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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 125-130

Predictors of in-hospital mortality in patients admitted with congestive Heart failure (HF) in a general medical ward – A case-control study from a tertiary care centre in South India


1 Department of Internal Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
2 Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission14-Jun-2020
Date of Decision02-Oct-2020
Date of Acceptance05-Jul-2021
Date of Web Publication27-Oct-2021

Correspondence Address:
K Muruga Bharathy
Department of Internal Medicine, Unit-2, Christian Medical College and Hospital, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_70_20

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  Abstract 


Background and Objectives: Studies around the world have shown that incidence of HF is increasing with the highest risk of mortality during their first admission and in the subsequent 1 year. Only a few Indian studies had looked at the predictors of in-hospital mortality in patients admitted with HF in patients admitted in medical wards. We have done a case control study to determine the risk factors for in-hospital mortality, in patients admitted with HF, in general medical ward, in a tertiary care centre in south India. Methods: We collected demographic data, clinical details and outcome data from case records. We performed a univariate analysis comparing those who died as compared to those who did not. Factors that were significant in the above, were entered into a logistic regression analysis to identify factors that independently predicted poor outcomes. Results: The in-hospital mortality rate in patients admitted with HF was 12.19%. On multivariate analysis, Systolic blood pressure < 115 mmHg {OR – 2.82, CI (1.29 – 6.19)}, serum lactate > 2 mmol/l {OR-2.61, CI (1.16 – 5.87)}, and GCS < 15 {OR 6.64, CI (2.26 – 19.51)} were statistically significant. Conclusion: Our study has shown that, in patients admitted with HF in general medical ward, at admission, low systolic blood pressure, high serum lactates, low GCS were predictors of in-hospital mortality.

Keywords: Congestive heart failure, mortality, risk factors, general medical ward


How to cite this article:
John FM, Joy A, Nellimala NJ, Bharathy K M, Prakash TV, John KJ, Mathuram AJ, Sathyendra S, Abraham O C, Ramya I, Jayaseelan V, Sudarsanam TD. Predictors of in-hospital mortality in patients admitted with congestive Heart failure (HF) in a general medical ward – A case-control study from a tertiary care centre in South India. CHRISMED J Health Res 2021;8:125-30

How to cite this URL:
John FM, Joy A, Nellimala NJ, Bharathy K M, Prakash TV, John KJ, Mathuram AJ, Sathyendra S, Abraham O C, Ramya I, Jayaseelan V, Sudarsanam TD. Predictors of in-hospital mortality in patients admitted with congestive Heart failure (HF) in a general medical ward – A case-control study from a tertiary care centre in South India. CHRISMED J Health Res [serial online] 2021 [cited 2021 Nov 27];8:125-30. Available from: https://www.cjhr.org/text.asp?2021/8/2/125/329451




  Introduction Top


The prevalence of Heart Failure (HF) is approximately 1%-2% in the adult population in developed countries, rising to ≥10% among people >70 years of age.[1],[2] Age, length of hospital stay, New York Heart Association (NYHA) grade of dyspnea, lower blood pressure values on admission, previous HF admissions, hemoglobin, renal dysfunction, presence of ischemic heart disease, noncompliance to medications, are predictors of death during admission in HF patients.[3],[4],[5],[6],[7],[8],[9] Most Indian studies of HF admissions were done in the setting of acute coronary syndrome and their complications in cardiology units. Most HF patients are in fact managed by internists.[10],[11]

Predictors of poor in-hospital outcomes will guide treating physicians in better prognostication of patients admitted for HF.

Objective

The primary objective was to determine the risk factors for the in-hospital mortality in patients with HF admitted in general medical ward.


  Methods Top


Setting and participants

This, retrospective study, is a single center case–control study conducted in large tertiary care medical college hospital in South India. Patients admitted to General medicine wards from January 2014 to December 2016, with a discharge diagnosis of HF were included. Patients who died during their course in hospital were cases, while those discharged alive were controls. Controls were selected (every 7th patient) from the cohort of HF patients in a 1:1 ratio. Also, in patients with multiple admissions in the study period, only the latest admission was included. Those who were hospitalized for HF and discharged against advice were excluded from the study. Heart Failure (HF) diagnosis was confirmed by Boston Congestive Cardiac Failure Criteria (CCF) criteria.[12] We collected demographic data, risk factors, comorbidities, need for intensive care, ventilator support, investigation reports and the outcome. Selection bias was addressed by including all cases which were identified during the time period. The study was approved by the Institutional Review Board (IRB) of the participating institution (IRB no. 10842). There was no funding involved and the authors declare no conflict of interest.

Sample size calculation

The sample size calculated was 121 cases and 121 controls with 1:1 allocation with 80% power, 5% level of significance, based on a previous study.[4]

Statistical analysis

Data were reported as mean and standard deviation for continuous variables and as number and percentage for categorical variables. Significant predictors of in-hospital mortality were identified using logistic regression analysis. Epidata software version 3.1 (Epidata Association, Odense, Denmark) was used for data entry and SPSS 21 (SPSS Inc., Chicago, IL, USA) for data analysis.


  Results Top


During the three-year period from, January 2014–December 2016 [[Figure 1]-STROBE] 992 HF cases were admitted in medical wards. 121/992 (12.19%) died during their hospital stay. Both cases and controls were on an average nearly 60-year-old and stayed between 4 and 6 days as in-patients.
Figure 1: STROBE diagram

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There were differences at admission between the cases and controls as shown in [Table 1]. Dilated cardiomyopathy was seen in 25% and 15.4% of cases and controls, respectively. Cases had a higher proportion of NYHA Class 4 dyspnea, noncompliance to medications, intubation for respiratory failure, significant hypotension on admission, left ventricular third heart sound, HF with reduced ejection fraction, infection during current hospitalization, abnormal lactates, and hyperkalemia. On univariate analysis [Table 2], we found systolic pressure <115 mmHg, serum sodium <135 mEq/L, serum potassium >5 mEq/L, left ventricular ejection fraction <40%, serum lactate >2 mmol/L, serum creatinine >1.4 mEq/L, duration of hospital stay >5 days, and admission Glasgow Coma Scale (GCS) <15 were statistically different between cases and controls.
Table 1: Baseline characteristics

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Table 2: Unadjusted univariate analysis

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In multivariate logistic regression [Table 3], the factors that independently predicted in-hospital mortality were systolic blood pressure <115 mmHg (odds ratio [OR] – 2.82, confidence interval [CI] [1.29–6.19]), serum lactate >2 mmol/l (OR – 2.61, CI [1.16–5.87]), and GCS <15 (OR – 6.64, CI [2.26–19.51]). Hospital stay >5 days decreased the odds of dying during the current hospitalization with an OR – 0.35, CI (0.16–0.75).
Table 3: Adjusted multivariate analysis

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  Discussion Top


In three large HF cohort registries ADHERE, OPTIMISE-HF, and EFFECT the in-hospital mortality rates were 4.2%, 3.8%, and 8.9% respectively.[3],[4],[13] Indian studies, namely Trivandrum Heart Failure Registry (THFR), Thanusubramanian et al. and Palaniappan et al. had shown a mortality rate of 8.46%, 12.8%, and 11%, respectively, for hospitalized HF patients.[14],[15],[16] Our study also revealed an in-hospital mortality rate of 12.19% for HF admissions in general medical ward.

The average age of our patients was close to that of the THFR registry (61.2 years).[15] We did not find age as an independent risk factor for mortality, while Munusamy et al. found age >65 to be an independent predictor of death at 2 years.[17]

A low systolic blood pressure was documented as a risk factor for mortality by the ADHERE cohort,[3] OPTIMISE HF trial and a study by Zoghi et al.[4],[18] Our study results were in line with the above studies with odds of dying during hospitalization 2.82 (CI 1.29–6.19), when HF patients present with systolic pressure <115 mmHg, with the lower systolic pressures probably indicating severe cardiac dysfunction. Indian studies looking at the in-hospital mortality in patients admitted for HF, by Mpalaniappan et al., Harikrishnan et al., and Thanusubramanian et al. did not report on the between association between lower systolic blood pressure and in-hospital mortality in HF patients.[14],[15],[16]

Zymliński et al., in his prospective cohort study, had shown that patient admitted with HF with higher admission serum lactates had higher odds for dying during hospital admission and increased mortality at 1 year.[19] Kawase et al.,[20] had also validated higher serum lactate, in hospitalized HF patients, as an independent predictor of in-hospital mortality. Our findings also concurred with the above studies. For patients admitted with HF, with admission serum lactates >2 mmol/l, the Odds ratio for dying during current hospital admission is 2.61, CI (1.16–5.87). They reflect diminished tissue perfusion, despite all compensatory mechanisms, in turn indicating, severe cardiac dysfunction, leading to increased mortality.

Admission GCS <15, an easy clinical score was also found to be an independent predictor of in-hospital mortality in our study. Our findings were similar to the study done by Kataja et al.,[21] which also showed a statistically significant relative risk of 2.6, for in-hospital mortality in patients admitted with HF with cardiogenic shock with altered sensorium. The cause of altered sensorium in patients with HF can be multifactorial with metabolic derangements, sepsis and cerebral hypoperfusion. Despite adjusting for some of these factors a low GCS was still associated with higher mortality. Perhaps, studying other factors such as blood hyper-viscosity, neurohormonal regulation of cerebral blood flow, cerebral small vessel disease, paroxysmal arrhythmia with embolic stroke, may shed light on this association.[22],[23]

Our study showed that the median days of hospital stay was 4 days in cases and 6 days in controls, which was statistically significant. In multivariate analysis, interestingly, duration of hospital stay >5 days was associated with decreased risk of death during hospital admission with an Odds ratio of 0.35, CI (0.16–0.75). Many studies have shown that longer length of hospital stay is associated with increased short-term mortality,[6],[24],[25] implicating length of hospital stay as a proxy for severity of HF. Our study finding may stem from the fact that in the cases group around 50% of patients died on or before 4th day of hospital stay with around 25% of deaths on the 1st day of admission, whereas around 50% of the patients in control group were discharged only at day 6 of admission. However, Philbin et al. had shown that length of hospital stay and death rates were not unidirectionally correlated all the time and there were significant inter-hospital variations, perhaps explained by variations in initial treatment.[26]

Aetiologies of HF such as ischemic heart disease, rheumatic heart disease, and dilated cardiomyopathy were statistically significant between two groups, but should be interpreted with caution because of large number of missing values in these variables. We did not include left ventricular ejection fraction, noncompliance to medications and infection during current HF admission in multivariate analysis, though they were significant in univariate analysis, because of large number of missing values in these two variables (more than 40%).

In our study, well-known established risk factors for mortality in HF[4],[5],[8],[9],[13],[14],[16],[17],[27],[28] like NYHA Grade 4 dyspnea at presentation, hyponatremia (serum sodium <135 mEq/L), hyperkalemia (serum potassium >5 mEq/L), anemia were not statistically significant in the multivariate analysis.

Limitations

We had missing data for some variables as this was a retrospective study. We could not assess the impact of promptness and adequacy of management of HF, which are important determinants of mortality.


  Conclusion Top


In-hospital mortality rate for patients admitted to general medical ward with HF was 12.19%. These are comparable to cohorts managed by cardiologists in India and globally. Systolic blood pressure <115 mmHg, GCS <15, serum lactate >2 mmol/L at admission, were significant predictors of in-hospital mortality. Length of hospital stay >5 days was associated with decreased risk of death during hospitalization. These could be used to guide patient care decisions.

Acknowledgment

We are thankful to the patients who have been admitted to our institution and contributed to the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart 2007;93:1137-46.  Back to cited text no. 1
    
2.
Filippatos G, Parissis JT. Heart failure diagnosis and prognosis in the elderly: The proof of the pudding is in the eating. Eur J Heart Fail 2011;13:467-71.  Back to cited text no. 2
    
3.
Fonarow GC, Adams KF Jr., Abraham WT, Yancy CW, Boscardin WJ, ADHERE Scientific Advisory Committee, Study Group, and Investigators. Risk stratification for in-hospital mortality in acutely decompensated heart failure: Classification and regression tree analysis. JAMA 2005;293:572-80.  Back to cited text no. 3
    
4.
Abraham WT, Fonarow GC, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al. Predictors of in-hospital mortality in patients hospitalized for heart failure: Insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). J Am Coll Cardiol 2008;52:347-56.  Back to cited text no. 4
    
5.
Joshi PP, Mohanan CJ, Sengupta SP, Salkar RG. Factors precipitating congestive heart failure-role of patient non-compliance. J Assoc Physicians India 1999;47:294-5.  Back to cited text no. 5
    
6.
Nayar P, Yu F, Chandak A, Kan GL, Lowes B, Apenteng BA. Risk factors for in-hospital mortality in heart failure patients: Does rurality, payer or admission source matter? J Rural Health 2018;34:103-8.  Back to cited text no. 6
    
7.
Win TT, Davis HT, Laskey WK. Mortality Among patients hospitalized with heart failure and diabetes mellitus: Results from the national inpatient sample 2000 to 2010. Circ Heart Fail 2016;9:e003023.  Back to cited text no. 7
    
8.
McClellan WM, Flanders WD, Langston RD, Jurkovitz C, Presley R. Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: A population-based study. J Am Soc Nephrol 2002;13:1928-36.  Back to cited text no. 8
    
9.
Ruigómez A, Michel A, Martín-Pérez M, García Rodríguez LA. Heart failure hospitalization: An important prognostic factor for heart failure re-admission and mortality. Int J Cardiol 2016;220:855-61.  Back to cited text no. 9
    
10.
John KJ, Turaka VP, Muruga Bharathy K, Vignesh Kumar C, Jayaseelan L, Visalakshi J, et al. Predictors of mortality, strategies to reduce readmission, and economic impact of acute decompensated heart failure: Results of the Vellore Heart Failure Registry. Indian Heart J 2020;72:20-6.  Back to cited text no. 10
    
11.
Philbin EF, Jenkins PL. Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: Analysis of a large, statewide database. Am Heart J 2000;139:491-6.  Back to cited text no. 11
    
12.
Di Bari M, Pozzi C, Cavallini MC, Innocenti F, Baldereschi G, De Alfieri W, et al. The diagnosis of heart failure in the community. Comparative validation of four sets of criteria in unselected older adults: The ICARe Dicomano Study. J Am Coll Cardiol 2004;44:1601-8.  Back to cited text no. 12
    
13.
Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting mortality among patients hospitalized for heart failure: Derivation and validation of a clinical model. JAMA 2003;290:2581-7.  Back to cited text no. 13
    
14.
Palaniappan M, Karthikeyan N, Kumar DP, Vetriveeran B, Kumar TR, Vishnuram P, et al. Factors Predicting Mortality in Indian Patients Hospitalized for Acute Decompensated Heart Failure. IOSR J Dental Med Sci 2016;15:90-5.  Back to cited text no. 14
    
15.
Harikrishnan S, Sanjay G, Anees T, Viswanathan S, Vijayaraghavan G, Bahuleyan CG, et al. Clinical presentation, management, in-hospital and 90-day outcomes of heart failure patients in Trivandrum, Kerala, India: The Trivandrum Heart Failure Registry. Eur J Heart Fail 2015;17:794-800.  Back to cited text no. 15
    
16.
Thanusubramanian H, Kishore MK, Shetty R, Amberkar MB. A retrospective study of the treatment outcome of drug therapies used in heart failure patients with associated co-morbidities in a tertiary care hospital. J Clin Diagn Res 2016;10:C06-9.  Back to cited text no. 16
    
17.
Munusamy V, Goenka L, Sharma M, Ramamoorthy T, Jha D, Solaipriya S, et al. Clinical presentation and 2-year mortality outcomes in acute heart failure in a tertiary care hospital in South India: A retrospective cohort study. J Clin Prev Cardiol 2019;8:56.  Back to cited text no. 17
  [Full text]  
18.
Zoghi M, Duygu H, Güngör H, Nalbantgil S, Yilmaz GM, Tülüce K, et al. The determination of the factors impacting on in-hospital mortality in patients with acute heart failure in a tertiary referral center. Anadolu Kardiyol Derg 2008;8:255-9.  Back to cited text no. 18
    
19.
Zymliński R, Biegus J, Sokolski M, Siwołowski P, Nawrocka-Millward S, Todd J, et al. Increased blood lactate is prevalent and identifies poor prognosis in patients with acute heart failure without overt peripheral hypoperfusion: Lactates in acute heart failure. Eur J Heart Fail 2018;20:1011-8.  Back to cited text no. 19
    
20.
Kawase T, Toyofuku M, Higashihara T, Okubo Y, Takahashi L, Kagawa Y, et al. Validation of lactate level as a predictor of early mortality in acute decompensated heart failure patients who entered intensive care unit. J Cardiol 2015;65:164-70.  Back to cited text no. 20
    
21.
Kataja A, Tarvasmäki T, Lassus J, Køber L, Sionis A, Spinar J, et al. Altered mental status predicts mortality in cardiogenic shock – Results from the CardShock study. Eur Heart J Acute Cardiovasc Care 2018;7:38-44.  Back to cited text no. 21
    
22.
Heckman GA, Patterson CJ, Demers C, St. Onge J, Turpie ID, McKelvie RS. Heart failure and cognitive impairment: Challenges and opportunities. Clin Interv Aging 2007;2:209-18.  Back to cited text no. 22
    
23.
Leto L, Feola M. Cognitive impairment in heart failure patients. J Geriatr Cardiol 2014;11:316-28.  Back to cited text no. 23
    
24.
Cotter G, Davison BA, Milo O, Bourge RC, Cleland JG, Jondeau G, et al. Predictors and associations with outcomes of length of hospital stay in patients with acute heart failure: Results from VERITAS. J Card Fail 2016;22:815-22.  Back to cited text no. 24
    
25.
Reynolds K, Butler MG, Kimes TM, Rosales AG, Chan W, Nichols GA. Relation of acute heart failure hospital length of stay to subsequent readmission and all-cause mortality. Am J Cardiol 2015;116:400-5.  Back to cited text no. 25
    
26.
Philbin EF, Rogers VA, Sheesley KA, Lynch LJ, Andreou C, Rocco TA Jr. The relationship between hospital length of stay and rate of death in heart failure. Heart Lung 1997;26:177-86.  Back to cited text no. 26
    
27.
Cardoso JN, Del Carlo CH, Oliveira Junior MT, Ochiai ME, Kalil Filho R, Barretto AC. Infection in patients with decompensated heart failure: In-hospital mortality and outcome. Arq Bras Cardiol 2018;110:364-70.  Back to cited text no. 27
    
28.
Kajimoto K, Minami Y, Sato N, Takano T; Investigators of the Acute Decompensated Heart Failure Syndromes (ATTEND) registry. Serum sodium concentration, blood urea nitrogen, and outcomes in patients hospitalized for acute decompensated heart failure. Int J Cardiol 2016;222:195-201.  Back to cited text no. 28
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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