Predictors of congestive heart failure in the elderly: the

cardiovascular health study

OBJECTIVES
We sought to characterize the predictors of incident congestive

heart failure (CHF), as
determined by central adjudication,

in a community-based elderly population.
BACKGROUND
The elderly constitute a growing proportion of patients admitted

to the hospital with CHF, and
CHF is a leading source of morbidity

and mortality in this group. Elderly patients differ from
younger

individuals diagnosed with CHF in terms of biologic characteristics.
METHODS
We analyzed data from the Cardiovascular Health Study, a prospective

population-based study of
5,888 elderly people >65 years old

(average 73 5, range 65 to 100) at four locations.

Multiple
laboratory measures of cardiovascular structure and

function, blood chemistries and functional
assessments wereobtained.
RESULTS
During an average follow-up of 5.5 years (median 6.3), 597 participants

developed incident CHF
(rate 19.3/1,000 person-years). The incidence

of CHF increased progressively across age groups
and was greaterin men than in women. On multivariate analysis, other independent

predictors
included prevalent coronary heart disease, stroke

or transient ischemic attack at baseline,
diabetes, systolic

blood pressure (BP), forced expiratory volume 1 s, creatinine

>1.4 mg/dl, C-
reactive protein, ankle-arm index <0.9, atrial

fibrillation, electrocardiographic (ECG) left
ventricular (LV)

mass, ECG ST-T segment abnormality, internal carotid artery

wall thickness and
decreased LV systolic function. Population-attributable

risk, determined from predictors of risk
and prevalence, was

relatively high for prevalent coronary heart disease (13.1%),

systolic BP
140 mm Hg (12.8%) and a high level of C-reactive

protein (9.7%), but was low for subnormal
LV function (4.1%)

and atrial fibrillation (2.2%).
CONCLUSIONS
The incidence of CHF is high in the elderly and is related mainly

to age, gender, clinical and
subclinical coronary heart disease,

systolic BP and inflammation. Despite the high relative risk

of
subnormal systolic LV function and atrial fibrillation, the

actual population risk of these for CHF
is small because of

their relatively low prevalence in community-dwelling elderly

people.

Background
Chronic heart failure (CHF) is a disabling illness with significant morbidity and mortality
that affects >5 million Americans.
[1]
The morbidity of CHF includes not only physical
symptoms but also significant psychological distress, including anxiety and depression,
due to changes in functional level, work status, and relationships.
[2-5]
Studies have
demonstrated that significant depression in CHF is common, with prevalence rates
ranging from 24% to 39%, and is related to a higher risk of functional decline.
[2,6-12]
At
least 2 dozen studies have shown depression to be an important risk factor for morbidity
and mortality, independent of physiologic measures of disease severity.
[5,7,8,10,11,13-
19]
Significant depression is related to a 2.5-fold increase in mortality at 3 months and a
3-fold increase in re-hospitalization at 1 year, among hospitalized patients with
CHF.
[10]
Other studies have suggested that social support also has an important impact
on medical outcomes in chronic heart failure.
[2,14,20-22]
Quality of life is substantially
impaired in this socially isolated population, often with higher rates of hospitalization and
mortality.
[14,23]
Although the underlying pathophysiology responsible for this major effect
of depression on mortality in CHF is not fully understood, it has been demonstrated that
depression causes increases in neurohormonal activation, proinflammatory cytokines,
hypercoaguability, and arrhythmias that may all contribute to its deleterious
effects.
[24,25]
Despite the important impact of depression on outcomes, no large study
has examined interventions aimed at psychosocial variables in CHF.
The present study examined the effects of an 8-week psychoeducational intervention on
depression, anxiety, quality of life, symptoms, and medical outcomes in patients with
CHF. The intervention included teaching skills based on Mindfulness Based Stress
Reduction (MBSR) plus education on improving coping skills that included better social
support, living with heart failure, non-denominational spirituality,
[26,27]
and an expressive
support group.
[28]
Previous studies suggest that these program components can
positively affect psychosocial outcomes in various patient populations.
[29-33]
The MBSR
component has been demonstrated to be helpful in coping with stress, pain, anxiety,
and depression in chronic illnesses.
[29,34-37]
Based on these results, we hypothesized
that this treatment might result in lower levels of depression and psychological distress
as measured by the Center of EpidemiologyDepression (CES-D), Kansas City
Cardiomyopathy Questionnaire (KCCQ), and Profile of Mood States (POMS) in patients
with CHF.
http://www.medscape.com/viewarticle/585981









Survival after the onset of congestive heart
failure in Framingham Heart Study subjects


BACKGROUND. Relutlvely llmlted epldemlologlcul dutu ure uvulluble regurdlng the
prognosls of congestlve heurt fullure (CHF) und temporul chunges ln survlvul ufter lts onset
ln u populutlon-bused settlng.
METHODS AND RESULTS. Proportlonul huzurds models were used to evuluute the effects
of selected cllnlcul vurlubles on survlvul ufter the onset of CHF umong 652 members of the
Frumlnghum Heurt Study (51% men; meun uge, 70.0 +/- 10.8 yeurs) who developed CHF
between 1948 und 1988. Sub|ects were older ut the dlugnosls of heurt fullure ln the luter
decudes of thls study (meun uge ut heurt fullure dlugnosls, 57.3 +/- 7.6 yeurs ln the 1950s,
65.9 +/- 7.9 yeurs ln the 1960s, 71.6 +/- 9.4 yeurs ln the 1970s, und 76.4 +/- 10.0 yeurs ln
the 1980s; p < 0.001). Medlun survlvul ufter the onset of heurt fullure wus 1.7 yeurs ln men
und 3.2 yeurs ln women. Overull, 1-yeur und 5-yeur survlvul rutes were 57% und 25% ln
men und 64% und 38% ln women, respectlvely. Survlvul wus better ln women thun ln men
(uge-ud|usted huzurds rutlo for mortullty, 0.64; 95% CI, 0.54-0.77). Mortullty lncreused wlth
udvunclng uge ln both sexes (huzurds rutlo for men, 1.27 per decude of uge; 95% CI, 1.09-
1.47; huzurds rutlo for women, 1.61 per decude of uge; 95% CI, 1.37- 1.90). Ad|ustlng for
uge, there wus no slgnlflcunt temporul chunge ln the prognosls of CHF durlng the 40 yeurs
of observutlon (huzurds rutlo for men for mortullty, 1.08 per culendur decude; 95% CI, 0.92-
1.27; huzurds rutlo for women for mortullty, 1.02 per culendur decude; 95% CI, 0.83-1.26).
CONCLUSIONS. CHF remulns hlghly lethul, wlth better prognosls ln women und ln
younger lndlvlduuls. Advunces ln the treutment of hypertenslon, myocurdlul lschemlu, und
vulvulur heurt dlseuse durlng the four decudes of observutlon dld not trunslute lnto
upprecluble lmprovements ln overull survlvul ufter the onset of CHF ln thls lurge, unselected
populutlon.

http://circ.ahajournals.org/content/88/1/107