hildebrandt P.R. The Frederiksberg Heart Failure Study: rationale, design and methodology, with special emphasis on the sampling procedure for the study population and its comparison to the background population. Heart Drug (2002) 2:160.
  11. Rose G.A. Blackburn H. Gillum RF, Prineas R.J. Cardiovascular survey methods. 2nd. WHO Geneva Monography series 56, 1982.
  12. Berning J., Rokkedal N.J., Launbjerg J., Fogh J., Mickley H., Andersen P.E. Rapid estimation of left ventricular ejection fraction in acute myocardial infarction by echocardiographic wall motion analysis. Cardiology (1992) 80(3–4):257–266.[Web of Science][Medline]
  13. International statistical classification of disease and related health problems, 10th revision. 1992. Geneva: WHO.
  14. Remme W.J., Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J (2001) 22(17):1527–1560.[Free Full Text]
  15. Fried L.P., Kronmal R.A., Newman A.B., Bild D.E., Mittelmark M.B., Polak J.F., et al. Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. J Am Med Assoc (1998) 279(8):585–592.[Abstract/Free Full Text]
  16. Ho K.K., Anderson K.M., Kannel W.B., Grossman W., Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation (1993) 88(1):107–115.[Abstract/Free Full Text]
  17. Eriksson H., Wilhelmsen L., Caidahl K., Svardsudd K. Epidemiology and prognosis of heart failure. Z Kardiol (1991) 80(Suppl_8):1–6.[Web of Science][Medline]
  18. Eriksson H., Svardsudd K., Caidahl K., Bjuro T., Larsson B., Welin L., et al. Early heart failure in the population. The study of men born in 1913. Acta Med Scand (1988) 223(3):197–209.[Web of Science][Medline]
  19. Senni M., Tribouilloy C.M., Rodeheffer R.J., Jacobsen S.J., Evans J.M., Bailey K.R., et al. Congestive heart failure in the community: trends in incidence and survival in a 10-year period. Arch Intern Med (1999) 159(1):29–34.[Abstract/Free Full Text]
  20. Cowie M.R., Wood D.A., Coats A.J., Thompson S.G., Suresh V., Poole-Wilson P.A., et al. Survival of patients with a new diagnosis of heart failure: a population based study. Heart (May 2000) 83(5):505–510.[Abstract/Free Full Text]
  21. Goldstein S. Clinical studies on beta blockers and heart failure preceding the MERIT- HF Trial. Metoprolol CR/XL Randomized Intervention Trial in Heart Failure. Am J Cardiol (1997) 80(9B):50J–53J.[CrossRef][Medline]
  22. Packer M., Bristow M.R., Cohn J.N., Colucci W.S., Fowler M.B., Gilbert E.M., et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. US Carvedilol Heart Failure Study Group. N Engl J Med (1996) 334(21):1349–1355.[Abstract/Free Full Text]
  23. Pitt D. ACE inhibitor co-therapy in patients with heart failure: rationale for the Randomized Aldactone Evaluation Study (RALES). Eur Heart J (1995) 16(Suppl N):107–110.[Abstract/Free Full Text]
  24. Cohn J.N., Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med (2001) 345(23):1667–1675.[Abstract/Free Full Text]
  25. Kober L., Torp-Pedersen C., Jorgensen S., Eliasen P., Camm A.J. Changes in absolute and relative importance in the prognostic value of left ventricular systolic function and congestive heart failure after acute myocardial infarction. TRACE Study Group. Trandolapril Cardiac Evaluation. Am J Cardiol (1998) 81(11):1292–1297.[CrossRef][Web of Science][Medline]
  26. Wang TJ, Levy D, Benjamin EJ, Vasan RS The epidemiology of ‘asymptomatic’ left ventricular systolic dysfunction: implications for screening. Ann. Intern. Med 6 A.D.;3(138(11)):907–916.
  27. Raymond I, Pedersen F, Steensgaard-Hansen F, Green A, Busch-Sorensen M, Tuxen C et al. The prevalence of impaired left ventricular systolic function and heart failure in a middle-aged and elderly urban population segment of Copenhagen. Heart 2003; in press.
  28. Nielsen O.W., Hilden J., Hansen J.F. Strong prognostic value of combining N-terminal atrial natriuretic peptide and ECG to predict death in heart patients from general practice. Heart (2001) 86(2):218–219.[Free Full Text]
  29. Miller W.L., Hodge D.O., Hammill. Electrocardiographic features of uncomplicated ventricular conduction blocks predict long term risk of cardiovascular morbidity. Eur Heart J (2002) 24(Suppl):146. (Abstract).
  30. Vasan R.S., Larson M.G., Benjamin E.J., Evans J.C., Reiss C.K., 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(7):1948–1955.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Eur Heart JHome page
G. A. Whalley, S. P. Wright, A. Pearl, G. D. Gamble, H. J. Walsh, M. Richards, and R. N. Doughty
Prognostic role of echocardiography and brain natriuretic peptide in symptomatic breathless patients in the community
Eur. Heart J., February 2, 2008; 29(4): 509 - 516.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
D. S. Owens and J. F. Plehn
Recognizing Unrecognized Risk: The Evolving Role of Ventricular Functional Assessment in Population-Based Studies
Circulation, July 10, 2007; 116(2): 126 - 130.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Raymond, I.
Right arrow Articles by Hildebrandt, P. R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Raymond, I.
Right arrow Articles by Hildebrandt, P. R.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?