Clinical investigations: congestive heart failure
Incident cases of heart failure in a community cohort: importance and outcomes of patients with preserved systolic function

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Abstract

Background

The clinical presentation and outcomes of patients with heart failure and preserved systolic function have not been well characterized in the outpatient setting.

Methods

This was a retrospective cohort study of 403 patients with new-onset heart failure in a large regional health maintenance organization between July 1996 and December 1996. The clinical characteristics and treatment of patients with preserved ejection fractions (PrEF; >45%) were compared with those of patients with with reduced left ventricular function (Low EF) after excluding patients with terminal comorbidities. The main outcome measure was the combination of death, cardiovascular (CV) hospitalization, or both, which was assessed for as long as 24 months (mean, 22 months) with proportional hazards models.

Results

Sixty-five patients (16%) did not have an assessment of left ventricular (LV) function. Of the remaining 338 patients, 191(57%) had an EF <45% (Low EF group) and 147 (44%) had preserved LV function (PrEF group). Patients with PrEF tended to be older, more frequently women, have less coronary disease and myocardial infarction, and have more atrial fibrillation and other comorbid conditions. They had higher systolic blood pressures and pulse pressures and slower heart rates than the patients with reduced LV function on initial presentation. Overall, mortality and CV hospitalization rates were similar in the 2 groups; however, on multivariate analysis, which took into account baseline differences between groups, low EF was a significant independent predictor of the combined end point (hazard ratio, 1.9; 95% CI, 1.3-2.9).

Conclusions

Patients with preserved LV function constitute a significant portion of incident outpatient patients with heart failure and carry a better prognosis than patients with reduced LV function.

Section snippets

Identification of study cohort

The cohort that provides the basis for this study was designed to evaluate the hypothesis that cardiology specialty care provided early in the course of heart failure has a favorable effect on the treatment and outcomes of outpatients with new-onset heart failure.10 This was a retrospectively identified cohort study of patients with new-onset heart failure in the outpatient setting in the Northern California Kaiser Permanente system between July 1996 and August 1997. The Kaiser program was

Baseline characteristics

A total of 403 patients were identified with the chart review. Sixty-five patients (16%) did not undergo an assessment of LV function. Of the remaining 338 patients, 191 (57%) had an EF <45% (Low EF group) and 147 (44%) had preserved LV function (PrEF group). The patients’ baseline characteristics are shown in Table I. The average EF in the Low EF group was 31% ± 8%, and in the PrEF group, it was 56% ± 11%. The PrEF group was older (69 ± 11 vs 66 ± 11 years, P = .0124) and included more women

Discussion

In this unique cohort of patients with new-onset heart failure in the outpatient setting, approximately half (44%) of the patients had preserved LV function. This proportion is quite similar to that in recent reports from hospitalized cohorts and epidemiological studies,4, 6, 12 which confirm the importance of this group regardless of the clinical setting and presentation.

Patients with preserved systolic function tended to be older, more frequently women, have less coronary disease and

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Supported by a grant-in-aid from the California Affiliate of the American Heart Association and by a Health Services Research and Development Grant from the Department of Veterans Affairs. Dr Ansari was a recipient of an ACC Merck Fellowship, an Associate Investigator Award from the Department of Veterans Affairs, and an NHRSA award from the National Heart Lung and Blood Institute.

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