Heart failure: severe heart failure, reduced ejection fraction, atrial fibrillation, stroke and diabetes increased the risk of death.

Clinical bottom line (level 2b)

  1. A quarter of patients with heart failure were dead within 3 years.
  2. Patients were at increased risk of dying if they had
    • NYHA class III or IV
    • reduced ejection fraction
    • previous stroke
    • atrial fibrillation
    • diabetes mellitus
Dries et al: Journal of the American College of Cardiology 1998; 32 (3): 695-703
Expires October 2003

The study

Retrospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: acute hospitals, USA

6517 patients (aged mean 60, ?% male) with ejection fraction = 35% (assessed by echocardiography, radionuclide ventriculography or angiography)

Excluded if
  • active angina requiring surgery
  • unstable angina or MI within previous month
  • renal failure (creatinine > 2.0 g/dl)
  • severe pulmonary disease



    • Factors studied:
  • medication used, severity of heart failure
  • NYHA class III or IV
  • ejection fraction per 10% decrease
  • prior stroke
  • atrial fibrillation
  • diabetes






    • 96% followed for mean 33 months
    Outcomes studied:
  • death

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    death mean 33 months 1538/6517 24%
    (23% to 25%)

    prognostic factor for
    death     		time to outcome control rate (%) adjusted OR
    (95% CI)    		 NNF+
    (95% CI)
    NYHA class III or IV 33 months 1538/6517
    (23.6%)     		1.74
    (1.53 to 1.97)     		9
    (7 to 12)
    ejection fraction per 10% decrease 33 months 1538/6517
    (23.6%)     		1.45
    (1.39 to 1.50)     		14
    (12 to 16)
    prior stroke 33 months 1538/6517
    (23.6%)     		1.43
    (1.20 to 1.71)     		14
    (9 to 29)
    atrial fibrillation 33 months 1538/6517
    (23.6%)     		1.34
    (1.12 to 1.62)     		18
    (10 to 44)
    diabetes 33 months 1538/6517
    (23.6%)     		1.34
    (1.19 to 1.51)     		18
    (12 to 30)

    Comments

    1. Patients were enrolled in a randomised controlled trial assessing the effect of ACE inhibitors on mortality.
    2. Beta-blocker, anticoagulant, antiplatelet and ACE inhibitor use was associated with reduced mortality. Diuretic and antiarrhythmic use was associated with an increase in mortality.
    3. This is a retrospective analysis of highly-selected patients making these results less certain.

    Citation

    1. Dries NL, Exner DV, Gersh BJ, et al: atrial fibrillation is associated with an increased risk of mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Journal of the American College of Cardiology 1998; 32 (3): 695-703
    Contributor: Chris Ball and Clare Wotton, October 1999
    Reviewer:

    Clinical Question.
    Patient heart failure
    Intervention or Exposure risk factors, clinical factors
    Outcome mortality