Systolic versus diastolic heart failure in community practice: Clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors

BACKGROUND: Among patients with heart failure, there is controversy about w hether there are clinical features and laboratory tests that can differenti ate patients who have low ejection fractions from those with normal ejectio n fractions. The usefulness of angiotensin-converting enzyme (ACE) inhibito rs among heart failure patients who have normal left ventricular ejection f ractions is also not known. METHODS: from a registry of 2,906 unselected consecutive patients with hear t failure who were admitted to 10 acute-care community hospitals during 199 5 and 1997, we identified 1291 who had a quantitative measurement of their left ventricular ejection fraction. Patients were separated into three grou ps based on ejection fraction: less than or equal to0.39 (n = 741, 57%), 0. 40 to 0.49 (n = 238, 18%), and greater than or equal to0.50 (n = 312, 24%). In-hospital mortality, prescription of ACE inhibitors at discharge, subseq uent rehospitalization, quality of life, and survival were measured; surviv ors were observed for at least 6 months after hospitalization. RESULTS: The mean (+/- SD) age of the sample was 75 +/- 11 years; the major ity (55%) of patients were women. In multivariate models, age >75 years, fe male sex, weight >72.7 kg, and a valvular etiology for heart failure were a ssociated with an increased probability of having an ejection fraction grea ter than or equal to0.50; a prior history of heart failure, an ischemic or idiopathic cause of heart failure, and radiographic cardiomegaly were assoc iated with a lower probability of having an ejection fraction greater than or equal to0.50. Total mortality was lower in patients with an ejection fra ction greater than or equal to0.50 than in those with an ejection fraction less than or equal to0.39 (odds ratio [OR] = 0.69, 95% confidence interval [CI]: 0.49 to 0.98, P = 0.04). Among hospital survivors with an ejection fr action of 0.40 to 0.49, the 65% who were prescribed ACE inhibitors at disch arge had better mean adjusted quality-of-life scores (7.0 versus 6.2, P = 0 .02), and lower adjusted mortality (OR = 0.34, 95% CI: 0.17 to 0.70, P = 0. 01) during follow-up than those who were not prescribed ACE inhibitors. Amo ng hospital survivors with an ejection fraction greater than or equal to0.5 0, the 45% who were prescribed ACE inhibitors at discharge had better (lowe r) adjusted New York Heart Association (NYHA) functional class (2.1 versus 2.4, P = 0.04) although there was no significant improvement in survival. CONCLUSIONS: Among patients treated for heart failure in community hospital s, 42% of those whose ejection fraction was measured had a relatively norma l systolic function (ejection fraction greater than or equal to0.40). The c linical characteristics and mortality of these patients differed from those in patients with low ejection fractions. Among the patients with ejection fractions greater than or equal to0.40, the prescription of ACE inhibitors at discharge was associated favorable effects. (C) 2000 by Excerpta Medica, Inc.