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J Am Coll Cardiol, 1999; 33:1948-1955
© 1999 by the American College of Cardiology Foundation
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CLINICAL STUDIES

Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction

Prevalence and mortality in a population-based cohort

Ramachandran S. Vasan, MD, FACC* §,1, Martin G. Larson, ScD* §, Emelia J. Benjamin, MD, ScM, FACC* {ddagger} §, Jane C. Evans, MPH* §, Craig K. Reiss, MD, FACC|| and Daniel Levy, MD, FACC* {dagger} §

* National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts, USA
{dagger} Division of Cardiology and Division of Clinical Epidemiology, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts, USA
{ddagger} Cardiology Section, Boston Medical Center, Boston, Massachusetts, USA
§ Department of Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, Massachusetts, USA
|| Barnes Hospital, St. Louis, Missouri, USA
National Heart, Lung and Blood Institute, Bethesda, Maryland, USA

Manuscript received November 3, 1998; revised manuscript received January 21, 1999, accepted February 10, 1999.

Reprint requests and correspondence: Dr. Daniel Levy, Framingham Heart Study, 5 Thurber Street, Framingham, Massachusetts 01702
dan{at}fram.nhlbi.nih.gov

OBJECTIVES

The purpose of this study was to assess the relative proportions of normal versus impaired left ventricular (LV) systolic function among persons with congestive heart failure (CHF) in the community and to compare their long-term mortality during follow-up.

BACKGROUND

Several hospital-based investigations have reported that a high proportion of subjects with CHF have normal LV systolic function. The prevalence and prognosis of CHF with normal LV systolic function in the community are not known.

METHODS

We evaluated the echocardiograms of 73 Framingham Heart Study subjects with CHF (33 women, 40 men, mean age 73 years) and 146 age- and gender-matched control subjects (nested case–control study). Impaired LV systolic function was defined as an LV ejection fraction (LVEF) <0.50.

RESULTS

Thirty-seven CHF cases (51%) had a normal LVEF; 36 (49%) had a reduced LVEF. Women predominated in the former group (65%), whereas men constituted 75% of the latter group. During a median follow-up of 6.2 years, CHF cases with normal LVEF experienced an annual mortality of 8.7% versus 3.0% for matched control subjects (adjusted hazards ratio = 4.06, 95% confidence interval 1.61 to 10.26). Congestive heart failure cases with reduced LVEF had an annual mortality of 18.9% versus 4.1% for matched control subjects (adjusted hazards ratio = 4.31, 95% confidence interval 1.98 to 9.36).

CONCLUSIONS

Normal LV systolic function is often found in persons with CHF in the community and is more common in women than in men. Although CHF cases with normal LVEF have a lower mortality risk than cases with reduced LVEF, they have a fourfold mortality risk compared with control subjects who are free of CHF.

Abbreviations and Acronyms
  CHF = congestive heart failure
  CI = confidence interval
  LVEF = left ventricular ejection fraction




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S. J. Pocock, D. Wang, M. A. Pfeffer, S. Yusuf, J. J.V. McMurray, K. B. Swedberg, J. Ostergren, E. L. Michelson, K. S. Pieper, C. B. Granger, et al.
Predictors of mortality and morbidity in patients with chronic heart failure
Eur. Heart J., January 1, 2006; 27(1): 65 - 75.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
T. K. Lim, H. Ashrafian, G. Dwivedi, P. O. Collinson, and R. Senior
Increased left atrial volume index is an independent predictor of raised serum natriuretic peptide in patients with suspected heart failure but normal left ventricular ejection fraction: Implication for diagnosis of diastolic heart failure
Eur J Heart Fail, January 1, 2006; 8(1): 38 - 45.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
S. D. Solomon, N. Anavekar, H. Skali, J. J.V. McMurray, K. Swedberg, S. Yusuf, C. B. Granger, E. L. Michelson, D. Wang, S. Pocock, et al.
Influence of Ejection Fraction on Cardiovascular Outcomes in a Broad Spectrum of Heart Failure Patients
Circulation, December 13, 2005; 112(24): 3738 - 3744.
[Abstract] [Full Text] [PDF]

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 Journals of Gerontology Series A: Biological Sciences and Medical SciencesHome page
W. S. Aronow
Drug Treatment of Systolic and of Diastolic Heart Failure in Elderly Persons
J. Gerontol. A Biol. Sci. Med. Sci., December 1, 2005; 60(12): 1597 - 1605.
[Abstract] [Full Text] [PDF]

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 HeartHome page
P M Mottram, B A Haluska, R Leano, S Carlier, C Case, and T H Marwick
Relation of arterial stiffness to diastolic dysfunction in hypertensive heart disease
Heart, December 1, 2005; 91(12): 1551 - 1556.
[Abstract] [Full Text] [PDF]

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 Arch Intern MedHome page
D. T. Ko, J. V. Tu, F. A. Masoudi, Y. Wang, E. P. Havranek, S. S. Rathore, A. M. Newman, L. R. Donovan, D. S. Lee, J. M. Foody, et al.
Quality of Care and Outcomes of Older Patients With Heart Failure Hospitalized in the United States and Canada
Arch Intern Med, November 28, 2005; 165(21): 2486 - 2492.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
M. Guazzi, J. Myers, and R. Arena
Cardiopulmonary Exercise Testing in the Clinical and Prognostic Assessment of Diastolic Heart Failure
J. Am. Coll. Cardiol., November 15, 2005; 46(10): 1883 - 1890.
[Abstract] [Full Text] [PDF]

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 Eur Heart JHome page
L. Grigorian Shamagian, J. R. Gonzalez-Juanatey, A. V. Roman, J. M. G. Acuna, and A. V. Lamela
The death rate among hospitalized heart failure patients with normal and depressed left ventricular ejection fraction in the year following discharge: evolution over a 10-year period
Eur. Heart J., November 1, 2005; 26(21): 2251 - 2258.
[Abstract] [Full Text] [PDF]

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 Journals of Gerontology Series A: Biological Sciences and Medical SciencesHome page
A. Ahmed
Association of Diastolic Dysfunction and Outcomes in Ambulatory Older Adults With Chronic Heart Failure
J. Gerontol. A Biol. Sci. Med. Sci., October 1, 2005; 60(10): 1339 - 1344.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
J. Arnlov, J. Sundstrom, L. Lind, B. Andren, M. Andersson, R. Reneland, L. Berglund, V. Kashuba, A. Protopopov, E. Zabarovsky, et al.
hUNC-93B1, a novel gene mainly expressed in the heart, is related to left ventricular diastolic function, heart failure morbidity and mortality in elderly men
Eur J Heart Fail, October 1, 2005; 7(6): 958 - 965.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
I. Olivotto, M. S. Maron, A. S. Adabag, S. A. Casey, D. Vargiu, M. S. Link, J. E. Udelson, F. Cecchi, and B. J. Maron
Gender-Related Differences in the Clinical Presentation and Outcome of Hypertrophic Cardiomyopathy
J. Am. Coll. Cardiol., August 2, 2005; 46(3): 480 - 487.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
E. Ingelsson, J. Arnlov, J. Sundstrom, and L. Lind
The validity of a diagnosis of heart failure in a hospital discharge register
Eur J Heart Fail, August 1, 2005; 7(5): 787 - 791.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
D. de Santis, P. Abete, G. Testa, F. Cacciatore, G. Galizia, D. Leosco, L. Viati, V. D. Villano, D. D. Morte, F. Mazzella, et al.
Echocardiographic evaluation of left ventricular end-systolic elastance in the elderly
Eur J Heart Fail, August 1, 2005; 7(5): 829 - 833.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
J. J. Thune, C. Carlsen, P. Buch, M. Seibaek, H. Burchardt, C. Torp-Pedersen, L. Kober, and on behalf of the DIAMOND investigators
Different prognostic impact of systolic function in patients with heart failure and/or acute myocardial infarction
Eur J Heart Fail, August 1, 2005; 7(5): 852 - 858.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
A. Varela-Roman, L. G. Shamagian, E. B. Caballero, P. M. Ramos, P. R. Veloso, and J. R. Gonzalez-Juanatey
Influence of diabetes on the survival of patients hospitalized with heart failure: A 12-year study
Eur J Heart Fail, August 1, 2005; 7(5): 859 - 864.
[Abstract] [Full Text] [PDF]

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 BMJHome page
G. S Hillis and P. Bloomfield
Basic transthoracic echocardiography
BMJ, June 18, 2005; 330(7505): 1432 - 1436.
[Full Text] [PDF]

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 Eur J Heart FailHome page
L. Lacey and M. Tabberer
Economic burden of post-acute myocardial infarction heart failure in the United Kingdom
Eur J Heart Fail, June 1, 2005; 7(4): 677 - 683.
[Abstract] [Full Text] [PDF]

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 J Am Board Fam MedHome page
S. Haney, D. Sur, and Z. Xu
Diastolic Heart Failure: A Review and Primary Care Perspective
J Am Board Fam Med, May 1, 2005; 18(3): 189 - 198.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
R. K. Wali, G. S. Wang, S. S. Gottlieb, L. Bellumkonda, R. Hansalia, E. Ramos, C. Drachenberg, J. Papadimitriou, M. A. Brisco, S. Blahut, et al.
Effect of kidney transplantation on left ventricular systolic dysfunction and congestive heart failure in patients with end-stage renal disease
J. Am. Coll. Cardiol., April 5, 2005; 45(7): 1051 - 1060.
[Abstract] [Full Text] [PDF]

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 HeartHome page
A Varela-Roman, L Grigorian, E Barge, P Bassante, M G de la Pena, and J R Gonzalez-Juanatey
Heart failure in patients with preserved and deteriorated left ventricular ejection fraction
Heart, April 1, 2005; 91(4): 489 - 494.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
U. Dahlstrom
Frequent non-cardiac comorbidities in patients with chronic heart failure
Eur J Heart Fail, March 16, 2005; 7(3): 309 - 316.
[Abstract] [Full Text] [PDF]

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 Am. J. Respir. Crit. Care Med.Home page
C. Casanova, C. Cote, J. P. de Torres, A. Aguirre-Jaime, J. M. Marin, V. Pinto-Plata, and B. R. Celli
Inspiratory-to-Total Lung Capacity Ratio Predicts Mortality in Patients with Chronic Obstructive Pulmonary Disease
Am. J. Respir. Crit. Care Med., March 15, 2005; 171(6): 591 - 597.
[Abstract] [Full Text] [PDF]

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 Eur J EchocardiogrHome page
O. W. Nielsen, A. Sajedieh, F. Petersen, and J. Fischer Hansen
Value of left ventricular filling parameters to predict mortality and functional class in patients with heart disease from the community
Eur J Echocardiogr, March 1, 2005; 6(2): 85 - 91.
[Abstract] [Full Text] [PDF]

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 Eur Heart JHome page
F. Gustafsson, C. B. Kragelund, C. Torp-Pedersen, M. Seibaek, H. Burchardt, D. Akkan, J. J. Thune, L. Kober, and for the DIAMOND study group
Effect of obesity and being overweight on long-term mortality in congestive heart failure: influence of left ventricular systolic function
Eur. Heart J., January 1, 2005; 26(1): 58 - 64.
[Abstract] [Full Text] [PDF]

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 NEJMHome page
L.-F. Hsu, P. Jais, P. Sanders, S. Garrigue, M. Hocini, F. Sacher, Y. Takahashi, M. Rotter, J.-L. Pasquie, C. Scavee, et al.
Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure
N. Engl. J. Med., December 2, 2004; 351(23): 2373 - 2383.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
C. Fonseca, H. Morais, T. Mota, F. Matias, C. Costa, A. Gouveia-Oliveira, F. Ceia, and on behalf of the EPICA Investigators
The diagnosis of heart failure in primary care: value of symptoms and signs
Eur J Heart Fail, October 1, 2004; 6(6): 795 - 800.
[Abstract] [Full Text] [PDF]

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 Eur J Heart FailHome page
F. Ceia, C. Fonseca, T. Mota, H. Morais, F. Matias, C. Costa, and A. G. Oliveira
Aetiology, comorbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy
Eur J Heart Fail, October 1, 2004; 6(6): 801 - 806.
[Abstract] [Full Text] [PDF]

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 Cardiovasc ResHome page
P. Steendijk
Heart failure with preserved ejection fraction. Diastolic dysfunction, subtle systolic dysfunction, systolic-ventricular and arterial stiffening, or misdiagnosis?
Cardiovasc Res, October 1, 2004; 64(1): 9 - 11.
[Full Text] [PDF]

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 Circ. Res.Home page
R. D. Patten, I. Pourati, M. J. Aronovitz, J. Baur, F. Celestin, X. Chen, A. Michael, S. Haq, S. Nuedling, C. Grohe, et al.
17{beta}-Estradiol Reduces Cardiomyocyte Apoptosis In Vivo and In Vitro via Activation of Phospho-Inositide-3 Kinase/Akt Signaling
Circ. Res., October 1, 2004; 95(7): 692 - 699.
[Abstract] [Full Text] [PDF]

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 Am. J. Physiol. Heart Circ. Physiol.Home page
B. D. Rosen, B. L. Gerber, T. Edvardsen, E. Castillo, L. C. Amado, K. Nasir, D. L. Kraitchman, N. F. Osman, D. A. Bluemke, and J. A. C. Lima
Late systolic onset of regional LV relaxation demonstrated in three-dimensional space by MRI tissue tagging
Am J Physiol Heart Circ Physiol, October 1, 2004; 287(4): H1740 - H1746.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
A. Arbab-Zadeh, E. Dijk, A. Prasad, Q. Fu, P. Torres, R. Zhang, J. D. Thomas, D. Palmer, and B. D. Levine
Effect of Aging and Physical Activity on Left Ventricular Compliance
Circulation, September 28, 2004; 110(13): 1799 - 1805.
[Abstract] [Full Text] [PDF]


 
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