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Original Articles

Death in Heart Failure

A Community Perspective

Danielle M. Henkel, MD; Margaret M. Redfield, MD; Susan A. Weston, MS; Yariv Gerber, PhD and Véronique L. Roger, MD, MPH

From the Department of Medicine (D.M.H), Division of Cardiovascular Diseases, Department of Medicine (M.M.R., Y.G., V.L.R.), Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minn (S.A.W., V.L.R.), Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Medical School (Y.G.), Tel Aviv University, Tel Aviv, Israel.

Correspondence to Véronique L. Roger, MD, MPH, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail roger.veronique{at}mayo.edu

Received October 2, 2007; accepted May 7, 2008.

Background— Mortality in patients with heart failure (HF) remains high, but causes of death are incompletely defined. As HF is a heterogeneous syndrome categorized according to the ejection fraction (EF), the association between EF and causes of death is important, yet elusive.

Methods and Results— Community subjects with HF were classified according to the preserved (50%) and the reduced EF (<50%). Deaths were classified as due to coronary heart disease and other cardiovascular and noncardiovascular diseases. Among 1063 persons with HF, 45% had preserved EF with fewer cardiovascular risk factors and less coronary disease than those with reduced EF. At 5 years, survival was 45% (95% CI, 43% to 49%), and 43% of the deaths were noncardiovascular. The leading cause of death in subjects with preserved EF was noncardiovascular disease (49%) versus coronary heart disease (43%) for subjects with reduced EF. The proportion of cardiovascular deaths decreased from 69% in 1979–1984 to 40% in 1997–2002 (P=0.007) among subjects with preserved EF, which is in contrast to a modest change among those with reduced EF (77% to 64%, P=0.08). Advanced age, male sex, diabetes, smoking, and kidney disease were associated with an increased risk of all-cause and cardiovascular deaths. After adjustment, preserved EF was associated with a lower risk of cardiovascular death but not all-cause death.

Conclusions— Community subjects with HF experience a persistently high mortality, and a large proportion of deaths is noncardiovascular. Cardiovascular disease before death is less in subjects with preserved EF, and they are less likely to experience cardiovascular deaths compared with those with reduced EF. In those with preserved EF, the proportion of cardiovascular deaths declined over time.

Key Words: heart failure • ejection fraction • epidemiology • mortality

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