(Circulation. 1998;98:2282-2289.)
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports |
Congestive Heart Failure in the Community
A Study of All Incident Cases in Olmsted County, Minnesota, in 1991
From the Division of Cardiovascular Diseases and Internal Medicine (M.S., C.M.T., R.J.R., M.M.R.), the Department of Health Sciences Research (S.J.J., K.R.B.), and the Division of Community Internal Medicine (J.M.E.), Mayo Clinic and Mayo Foundation, Rochester, Minn.
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Abstract |
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Background—Data are limited regarding the classification and prognosis of patients with congestive heart failure (CHF) in the community.
Methods and Results—Using the resources of the Rochester
Epidemiology Project, we evaluated all
patients receiving a first diagnosis of CHF in Olmsted County,
Minnesota, in 1991 (n=216). Among these patients, 88% were 
65 years
and 49% were 80 years of age. The prognosis of patients with a new
diagnosis of CHF was poor; survival was 86±2% at 3 months, 76±3% at
1 year, and 35±3% at 5 years. Of the 216 patients, 137 (63%) had an
assessment of ejection fraction. In these patients, systolic
function was preserved (ejection fraction 50%) in 59 (43%) and
reduced (ejection fraction <50%) in 78 (57%). Survival adjusted for
age, sex, NYHA class, and coronary artery disease was not
significantly different between patients with preserved and those with
reduced systolic function (relative risk, 0.80;
P=0.369). ACE inhibitors were used in
only 44% of the total population with CHF.
Conclusions—The present study reports the clinical characteristics and natural history of CHF as it presents in the community in the vasodilator era. CHF is a disease of the "very elderly," frequently occurs in the setting of normal ejection fraction, and has a poor prognosis, regardless of the level of systolic function. Diagnostic and therapeutic methods are underused in the community.
Key Words: epidemiology • heart failure • prognosis
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Introduction |
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During the past 25 years, death rates for cardiovascular disease have been decreasing in western countries.1 2 In contrast, congestive heart failure (CHF) is the only common cardiovascular condition whose prevalence is increasing, particularly in elderly patients.3 This condition is associated with high morbidity and mortality. Approximately 2 million persons in the United States have CHF; every year there are 400 000 new cases4 and 274 000 deaths.5 Furthermore, as the US population becomes older, the prevalence of CHF may continue to increase.6 7 Most studies that have characterized patients with CHF include only patients with systolic left ventricular dysfunction and are limited by significant referral bias because they often focus on hospital-based practices or patients referred to a tertiary center and generally have excluded very elderly patients.
Limited data are available about the characterization and prognosis of CHF in the community.8 9 10 11 12 There has been considerable interest in isolated diastolic dysfunction in recent years, and several studies have reported that a substantial number of patients with CHF have normal systolic function.13 Most of the previous studies were small and subject to referral bias. In the community setting, it is unknown how many patients with CHF have normal systolic function and whether their clinical characteristics and prognosis are unique. Furthermore, few data are available regarding the use of therapeutic agents in the community. These data are essential to the understanding of potential differences between patients with CHF in the community and those commonly studied in CHF therapeutic trials and to the determination of whether recommendations from these trials have an impact on the management and outcome of CHF in the community.
Therefore, we studied patients receiving a first-time diagnosis of CHF in a well-defined community. We specifically wanted to evaluate (1) the age distribution of patients with CHF in the community; (2) the prevalence of normal systolic function in patients with CHF; (3) the prognosis of new-onset CHF in the community, including the prognosis of patients with CHF and preserved ejection fraction; and (4) the use of vasodilators and other therapies for CHF after diagnosis.
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Methods |
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Study Setting
This study was approved by the Mayo Institutional Review Board. Olmsted County, Minnesota, is located
80 miles southeast of
Minneapolis. Approximately 70% of the population of the county resides
within the city limits of Rochester. Demographic information about
Olmsted County is available from each published decennial census. In
1990, Olmsted County population was 106 470 (96% white); 28% of the
population was >45 years of age, and 11% was 65 years of age. The
population is primarily middle class; 82% of the adult population
have graduated from high school. Except for a higher proportion of the
working population employed in healthcare-related facilities, the
characteristics of the population of Olmsted County are similar to
those of other US whites.14 Population-based epidemiological research is feasible in Olmsted County because the city and county are relatively isolated from other urban centers and patient care is available from a limited number of healthcare providers: the Mayo Clinic, the Olmsted Medical Center, their hospitals, and a few private practitioners. Most care is provided through the Mayo Clinic, which has maintained a unified medical record with 2 hospitals for the past 80 years. The Mayo Clinic unit record contains a master sheet that includes all diagnoses made during outpatient office visits, clinic consultations, emergency department visits, nursing home care, hospital admission, autopsy examination, and death certification. This information has been indexed since the turn of the century.14 15 The Rochester Epidemiology Project has developed a similar index for the records of other providers of medical care to local residents. The epidemiological potential of this index system is further enhanced because each provider uses the unified medical record system, whereby all data collected on an individual patient are assembled in 1 place. The result is the linkage of medical records from essentially all sources of medical care available to and used by the Olmsted County population.14 15
Identification of Cases
Potential cases of CHF were identified through the available
indexes, which indicated patients who had a new diagnosis of CHF from
January 1,1991, through December 31,1991. Once these patients had been
identified, the complete community medical records of each
candidate case were reviewed carefully. The validity of the diagnosis
of CHF was ascertained by use of a slight modification of the
Framingham criteria.8 These criteria are
classified as major or minor. The major criteria were paroxysmal
nocturnal dyspnea, orthopnea, abnormal jugular venous distention,
pulmonary rales, cardiomegaly, pulmonary edema,
presence of a third heart sound, and central venous pressure of >16 cm
H2O. The minor criteria were edema, night cough,
dyspnea on exertion, hepatomegaly, pleural effusion,
tachycardia (>120 bpm), and weight loss of 4.5 kg in 5
days (considered a major criterion if it occurred during therapeutic
interventions for CHF). A patient was considered to have CHF if 2 major
criteria were present or if 1 major and 2 minor criteria were
present concurrently. The medical record was examined to
determine whether systolic function, assessed according to
ejection fraction, had been evaluated within 3 weeks before or after
the diagnosis. Left ventricular systolic function
was classified as indeterminate (not assessed), normal (ejection
fraction 50%), or reduced (ejection fraction <50%). Patients with
an ejection fraction of 50% were classified as having CHF with
normal systolic function. Clinical characteristics that provide
information pertinent to potential cause, diagnosis, therapy, and
prognosis were collected. The number of hospitalizations and days of
hospitalization in which CHF was a primary or major contributing factor
subsequent to the diagnosis of CHF were noted. Total mortality was
determined from the clinical record and the death certificate
listings.
The clinical record was reviewed to establish residency at the time of diagnosis of CHF. Residency in Olmsted County 1 year before the diagnosis of CHF was required to exclude the possibility that a patient moved to Rochester to facilitate diagnosis or treatment of the condition (residency for these reasons would introduce a form of referral bias).16
Coronary artery disease was defined as (1) the presence of a
clinical diagnosis of coronary artery disease, (2) positive
results of a stress test, (3) coronary angiography showing 1
vessel with stenosis of >50%, (4) a clinical diagnosis of
myocardial infarction, or (5) ECG findings of Q-wave myocardial
infarction. A patient was considered to have hypertension if (1) this
was a clinical diagnosis indicated in the medical record, (2)
arterial blood pressure was normal with ongoing
antihypertensive therapy, or (3) at diagnosis there were 2 successive
determinations of either a systolic arterial blood
pressure of 160 mm Hg or a diastolic
arterial blood pressure of 90 mm Hg. The diagnosis
of severe valve disease was based on angiographic or
echocardiographic data. The criterion for idiopathic
dilated cardiomyopathy was global left
ventricular dilatation with impaired systolic
function occurring in the absence of a known cardiac or systemic cause.
A patient was considered to have chronic obstructive pulmonary
disease or restrictive lung disease if a clinical diagnosis was listed
in the medical record or if the patient had abnormal results of
pulmonary function tests.
Statistical Analysis
Continuous variables were expressed as mean±SD and were
compared between groups with Student's t test. Discrete
variables were summarized by frequency percents and were
analyzed with the 
2 test. Survival
function estimates were derived by the Kaplan-Meier method, and
differences in survival between groups were assessed by the 2-sample
log-rank test. Expected survival overall or for subgroups was based on
age- and sex-matched mortality data for the 1990 Minnesota white
population, and comparisons of observed and expected survival were
based on the 1-sample log-rank test. Univariate and
multivariate Cox proportional hazards regression
analyses were used to identify predictors of survival.
Univariate and multivariate logistic
regression analyses were used to evaluate clinical predictors
of abnormal systolic function (ejection fraction <50%). The
independent candidate variables corresponded to the variables
listed in Table 1
. A value of
P<0.05 was considered statistically significant. S-PLUS
software (Statistical Sciences, Inc) was used for the survival
analyses; all other computations were performed with the SAS
System (SAS Institute, Inc).
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Results |
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Total Incident Population
A total of 216 new cases of definite CHF were identified in Olmsted County in 1991. The clinical characteristics of the patients are summarized in Table 1
. The distribution of the diagnostic criteria
is reported in Table 2.
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The age distribution of incident cases of CHF is shown in Figure 1. The number of patients with heart
failure dramatically increased with advancing age.
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The prognosis of patients with a new diagnosis of CHF was poor (Figure 2A). Cumulative survival was 86% ± 2%
at 3 months, 76% ± 3% at 1 year, and 35% ± 3% at 5 years.
Survival of the 185 patients still alive 90 days after the diagnosis of
CHF was 88±2% at 1 year and 41±4% at 5 years (Figure 2B). By
multivariate analysis, advanced age
(P=0.0001; relative risk [RR], 1.042; 95% CI, 1.024 to
1.062) and moderate to severe NYHA functional class
(P=0.027; RR, 1.47; 95% CI, 1.04 to 2.09) were negative
predictors of long-term survival. After the first episode of CHF, 34%
of patients were subsequently hospitalized for symptoms of heart
failure. In all, only 27% of patients were never hospitalized for
CHF.
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Normal Versus Reduced Ejection Fraction
Of the 216 patients, 137 (63%) had an assessment of ejection
fraction by echocardiography within 3 weeks before
or after diagnosis. Of these patients, 59 (43%) had preserved
systolic function (ejection fraction 50%), and 78 (57%) had
predominantly systolic dysfunction. Clinical characteristics of
the patients with preserved and those with reduced systolic
function are outlined in Table 3. In the 59 patients with
normal systolic function, only 5 (3 with severe mitral
regurgitation and 2 with severe mitral
stenosis) had significant valve disease at diagnosis. By
logistic regression analysis, female sex was identified to be
associated with preserved ejection fraction. Age 90 years was an
independent positive predictor of normal systolic function. The
presence of left bundle-branch block or a myocardial infarction pattern
on ECG was independently associated with decreased ejection fraction
(Table 4). Survival
adjusted for age and sex was significantly reduced in both ejection
fraction groups compared with expected survival (P=0.0001
for both; Figure 3).
Unadjusted survival was similar in the two groups (P=0.279;
Figure 4). By
multivariate analysis, survival adjusted for
age, sex, NYHA class, and coronary artery disease was still not
significantly different between patients with ejection fractions <50%
and those with ejection fractions of 50% (RR, 0.80;
P=0.369). In patients with CHF and ejection fractions of
50%, survival was not different in patients with recognized
coronary artery disease (RR, 1.170; 95% CI, 0.79 to 1.73;
P=0.42). Survival was not different in the 18 patients
treated with ACE inhibitors (RR, 0.905; 95% CI, 0.62 to
1.33; P=0.60).
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Medical and Surgical Treatments
Medical and surgical treatments prescribed after the
diagnosis of CHF are outlined in Table 5. Treatment for all
patients and for those who had assessment of ejection fraction
(preserved or reduced systolic function) is presented.
Patients with heart failure and systolic dysfunction were
hospitalized more frequently for heart failure (P<0.05). In
patients with ejection fractions <50%, 8 (10%) were never
hospitalized for heart failure, 32 (41%) were hospitalized 1 time, and
38 (49%) were hospitalized 2 times for heart failure. In patients
with ejection fractions of 50%, 14 (24%) were never hospitalized
for heart failure, 30 (51%) were hospitalized 1 time, and 15 (25%)
were hospitalized 2 times for heart failure.
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Discussion |
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This study was performed in a well-defined community-based population and examined all patients receiving a first diagnosis of CHF in 1991 who fulfilled the Framingham criteria for CHF.8 We found that 49% of patients with a first-time diagnosis of CHF in the community are
80 years of age.
Prognosis for CHF in the community is extremely poor, even when
patients with early mortality are excluded. For the first time in a
large community-based study, we confirmed that among patients with
clinical CHF who undergo assessment of ventricular
function, nearly as many have preserved systolic function
(43%) as have reduced ejection fraction. At the time of diagnosis,
patients with preserved function were as symptomatic as
patients with reduced ejection fraction and had a similar poor
prognosis.
Age of Patients With New Diagnosis of CHF
The changing age demographics of the population have
recognized implications for health care. The "very elderly," those
80 years, is the fastest growing segment of our population. The
Framingham study, a community-based volunteer study, reported that the
incidence of CHF increases exponentially with advancing
age.7 However, analysis of the Framingham
study population regarding the incidence of CHF in very elderly
patients (>84 years of age) must be interpreted cautiously because
relatively few patients were 84 years of age. A previous study of CHF
in Olmsted County16 and the NHANES-I
study11 excluded patients >74 years of age. The
present study confirms that CHF is a disease of the elderly in that
the age of patients was 65 years in 88% of incident cases. However,
the finding that 50% of patients with a new diagnosis of CHF in the
community are among the very elderly (80 years old) is striking.
As pointed out recently, the age of patients usually seen by a cardiologist is 65 to 75 years.17 In the community, the age of most patients with CHF is much higher. These patients are routinely followed by primary-care physicians, geriatricians, or internal medicine specialists. If cardiologists are to offer meaningful consultation to their general medicine colleagues regarding the management of CHF, more data are needed for very elderly patients with CHF. These patients are characterized by a host of age-related comorbid conditions that may alter their clinical presentation and response to therapy.17 Except for the CONSENSUS I and ELITE trials,18 19 in which the mean ages were 71 and 74 years, respectively, these patients were not represented in major CHF treatment trials, in which the mean age ranges from 59 to 65 years.20 21 22 23 24 25
Diastolic Heart Failure
Preliminary data from the Framingham study showed that 52%
of 77 patients with new-onset CHF had preserved ejection
fraction.26 Data from 31 small uncontrolled
studies showed a significant disagreement in regard to the frequency of
diastolic heart failure and the clinical characteristics
and prognosis in these patients.13 None of these
studies examined a large number of consecutive cases of CHF in the
community. In this community-based population, 43% of patients with
definite CHF who had echocardiography had normal
ejection fractions, and even if patients found to have unexpected,
significant valvular disease are excluded, the percentage of
patients with preserved ejection fraction and CHF remains high (41%).
Nevertheless, the true prevalence of diastolic heart
failure in patients with a new diagnosis of CHF in our total population
remains unknown because 37% did not have assessment of
systolic function at the time of diagnosis. However, the
prevalence ranges from 27% to 64% whether we assume that no patient
or all patients without echocardiography had
ejection fractions of 50%, respectively.
Our series also shows that in patients with CHF, advanced age,
female sex, and a history of hypertension are associated with a high
ejection fraction, whereas a history of coronary artery disease
and a markedly abnormal ECG were associated with a lower ejection
fraction, although no clinical characteristics reliably predicted
normal systolic function in an individual patient.
Diastolic dysfunction appears to be a primary cause of
heart failure in elderly patients. Among patients 80 years of age who
have heart failure, >50% have normal or nearly normal
systolic function.13 In our
community-based study, 48% of patients >80 years of age with CHF had
ejection fractions of 50%. This increased prevalence of heart
failure caused by diastolic dysfunction in elderly patients
may reflect duration of hypertension and coronary artery
disease and perhaps the concomitant effects of age-related changes in
the cardiovascular system.27
Specific diagnostic criteria for diastolic heart failure are lacking, and currently one must rely on a firm clinical diagnosis of CHF in the absence of systolic dysfunction at the time of symptoms.28
For accurate characterization of diastolic function and detection of increased filling pressures in patients with normal ejection fractions, sophisticated combined analysis of pulmonary venous and mitral inflow flow velocity profile, Valsalva maneuver, and color M-mode analysis of the velocity of flow propagation are required,29 and these were not routinely performed in our echocardiography laboratory in 1991.29 30 Few patients had cardiac catheterization. Initial assessment of comorbid conditions such as renal and pulmonary disease failed to reveal a higher prevalence of these conditions in patients with diastolic heart failure. Thus, the diagnosis of diastolic heart failure remains presumptive, although highly likely.
Prognosis
Previous studies reporting mortality in a community-based
population enrolled only patients <74 years of
age.8 9 10 11 12 Only the Framingham Heart Study, which
evaluated survival in patients who developed CHF between 1948 and 1988,
included patients without age limits and reported 3-month, 1-year, and
5-year survival rates of 73%, 57%, and 25%, respectively.
Surprisingly, there was no significant change in overall survival after
the onset of CHF during 40 years of follow-up. However, as emphasized
by the authors, use of vasodilators and cardiac transplantation was not
widespread during most of the follow-up
period.31
In the present study, survival at 3 months, 1 year, and 5 years was 86%, 76%, and 35%, respectively. We have previously reported the impact of both secular trends and referral bias on survival in patients with idiopathic dilated cardiomyopathy.32 Although a cross-study comparison must be made with caution, the improved survival in this 1991 cohort compared with the Framingham cohort suggests some impact of improved diagnosis and therapy on survival for patients with CHF in the community.
The prognosis for patients with CHF and preserved ejection fraction has not been extensively studied. The reported annual mortality rate varies from 1.3% to 17.5% in hospital-based series.13 These differences in prognosis are likely related to differences in the study population, especially in regard to age, origin, and functional class. In the V-HeFT study,33 the mortality rate of patients with CHF and normal ejection fractions was 23% at 5.7 years, but patients with myocardial ischemia were excluded, and the mean age was only 60 years. In a study by Setaro et al34 of a cohort of patients referred to a nuclear cardiology laboratory with a diagnosis of CHF whose mean age was 71 years and in whom coronary artery disease was the predominant underlying disease, the mortality rate at 7 years was 46%. In the present study, prognosis was poor for patients with diastolic heart failure; the survival rate at 3 months, 1 year, and 5 years was 86%, 76%, and 48%, respectively.
Although the prognostic value of ejection fraction is well accepted,
previous studies have shown that the relationship between ejection
fraction and survival in CHF may not be as
strong.35 36 Indeed, Taffet et
al37 did not report differences in survival
between patients 75 years of age with CHF and normal or reduced
systolic function. Setaro et al34 also
confirmed a high risk of cardiovascular events in
patients with CHF and normal systolic function. In a
preliminary report from a study of 77 patients with CHF detected as
part of the Framingham study, mortality adjusted for age and sex was
not significantly lower in patients with normal systolic
function (RR, 0.58; 95% CI, 0.30 to 1.1; P=0.10), although
unadjusted mortality was lower in patients with preserved
systolic function. The poor survival may be related to the
advanced symptom level and very advanced age, as suggested by the study
by Taffet et al.37 Younger cohorts with CHF and
preserved systolic function may have improved survival compared
with patients who have reduced ejection fraction. This finding is
consistent with our data, which reveal that the adjusted
mortality, controlling for age, sex, NYHA functional class, and the
presence of coronary artery disease, is similar in patients
with diastolic and systolic heart failure. There
was a trend toward separation of the survival curves beginning at
3.5 years after diagnosis. This finding may suggest that a subset of
patients with preserved systolic function do well over the long
term, whereas patients with systolic dysfunction have a more
homogeneously poor outcome.
In the patients with CHF and ejection fractions of 50%, survival was
not significantly lower in patients with recognized coronary
artery disease. This finding may be related to sample size, with an
insufficient number to demonstrate the impact of coronary
artery disease, underrecognition of coronary artery disease in
this elderly population as a result of less aggressive evaluation, or
other factors that alter prognosis in this very elderly population and
may mask the effect of coronary artery disease.
In patients with CHF and ejection fractions of 50%, survival was not
significantly lower in patients treated with ACE
inhibitors. Only 18 patients were so treated. There was no
control for dose, duration of therapy, or underlying
cardiovascular disease. Thus, these data do not
adequately address whether ACE inhibition is useful therapy in patients
with CHF and ejection fractions of 50%.
Evaluation and Management of CHF in the Community
In the present study, 63% of patients with a new diagnosis of
CHF had an assessment of left ventricular systolic
function. Such assessment is recommended in patients with suspected
CHF.38 In this population receiving a diagnosis
of CHF in 1991, 44% of patients were treated with ACE
inhibitors. However, among the patients in whom
systolic dysfunction was confirmed, 69% were treated with ACE
inhibitors. This number is higher than previously reported
in patients with heart failure in the community39
and highlights the need for studies examining practice patterns in
patients with heart failure to determine whether systolic
function was assessed and whether systolic function was reduced
in patients not being treated with ACE inhibitors. However,
we should recognize that the SOLVD prevention19
and SAVE trials24 were not published at that
time; thus, treatment of asymptomatic or mildly
symptomatic patients with ACE inhibitors was
not universally accepted.
Study Limitations
This cohort study has the typical limitations of a retrospective
study. Patients with CHF were identified from medical records, and
the incidence of CHF may have been underestimated, particularly among
young patients, who may be less likely to seek medical attention.
Moreover, Framingham criteria are relatively insensitive for the
detection of early manifestations of CHF.40
Specific symptoms or signs of CHF may not have been reported by
physicians because they were considered synonymous with CHF. Therefore,
some patients may have been excluded because of an inability to fulfill
diagnostic criteria based on the clinical record.
Despite these limitations, this study in a nonvolunteer community and comprehensive of all ages and of institutionalized patients describes the clinical manifestations and natural history of CHF as it presents in the community. The study underscores that as it presents in the community, CHF is a disease of the very elderly and has a poor prognosis. Although CHF commonly occurs in the presence of normal systolic function, preservation of systolic function was not associated with lower mortality. Our findings underscore the differences between patients with CHF in the community and those commonly enrolled in therapeutic trials. These data are essential if we are to evaluate the impact of advances in diagnosis and therapy on the natural history of CHF in the community.
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Acknowledgments |
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This study was funded in part by grants from the Mayo Foundation; Joseph P. and Jeanne Sullivan Foundation, Chicago, Ill; Miami Heart Research Institute; NHLBI (1 R01 HL-55502-01A1); and US Public Health Service, National Institutes of Health (AR 30582). Dr Tribouilloy was supported by a grant from the Federation Française de Cardiologie.
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Footnotes |
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Reprint requests to Margaret M. Redfield, MD, Mayo Clinic, 200 First St SW, Rochester, MN, 55905.
Received December 15, 1997; revision received July 7, 1998; accepted July 16, 1998.
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F. Gustafsson, C. Torp-Pedersen, M. Seibaek, H. Burchardt, L. Kober, and for the DIAMOND study group Effect of age on short and long-term mortality in patients admitted to hospital with congestive heart failure Eur. Heart J., October 1, 2004; 25(19): 1711 - 1717. [Abstract] [Full Text] [PDF]
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N F Murphy, C R Simpson, F A McAlister, S Stewart, K MacIntyre, M Kirkpatrick, J Chalmers, A Redpath, S Capewell, and J J V McMurray National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland Heart, October 1, 2004; 90(10): 1129 - 1136. [Abstract] [Full Text] [PDF]
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G. P. Aurigemma and W. H. Gaasch Diastolic Heart Failure N. Engl. J. Med., September 9, 2004; 351(11): 1097 - 1105. [Full Text] [PDF]
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M. S. Maurer, M. Packer, D. Burkhoff, D. L. King, M. Grieff, M. R. Zile, C. F. Baicu, W. H. Gaasch, and M. M. Redfield Diastolic Heart Failure N. Engl. J. Med., September 9, 2004; 351(11): 1143 - 1145. [Full Text] [PDF]
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T. E. Sirak, S. Jelic, and T. H. Le Jemtel Therapeutic update: Non-selective beta- and alpha-adrenergic blockade in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure J. Am. Coll. Cardiol., August 4, 2004; 44(3): 497 - 502. [Abstract] [Full Text] [PDF]
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V. L. Roger, S. A. Weston, M. M. Redfield, J. P. Hellermann-Homan, J. Killian, B. P. Yawn, and S. J. Jacobsen Trends in Heart Failure Incidence and Survival in a Community-Based Population JAMA, July 21, 2004; 292(3): 344 - 350. [Abstract] [Full Text] [PDF]
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P. Banerjee, A. L. Clark, N. Nikitin, and J. G.F. Cleland Diastolic heart failure. Paroxysmal or chronic? Eur J Heart Fail, June 1, 2004; 6(4): 427 - 431. [Abstract] [Full Text] [PDF]
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F. Pedersen, I. Raymond, L. H. Madsen, J. Mehlsen, D. Atar, and P. Hildebrandt Echocardiographic indices of left ventricular diastolic dysfunction in 647 individuals with preserved left ventricular systolic function Eur J Heart Fail, June 1, 2004; 6(4): 439 - 447. [Abstract] [Full Text] [PDF]
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A. Bergstrom, B. Andersson, M. Edner, E. Nylander, H. Persson, and U. Dahlstrom Effect of carvedilol on diastolic function in patients with diastolic heart failure and preserved systolic function. Results of the Swedish Doppler-echocardiographic study (SWEDIC) Eur J Heart Fail, June 1, 2004; 6(4): 453 - 461. [Abstract] [Full Text] [PDF]
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T. Mueller, A. Gegenhuber, W. Poelz, and M. Haltmayer Preliminary Evaluation of the AxSYM B-Type Natriuretic Peptide (BNP) Assay and Comparison with the ADVIA Centaur BNP Assay Clin. Chem., June 1, 2004; 50(6): 1104 - 1106. [Full Text] [PDF]
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M C Petrie, K Hogg, L Caruana, and J J V McMurray Poor concordance of commonly used echocardiographic measures of left ventricular diastolic function in patients with suspected heart failure but preserved systolic function: is there a reliable echocardiographic measure of diastolic dysfunction? Heart, May 1, 2004; 90(5): 511 - 517. [Abstract] [Full Text] [PDF]
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M. Klapholz, M. Maurer, A. M. Lowe, F. Messineo, J. S. Meisner, J. Mitchell, J. Kalman, R. A. Phillips, R. Steingart, E. J. Brown Jr, et al. Hospitalization for heart failure in the presence of a normal left ventricular ejection fraction: Results of the New York heart failure registry J. Am. Coll. Cardiol., April 21, 2004; 43(8): 1432 - 1438. [Abstract] [Full Text] [PDF]
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D. Johnson and B. Cujec Reply J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1333 - 1334. [Full Text] [PDF]
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J. Yoshida, K. Yamamoto, T. Mano, Y. Sakata, N. Nishikawa, M. Nishio, T. Ohtani, T. Miwa, M. Hori, and T. Masuyama AT1 Receptor Blocker Added to ACE Inhibitor Provides Benefits at Advanced Stage of Hypertensive Diastolic Heart Failure Hypertension, March 1, 2004; 43(3): 686 - 691. [Abstract] [Full Text] [PDF]
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D. Logeart, G. Thabut, P. Jourdain, C. Chavelas, P. Beyne, F. Beauvais, E. Bouvier, and A. C. Solal Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure J. Am. Coll. Cardiol., February 18, 2004; 43(4): 635 - 641. [Abstract] [Full Text] [PDF]
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K. Hogg, K. Swedberg, and J. McMurray Heart failure with preserved left ventricular systolic function: epidemiology, clinical characteristics, and prognosis J. Am. Coll. Cardiol., February 4, 2004; 43(3): 317 - 327. [Abstract] [Full Text] [PDF]
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H. Yamaguchi, J. Yoshida, K. Yamamoto, Y. Sakata, T. Mano, N. Akehi, M. Hori, Y.-J. Lim, M. Mishima, and T. Masuyama Elevation of plasma brain natriuretic peptide is a hallmark of diastolic heart failure independent of ventricular hypertrophy J. Am. Coll. Cardiol., January 7, 2004; 43(1): 55 - 60. [Abstract] [Full Text] [PDF]
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C. W. Knudsen, J. S. Riis, A. V. Finsen, L. Eikvar, C. Muller, A. Westheim, and T. Omland Diagnostic value of a rapid test for B-type natriuretic peptide in patients presenting with acute dyspnoe: effect of age and gender Eur J Heart Fail, January 1, 2004; 6(1): 55 - 62. [Abstract] [Full Text] [PDF]
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J. E. Moller, B. Brendorp, M. Ottesen, L. Kober, K. Egstrup, S. H. Poulsen, and C. Torp-Pedersen Congestive heart failure with preserved left ventricular systolic function after acute myocardial infarction: clinical and prognostic implications Eur J Heart Fail, December 1, 2003; 5(6): 811 - 819. [Abstract] [Full Text] [PDF]
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D. S. Lee, P. C. Austin, J. L. Rouleau, P. P. Liu, D. Naimark, and J. V. Tu Predicting Mortality Among Patients Hospitalized for Heart Failure: Derivation and Validation of a Clinical Model JAMA, November 19, 2003; 290(19): 2581 - 2587. [Abstract] [Full Text] [PDF]
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O Wendelboe Nielsen, J Hilden, T McDonagh, and J Fischer Hansen Survival differences between heart failure in general practices and in hospitals Heart, November 1, 2003; 89(11): 1298 - 1302. [Abstract] [Full Text] [PDF]
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