Factors predicting mortality in elderly patients hospitalized for congestive heart failure

Meenaxi Sharda; Ankit Vijay; Nikhil Gandhi; Meghna Aggarwal

doi:10.4103/jiag.jiag_21_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 19 | Issue : 1 | Page : 9-13

Factors predicting mortality in elderly patients hospitalized for congestive heart failure

Meenaxi Sharda, Ankit Vijay, Nikhil Gandhi, Meghna Aggarwal
Department of Medicine, Government Medical College, Kota, Rajasthan, India

Date of Submission	19-May-2022
Date of Decision	17-Dec-2022
Date of Acceptance	28-Dec-2022
Date of Web Publication	17-Mar-2023

Correspondence Address:
Ankit Vijay
Plot No. 4&9, Chaudhary Colony, Near Chandrabhan Hospital, Tonk. Pin Code-304001, Rajasthan
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiag.jiag_21_22

Abstract

Background: Heart failure (HF) is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. There are range of factors that predict the mortality, morbidity, and outcome in congestive HF (CHF) patients. Objectives: The objective was to study the clinico-epidemiological characteristics and predictors of inhospital mortality of elderly patients ≥60 years hospitalized for HF. Subjects and Methods: A complete medical history of enrolled patients and physical examination inclusive of etiology, New York Heart Association (NYHA) grade, heart rate (HR), and systolic blood pressure (SBP) were noted. Complete blood count, blood urea, serum creatinine, serum sodium, serum potassium, 12-lead electrocardiogram, X-ray of the chest, and echo were obtained in all patients. Outcomes were analyzed till the study endpoints. Results: Compared to normal comparators, a higher mortality was observed in patients with age >75 years (33.3%), HR >100 beats per min (27.14%), SBP <80 mmHg (60%), NYHA IV HF (37.1%), hemoglobin (Hb) <12 mg/dl (31.25%), blood urea ≥40 mg/dl (26.39%), serum creatinine >1.30 mg/dl (29.17%), serum sodium <135 meq/L (26.69%), and ejection fraction (EF) <50% (26.39%). Conclusion: Increasing age, prior history of CHF on admission, higher NYHA grade on admission, higher HR, lower SBP, lower EF, low Hb, higher blood urea, serum creatinine, and low serum sodium levels are statistically significant predictors of inhospital mortality of elderly CHF patients.

Keywords: Congestive heart failure, elderly, heart failure predictors, mortality

How to cite this article:
Sharda M, Vijay A, Gandhi N, Aggarwal M. Factors predicting mortality in elderly patients hospitalized for congestive heart failure. J Indian Acad Geriatr 2023;19:9-13

How to cite this URL:
Sharda M, Vijay A, Gandhi N, Aggarwal M. Factors predicting mortality in elderly patients hospitalized for congestive heart failure. J Indian Acad Geriatr [serial online] 2023 [cited 2023 Apr 2];19:9-13. Available from: http://www.jiag.com/text.asp?2023/19/1/9/371901

Introduction

Heart failure (HF) is essentially a disease of old age. Incidence increases to about 20% in people over 75 years.^[1] It is the leading cause of frequent admissions to hospitals in patients over 65 years.^[2],[3] HF is considered a “geriatric syndrome” as its proportion is increasing due to the growing age of population consequent to the advancement in medical technology.^[1],[4] Various researchers have shown that the age of onset of HF in South Asians is significantly lower than that in the western population.^[5]

There are various factors that predict the mortality, morbidity, and outcome in patients of congestive HF (CHF). Widely studied factors are age, sex, weight, systolic blood pressure (SBP), heart rate (HR), New York Heart Association (NYHA) grading at the time of admission, hemoglobin (Hb), blood urea, serum creatinine, serum sodium, and liver diseases.^[6],[7] Studies analyzing the determinants of poor outcomes in CHF in elderly patients are scarce in India. Hence, we decided to study various factors which can predict inhospital mortality in elderly patients hospitalized for CHF.

Subjects and Methods

This cross-sectional study was conducted among individuals admitted in the emergency department, medicine wards, and intensive care unit of the government medical college and associated group of hospitals, Kota, during 2020–2021. Individuals with an age equal and above 60 years admitted for acute and chronic HF were selected. After an informed consent, patients were included in the study based on inclusion and exclusion criteria. The study was initiated after obtaining permission from the institutional ethics committee.

Study definitions

CHF was defined according to the American Heart Association guidelines as a clinical syndrome resulting from structural and functional impairment of ventricular filling and ejection of blood. HF was assessed with clinical symptoms of fatigue, dyspnea, and signs of fluid overload such as edema and rales,^[8] which was confirmed using echocardiographic parameters (ejection fraction [EF], contractility and wall thickness, and dimensions of the left ventricle).

The NYHA IV guidelines were used to categorize the cases of HF.^[8]

Inclusion criteria

Elderly patients of any gender of age 60 years and above at the time of hospital admission
Patients presenting with CHF (new onset or acute worsening of preexisting chronic HF) of any etiology.

Exclusion criteria

Patients suffering from the chronic obstructive pulmonary disease (COPD) OPD and acute exacerbation of COPD
Patients suffering from chronic liver diseases, acute kidney injury/chronic kidney disease with fluid overload, and pulmonary embolism
Patients suffering from malignancy
Patients with mental confusion
Patients not willing to participate in the study.

Methodology

A total of 100 random patients (60 or above) being hospitalized for CHF satisfying inclusion as well as exclusion criteria were enrolled in the study. A detailed medical history was taken, and a complete physical examination was performed as per the study pro forma inclusive of etiology, NYHA grade, HR, and SBP. The following investigations were done in all patients at any time during the hospital stay; complete blood count, blood urea, serum creatinine, serum potassium, serum sodium, 12-lead electrocardiogram, chest X-ray PA view, and echocardiography (recently done) were recorded if available, otherwise was got done from the cardiology department. Reverse transcription-polymerase chain reaction test for COVID-19 was done for all enrolled participants.

Outcomes were analyzed till the study end point: discharge after clinical improvement or inhospital death. The variables and the inhospital outcome were recorded in a confidential database, which in turn were subjected to correlation and statistical analysis at the end of the study.

Statistical methods

The data collected through the study pro forma were analyzed by statistical methods/techniques. The statistical analysis was performed using IBM SPSS (Epi info 7, 2021).

Data were presented as mean with standard deviation for normal distribution/scale data and as frequency with proportion n (%) for categorical data. The clinical, biochemical, and electrocardiographic characteristics of patients were assessed using the Chi-Square test among the categorical variables. All the statistical analyses were done at a 5% significance level or 95% confidence interval.

Results

In our study, a total of 100 patients were enrolled of age 60 years and above with the mean age of 74.67 years and standard deviation of 7.3 years. Fifty-five percent of patients were between 60 and 75 years, and 45% of patients had an age >75 years. The study comprised 55% of males and 45% of females. Of the total patients, 51% had a history of hypertension (HTN) and 33% had a history of diabetes mellitus. Sixty-two percent of patients were active smokers, and 16% of patients had dyslipidemia. Forty-five percent of patients had a history of admission due to CHF. Eighty percent of patients had underlying ischemic etiology (coronary artery disease [CAD]: 74% and Myocardial Infarction (MI): 6%), and 20% had nonischemic (dilated cardiomyopathy, thyroid disorder, anemia, atrial fibrillation, and HTN) cause of HF. The NYHA was Grade III in 46% of cases and Grade IV in 35% of cases at the time of admission. Of a total of 100 patients, 21% died and the rest were discharged in a stable condition [Table 1].

Table 1: Demographic variables of patients

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There was a statistically significant difference in the outcome of patients according to age groups and with a history of CHF (P < 0.01). A higher percentage (33.3%) of patients above 75 years of age died compared to the mortality rate (10.9%) in the age group of 60–75 years. Similarly, there was a higher mortality (33.3%) among those patients with a prior history of CHF compared to those admitted for the first time for CHF (10.9%). The difference in mortality according to sex, history of HTN, history of diabetes, smoking, dyslipidemia, history of CAD, and ischemic etiology was not significant [Table 2].

Table 2: Comparison of mortality outcome of congestive heart failure with demographics and comorbidities (n=100)

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Similarly, a statistically significant difference in mortality among CHF patients was observed according to HR, SBP, NYHA class, hemoglobin, serum creatinine, serum sodium, and EF (P < 0.05). A higher percentage of mortality was observed among patients with HR ≥100 (27.1%), SBP between 80 and 109 mmHg (26.7%), NYHA Grade IV (37.1%), hemoglobin <12 g/dl (31.3%), serum creatinine >1.3 mg/dl (29.1%), serum sodium 110–134 Meq/L (29.7%), and EF <50% (26.4%) compared to normal values of these parameters [Table 3].

Table 3: Comparison of mortality outcome of congestive heart failure with clinical examination and investigations (n=100)

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Applying binary logistic regression on those variables which were significant by the Chi-square test, it was observed that HR >100 was associated with mortality due to CHF with statistical significance but carried a small overall risk (adjusted odds ratio 1.04) and deranged renal function was associated with 3.9 times higher adjusted odds with marginal statistical significance [P = 0.05, [Table 4]].

Table 4: Correlation of mortality outcome of congestive heart failure with significant predictors (n=100)

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Discussion

HF is one of the most burgeoning health-care problems. Several studies have shown that a number of risk factors are related to short-term and long-term mortality after discharge, including age, gender,^[9] ventricular function,^[10],[11] and management.^[12],[13] Despite research revealing risk factors for HF mortality, data on HF mortality prediction in elderly patients during admission are limited.

Among the demographic parameters studied, mortality in patients with CHF was significantly higher in the age group of >75 years (P < 0.05), i.e., 33.33%, whereas group <75 years of age had a mortality of 10.9%. According to Rich MW^[14] and Munusamy et al^[15] results of both studies concluded that mortality significantly increased with increasing age >65 years. This could be attributed to old age-related changes in the cardiovascular system and a higher prevalence of comorbidities in the elderly.

Another significant demographic variable associated with higher mortality was a prior history of CHF. The mortality rate was 33.3% in patients with prior CHF (P < 0.05) compared to those who presented for the first time with CHF (10.9%). Greene et al. compared recently diagnosed HF (<1 month) to chronic worsening of CHF. A greater relief from shortness of breath and survival following discharge was found in acute HF diagnosed in <1 month compared to worsening of chronic HF (P < 0.05), similar to this study.^[16]

Dyslipidemia was present in 16% of cases, but survival was similar in both groups (P = 0.3). The findings were comparable to the study done by Reznik et al., in which there was no significant difference in the mortality outcome in patients with or without dyslipidemia.^[17]

Higher mortality was observed in patients with history of Diabetes Mellitus, HTN and Ischemic etiology of CHF. This difference was statistically insignificant (P = 0.1) when compared to their counterparts. Clough et al., study showed Diabetes Mellitus as a significant (P < 0.05) predictor of mortality in CHF but the study failed to show CHF mortality association with HTN and prior history of CHF.^[18]

Heart Rate> 100bpm, SBP<80 mmHg at the time of admission and NYHA class IV were significant predictors of mortality in CHF (P < 0.05). A study conducted by John et al.^[19] showed low SBP (115 mmHg) to be an independent predictor of mortality which could be attributed to severe left ventricular dysfunction. The findings of the study concorded with the present study. Likewise, a fall in SBP during inhospital stay was found as an independent risk factor of mortality, which was also approved by Zoghi et al.^[20] in their study and ADHERE cohort,^[21] OPTIMISE HF trial.^[22]

Laboratory parameters measured at any time during the hospital stay, such as Hb <12 mg/dl, rise in blood urea (>40 mg/dl) and serum creatinine (>1.3 mg/dl), and low serum sodium (<135 mmol/L), were associated with increased mortality (P < 0.05) in CHF. Low EF (<50%) was also significantly associated with mortality. The findings could be explained by the pathophysiologic phenomena of low EF leading to decreased cardiac output and SBP with compensatory tachycardia. Kidney hypoperfusion with the rise in blood urea and serum creatinine and secondary activation of the neurohormonal system cause water and salt retention resulting in dilutional hyponatremia. The findings were comparable to the study conducted by Pongsuthana and Chopchai,^[23] Barsheshet et al.,^[24] and Chansa,^[25] in which age, SBP, NYHA class III/IV, serum creatinine, and LVEF <40%–50% were some of the common factors indicating long-term mortality.

Although this study has predicted several factors that are associated with a poor outcome in elderly patients hospitalized for HF, the study carries the following limitations:

Limitation of the study

Due to the small sample size, the results cannot be extrapolated to community settings and are limited to inhospital mortality of HF
No analysis was done with respect to medications or compliance to the medications taken by the patients
We have included only hospital data, so there can be a possibility of Berksonian bias
Being cross-sectional in design, no follow-up was done
Levels of cardiac biomarkers were not included in the study.

Strength of the study

Studies focusing on elderly subsets with HF are not easily available in the literature, especially from developing countries like India, which is showing demographic transition leading to social and economic burdens. Hence, risk stratification with bedside clinical variables will help in clinical decision-making and optimal treatment of HF.

Conclusion

Factors that emerged as significant predictors of mortality in elderly patients hospitalized with CHF include age, prior history of CHF, NYHA grade, HR, SBP, EF, serum sodium, serum creatinine, blood urea, and hemoglobin. The presence of HTN, diabetes mellitus, history of smoking, dyslipidemia, and presence of peripheral edema did not show any significant association. Inhospital mortality is not significantly associated with underlying etiology, i.e., ischemic heart disease or nonischemic cause. These are some of the factors that can be used in clinical decision-making for a better outcome of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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