What factors most influence the care process and hospital-based outcome in patients with congestive heart failure?


Black patients with heart failure are younger and more likely to be treated in urban teaching hospitals; they have a higher prevalence of hypertensive heart disease, diabetes, and renal disease, and a lower prevalence of ischemic heart disease and prior cardiac surgery. Rehospitalization rates are also higher among black patients, for which differences in the causes of heart failure may be partially responsible. Thus, hypertensive heart disease, which is more common in blacks, is a more volume-sensitive state, exposing sufferers to sudden symptomatic pulmonary congestion and interstitial edema, hence rehospitalization.

Blacks undergo noninvasive cardiac procedures more often than whites. They also incur higher hospital charges despite an equivalent length of stay and lower rates of intensive care unit use. Mortality appears lower among blacks, but their rehospitalization rates for chronic heart failure are higher. Black patients are less often discharged to skilled nursing facilities, less often offered post-discharge home care, and less often transferred to other acute-care hospitals.

Cardiovascular disease is the leading cause of excess mortality in black Americans. Proposed explanations include high disease prevalence and severity, adverse socioeconomic and cultural factors, and poorer access to quality medical care. The aggregate available evidence suggests a higher incidence of chronic heart failure among blacks, but potentially an equivalent or lower case-fatality rate.


In the 1980s, the annual age-adjusted incidence of congestive heart failure among persons aged 45 years or more was 7.2 cases/1000 in men and 4.7 cases/1000 in women, whereas the age-adjusted prevalence of overt heart failure was 24/1000 in men and 25/1000 in women. Despite improved treatments for ischemic heart disease and hypertension, the age-adjusted incidence of heart failure has declined by only 11 %/calendar decade in men and by 17%/calendar decade in women over a 40-year observation period. In addition, congestive heart failure remains highly lethal, with a median survival of 1.7 years in men and 3.2 years in women, and a 5-year survival rate of 25% in men and 38% in women.

Compared with men with chronic heart failure, women with the disease are older, with a higher prevalence of hypertensive heart disease, valvular heart disease and diabetes, and a lower prevalence of ischemic heart disease, nonischemic nonhypertensive cardiomyopathy, prior cardiac surgery, serious ventricular arrhythmia, and renal disease.

Procedure and specialty rates are lower in women than in men. Men undergo twice as many invasive cardiac procedures as women during hospitalization. Use of cardiologists and most procedures is also lower in women.

Compared with men, women stay longer in hospital, incur higher hospital charges, and have lower rates of intensive care unit use, although in the study concerned these gender effects were largely driven by gender differences among the white group. Women are more often discharged to skilled nursing facilities and more often receive postdischarge home care, but are less often transferred to other acute-care hospitals.

Women are less prone than men to ventricular arrhythmia during Holter monitoring, show greater responsiveness to vagally mediated respiratory sinus arrhythmia, and differ in their myocardial adaptation to pressure load. Women develop concentric left ventricular hypertrophy with no change in cavity dimensions, whereas men develop eccentric hypertrophy with chamber dilatation. This gender-specific adaptation to pressure overload may result in more diastolic dysfunction among women and explain in part their higher prevalence of preserved left ventricular systolic function in chronic heart failure.


Almost 78% of men and about 80% of women hospitalized for heart failure are aged >65 years. In inpatients with any diagnosis of heart failure, age is associated with a higher prevalence of in-hospital death and discharge to long-term care. Acute myocardial infarction is the most frequent primary diagnosis in those aged <65 years; in those aged >65 years, respiratory infection (pneumonia and influenza) is the leading principal diagnosis, followed by acute myocardial infarction.

Patients aged 80 years and older represent 50% of all chronic heart failure hospital discharges and 75% of nursing home discharges in Sweden.

Older patients have higher comorbidity rates, typically including type 2 diabetes and a history of myocardial infarction, which can add to the likelihood of inpatient treatment.

Caregiver specialty

According to recent estimates, 83% of patients being treated for heart failure receive care from physicians other than cardiologists. In a recent study of the impact of caregiver specialty on cost and clinical outcome, Harjai et al found that patients treated by cardiologists were younger, less likely to have hypertension, and more likely to be men, to require intensive care stay, to have coronary artery disease, to have a left ventricular ejection fraction <40%, and to have lower systolic and diastolic blood pressures on admission. In subsets of patients who required intensive care during hospitalization, as well as those who did not, care by cardiologists was associated with a lower adjusted hospital cost. Any potential cost savings that could have accrued from care by cardiologists was, however, negated by the higher proportion of patients treated by cardiologists who required intensive care during hospitalization. The authors concluded that when differences were adjusted, care by cardiologists vs generalists was associated with similar or lower hospital cost for patients with a primary discharge diagnosis of heart failure and shock. No difference was found between patients treated by cardiologists vs those treated by generalists with respect to crude hospital cost, length of stay, or in-hospital mortality. The findings challenge the notion that inpatient care provided by specialists is more expensive than that provided by generalists. Reis et al found that patients treated by cardiologists with a primary discharge diagnosis of heart failure had longer lengths of stay and a greater number of diagnostic tests during hospitalization than those treated by generalists. However, they also had more severe heart failure than those under generalist care. [gallery ids=""]

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