Determinants of long-term survival in patients with congestive heart failure: the independent prognostic value of physical signs and symptoms

Background and Hypothesis: Technological advances have placed increasing emphasis on biochemical, echocardiographic, and invasivemeasurements for the purposes of predicting clinical outcomes among patients with heart failure (HF). We sought to re-evaluate the relationship between symptoms and physical findings and risk of death among a contemporary cohort of patients with heart failure treated with angiotensin-converting enzyme (ACE) inhibitors. Material and Methods: We performed retrospective analyses using the public access version of the Digitalis Investigation Group (DIG) trial database. Kaplan-Meier survival analyses with log-rank tests and proportional hazards models were used to study the relationship between symptoms and physical findings and risk of death among DIG trial participants. Results: A total of 7788 patients with HF were followed for a mean of 37 months. Of these, 77% were males, 65% had prior myocardial infarction, 94% were on ACE inhibitors, and 81% on diuretics. Mortality was significantly higher among patients with elevated jugular venous pressure (log-rank p 0.001), rales (p 0.001), edema (p 0.001), a third heart sound (p 0.001), and higher NYHA functional class (p 0.001). Proportional hazards models were constructed with adjustment for age, gender, race, ejection fraction, bodymass index, serum creatinine, duration of HF, heart rate, systolic and diastolic blood pressure, diabetes, etiology of HF, and treatment with ACE inhibitors, diuretics, and digoxin. After simultaneous adjustments for all these factors, elevated jugular venous pressure (Hazard Ratio, HR 1.4, 95% CI 1.3–1.6, p 0.0001), rales (HR 1.6, 95% CI 1.4–1.9, p 0.001), edema (HR 1.4, 95% CI 1.2–1.5, p 0.001), third heart sound (HR 1.2, 95% CI 1.1–1.4, p 0.001), and higher NYHA class (HR 2.1, 95% CI 1.7–2.8, p 0.001) remained strong independent predictors of death. Per the DIG trial protocol, the chronicity or persistence of symptoms and physical findings were noted at study enrollment as existing only within the prior month (“present”), only prior to that (“past”) or both (“past-present”). This simple designation was highly related to the risk of death. Patients without a history of rales had 74% actuarial survival. Past history of rales was associated with a 7% decline in survival (95% CI 6–9), present rales with a 14% decline (95% CI 10–19), and past-present rales with a 24% decline (95% CI 21–27) (p 0.001). Similar trends were observed for elevated jugular venous pressure, edema, and third heart sound. Utilization of End-of Life Services for Advanced Heart Failure Patients Patricia C. Shreve, Theo E. Meyer, Anna M. Bernard, Donna T. Gemme, Donna Muscente1—Advanced Heart Failure Center, UMMHC, Worcester, MA