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1 The Center for Health Equity Research and Promotion, VA Pittsburgh HealthCare System, Pittsburgh, Pennsylvania.
2 Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio.
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Abstract |
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Methods. Our sample consisted of 1058 patients 65 years of age or older who were admitted to 30 hospitals in Northeastern Ohio with a principal diagnosis of heart failure and a left ventricular ejection fraction of 
50% by echocardiogram.
Results. Of the 1058 patients with diastolic heart failure (13% African American and 87% white), African Americans and whites were comparable with respect to history of angina, stroke, being on dialysis, and alcohol use; the proportion of male patients was also comparable. The African American to white adjusted odds ratio for 18-month mortality (all cause) was 1.03 (0.66–1.59). For men versus women (30% vs 70%), the above-mentioned comorbidities were comparable, except women were more likely to have a do not resuscitate status (16% vs 7.3%; p =.000) and to be older (79.5 ± 8 vs 77 ± 7; p =.000). Men were more likely to have a history of tobacco use (30% vs 14%; p =.000) and alcohol use (36% vs 15%; p =.000), and a higher serum creatinine level (1.7 ± 1.2 vs 1.4 ± 1.1; p =.001). The men to women adjusted odds ratio for 18-month mortality (all cause) was 1.06 (0.76–1.46).
Conclusion. In this cohort of elderly patients admitted with diastolic heart failure, there were no ethnic or gender differences in 18-month mortality rates.
There are 4.6 million Americans who suffer from heart failure, and there are over half a million new cases each year (1). Approximately half of all patients with heart failure have diastolic heart failure, in which the left ventricular ejection fraction (LVEF) is preserved (2,3). Diastolic heart failure alone may account for over 300,000 annual hospitalizations in the United States.
Because of its links to hypertension, diastolic heart failure is more common among African Americans than among whites (4,5). In contrast to systolic heart failure, diastolic heart failure affects women disproportionately (3,5–10). However, little is known regarding the prognosis for African Americans and women with this condition, compared with whites and men, respectively. We examined gender and ethnic differences in 18-month survival in a cohort of older patients admitted to acute care hospitals with diastolic heart failure.
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Methods |
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Data Collection
The Health Quality Choice database, whose reliability and accuracy has been previously described (11,12), includes consecutive discharges identified by specific International Classification of Diseases, 9th Revision, Clinical Modification principal diagnosis codes (398.91, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, and 428.9). Patients directly transferred from other acute care hospitals were excluded. We chose our sample from a list of patients with an LVEF assessment on record; the criterion for diastolic heart failure was an LVEF 50%. To track postdischarge deaths, we utilized the Ohio MEDPRO (Medicare Peer Review Organization) files for Medicare beneficiaries aged 65 years and older. Using these data, we were able to determine vital status for 18 months after the index admission for all patients. We excluded patients whose race was reported as "other." We included in-hospital deaths in this analysis.
Statistical Analysis
Descriptive statistics were initially performed to compare demographic and clinical characteristics of African American and white male and female patients. The chi-square test was used for categorical variables, and Student's t test was used for continuous, normally distributed variables. Crude 18-month survival curves following the index congestive heart failure (CHF) hospitalization were compared for African Americans and whites, males and females, by using the Kaplan–Meier method. The log rank test was used to compare the survival curves.
Multivariate logistic regression models were utilized to determine the adjusted odds ratio for 18-month mortality for African Americans versus whites and for male versus female patients. Simultaneous equation models were created by using all variables, including race or ethnicity and gender, that had a multivariate association of p <.2 or less. The overall model was assessed with the Hosmer–Lemeshow Goodness of Fit Test (p >.05). All analyses were performed with SPSS (Chicago, IL).
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Results |
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50%. In this subsample, African American patients were slightly younger than whites (mean age 76 ± 7 vs 79 ± 8 years; p =.00). They were more likely to have hypertension (50% vs 36%; p =.001), diabetes (46% vs 29%; p =.000), malignancy (0% vs 3%; p =.03), and higher serum creatinine levels on admission (1.99 ± 2 vs 1.50 ± 1 mg/dL; p =.003), and they were more likely to use tobacco (27% vs 18%; p =.01). Whites were more likely to have ischemic heart disease (48% vs 32%; p =.000), atrial fibrillation (24% vs 14%; p =.002), and to have a do not resuscitate (DNR) status on record (14% vs 7%, p =.01). The two groups had no statistically significant differences with respect to other major comorbidities, including stroke (21% vs 16%; p =.16), angina (6% vs 6%; p =.96), and use of alcohol (19% vs 21%; p =.48). Female patients in this sample were more likely to be older (mean age 79 ± 5 vs 77 ± 7 years; p =.000) and to have a DNR order on record (16% vs 7%; p =.000). Male patients were more likely to use alcohol (36% vs 15%; p =.000) or tobacco (30% vs 14%; p =.000), and they were more likely to have higher serum creatinine levels on admission (1.7 ± 1.2 vs 1.4 ± 1.1 mg/dl; p =.001) (Table 1). There were no statistically significant differences between men and women with respect to other comorbidities, such as stroke (16% vs 17%; p =.85), hypertension (35% vs 39%; p =.16), ischemic heart disease (50% vs 45%; p =.14), malignancy (3.8% vs 2.3%; p =.17), diabetes (30% vs 32%; p =.55), atrial fibrillation (24% vs 24%; p =.95), or being on dialysis (0% vs 0.7%; p =.14).
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Discussion |
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Overall mortality for African Americans versus whites and for men versus women was similar to that previously reported for patients with diastolic heart failure (3,5,13,14), but higher than that of an age-matched normal population (3). Previous studies have reported an average annual mortality rate for diastolic heart failure of 8–17% (3,5,14). A recent study by Philbin and colleagues (5) examined a 6-month prognosis in diastolic heart failure for patients admitted to community hospitals. They found similar annual mortality rates. However, this study was limited by its short duration of follow-up and a lack of a significant number of African Americans in the sample. Senni and colleagues (9) reported comparable mortality rates for patients with diastolic and systolic CHF (9). However, their study compared long-term mortality rates for these two variants of heart failure (3–4 years). Although we did not directly compare mortalities for systolic versus diastolic heart failure, our 18-month mortality findings on diastolic heart failure do not approach those usually reported for systolic heart failure. This discrepancy may partially reflect the natural course of diastolic heart failure. Because most patients with diastolic heart failure eventually develop systolic heart failure, their cause of death may be attributed to systolic disease as opposed to diastolic disease. Furthermore, the proportion of patients in our sample who had an LVEF assessment on record was small (28%) compared with estimates (45–50%) from other studies (15,16). This may, in part, be due to the fact that our cohort was entirely composed of older patients. It has been reported in the past that older patients are less likely than younger patients to undergo LVEF assessment (17).
Conclusions
Our results must be interpreted with several limitations in mind. First, the diagnosis of diastolic heart failure is evolving and has to include objective evidence of ventricular relaxation, stiffness, or both (18). Therefore, although our definition of diastolic heart failure is consistent with common convention, it may lead to misclassification error. Second, we lack information on prescribed medications, which may differentially affect mortality. Although some studies have reported that treatment with angiotensin-converting enzyme inhibitors or beta-blockers may have a slight benefit for patients with diastolic disease (5,19,20), there is currently no consensus regarding the proven impact of treatment of any kind on the course of diastolic disease. Lastly, we have no information on disease-specific severity, nor do we know the duration of disease prior to the index admission. This information gap could have biased our findings in one way or another.
In summary, we identified patients with diastolic heart failure from a large cohort of elderly patients hospitalized for heart failure. In this sample, we found that African American and white patients had similar 18-month mortality rates; these rates were also comparable for male and female patients. Our findings are important in that they address a common but poorly studied cardiovascular condition; they are also timely in that they inform the current national effort to reduce gender and ethnic disparities in cardiovascular mortality. Additional studies are needed to confirm our findings.
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Acknowledgments |
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Dr. Ibrahim is a recipient of a VA HSR&D Career Development Award.
Received June 18, 2002
Accepted June 27, 2002
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This article has been cited by other articles:
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  S. A. Ibrahim Author's Response to Letter to the Editor: SEX AND RACE-RELATED DIFFERENCES IN ELDERLY HEART FAILURE PATIENTS WITH PRESERVED LEFT VENTRICULAR SYSTOLIC FUNCTION J. Gerontol. A Biol. Sci. Med. Sci., July 1, 2003; 58(7): M672 - 672. [Full Text] [PDF]
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