Heart failure: advanced age and moderate or severe functional class increased the risk of death within 5 years.

Clinical bottom line (level 2b)

  1. A third of patients who had congestive heart failure were alive at 5 years.
  2. Patients with heart failure were at increased risk of dying within 5 years if they were = 80 years old or had a New York Heart Association functional class III or IV.
  3. More than half of patients with congestive heart failure had an abnormal left ventricular systolic function.
  4. Patients were at increased risk of an abnormal left ventricular systolic function if they had a myocardial infarction.
  5. Patients were less likely to have an abnormal left ventricular systolic function if they were female.
Senni et al: Circulation 1998; 98: 2282-2289
Expires November 2003

The study

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

Setting: community, USA

216 patients (aged mean 77 years, 58% male) New diagnosis of congestive heart failure. Diagnosis was made using the Framingham criteria.

Excluded if
  • not resident in the community for at least a year before diagnosis



    • Factors studied:
  • long-term survival, abnormal left ventricular systolic function
  • advanced age = 80 years
  • moderate to severe New York Heart Association functional class class III or IV
  • female sex
  • age = 90 years
  • myocardial infarction


    • Patients were given standard therapy after diagnosis.

    A multivariate Cox proportional hazard regression analysis was used to adjust for confounding factors.

    100% followed for 5 years
    Outcomes studied:
  • mortality
  • abnormal left ventricular systolic function ejection fraction <50%

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    mortality 5 years 140/216 64.8%
    (58.4% to 71.2%)
    abnormal left ventricular systolic function 5 years 78/137 56.9%
    (% to %)

    prognostic factor for
    mortality     		time to outcome adjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    advanced age 5 years 1.04
    (1.02 to 1.06)     		51
    (34 to 103)
    moderate to severe New York Heart Association functional class 5 years 1.47
    (1.04 to 2.09)     		4
    (2 to 47)

    prognostic factor for
    abnormal left ventricular systolic function     		time to outcome control rate (%) adjusted OR
    (95% CI)    		 NNF+
    (95% CI)
    female sex 5 years 73/137
    (53.3%)     		0.29
    (0.10 to 0.56)     		-4
    (-2 to -7)
    age = 90 years 5 years 59/137
    (43.1%)     		0.24
    (0.06 to 1.03)     		-4
    (-3 to 138)
    myocardial infarction 5 years 42/137
    (30.7%)     		4.60
    (1.16 to 9.74)     		3
    (2 to 31)

    Comments

    1. The incidence of congestive heart failure may have been underestimated due to the insensitivity of the Framingham criteria in diagnosing early manifestations of the disease, some symptoms or signs of heart failure not being reported by physicians because they were considered synonymous with heart failure (and therefore, some patients being excluded due to an inability to fulfil diagnostic criteria based on the clinical record) or young patients not seeking medical attention.
    2. There is no clear evidence to suggest a link between age = 90 years and abnormal left ventricular systolic function.

    Citation

    1. Senni M, Tribouilloy CM, Rodeheffer RJ, et al: Congestive heart failure in the community: A study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation 1998; 98: 2282-2289
    Contributor: Clare Wotton and Musab Hayatli, November 1999
    Reviewer:

    Clinical Question.
    Patient congestive heart failure
    Intervention or Exposure prognostic factors
    Outcome survival