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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 21-28

Precipitating factors for acute decompensated heart failure in patients with stable chronic left ventricular systolic dysfunction


1 Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
3 Department of Paediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
4 All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication4-May-2018

Correspondence Address:
Dr. Bishav Mohan
Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_60_17

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  Abstract 

Background: The burden of HF in India is high, with an estimated prevalence of about 5 million patients, an annual incidence of one million, an in hospital mortality as high as 30.8%, with postdischarge 6 month major adverse event and mortality rates at 39.5% and 26.3%. Acute decompensated HF is caused by a variety of precipitating factors and many are preventable. Methods: This 1 year study was a prospective study conducted on the patients admitted under a tertiary care unit in north India. Patients included in the study had chronic stable left ventricular systolic dysfunction and developed acute decompensated HF. Results: This study included 150 Patients with ADHF . Moderate to severe anemia was found to be the factor in 63.8% of the patients. New onset myocardial ischemia was the next most common factor leading to acute decompensated HF, Dietary indiscretion was seen in 45.3% of the patients. Noncompliance to drugs was also very common. The study revealed that higher rates of admissions with acute decompensated HF were seen in winters (October to December and January to March). Conclusion: Anemia and noncompliance with drugs were most common precipitating factors leading acute decompensated HF in North Indian population.Every patient needs a more intensive regular follow up and adequate diet pattern for prevention of acute decompensated HF. Systematic patient education and treatment can reduce the burden, risk of ADHF, and re hospitalization.

Keywords: Acute decompensated heart failure, anemia, noncompliance, precipitating factors


How to cite this article:
Kaler GP, Mohan B, Gupta D, Kaler NK, Garg M, Wander GS. Precipitating factors for acute decompensated heart failure in patients with stable chronic left ventricular systolic dysfunction. J Pract Cardiovasc Sci 2018;4:21-8

How to cite this URL:
Kaler GP, Mohan B, Gupta D, Kaler NK, Garg M, Wander GS. Precipitating factors for acute decompensated heart failure in patients with stable chronic left ventricular systolic dysfunction. J Pract Cardiovasc Sci [serial online] 2018 [cited 2022 Aug 8];4:21-8. Available from: https://www.j-pcs.org/text.asp?2018/4/1/21/231937


  Introduction Top


Heart failure (HF) is an increasing health problem worldwide with rates of admission increasing day by day. Approximately 1%–2% of the adult population in developed countries has HF, with the prevalence of more than 10% among persons ≥70 years of age. Causes of HF vary in different parts of the world. HF-reduced ejection fraction (REF), a better-understood entity, and HF-preserved ejection fraction (PEF) each make up about half of the overall HF burden.[1] Coronary artery disease (CAD) is the cause of approximately two-thirds of cases of systolic HF, although hypertension and diabetes are probable contributing factors in many cases. Patients with HF-PEF are older and more often female and obese than those with HF-REF. Patients with HF-PEF have a better prognosis than those with HF-REF.[2] It is estimated that there are 6.5 million hospital days attributed to acute decompensated HF each year. Patients hospitalized with acute decompensated HF face a substantial risk of readmission, as high as 50% by 6 months after discharge.[3] The quest to control the menace of HF has recently lead to an update on HF management guidelines – by both the American College of Cardiology/American heart association (AHA) and European Society of Cardiology (ESC). The introduction of an angiotensin receptor-neprilysin inhibitor (valsartan/sacubitril) and a sinoatrial node modulator (ivabradine) in the management of HF represents a new milestone.[4],[5] However, still, more work requires to be done at primordial-primary level to prevent a decompensation. And hence, identification of such precipitating/etiological factors leading an acute decompensated HF is of utmost importance.

Heart failure in India

In India, we do not have much data regarding the exact etiology, prevalence, incidence of HF. With a higher propensity for cardiovascular diseases and aging population, the burden of HF is likely to be higher in comparison to the western population. Unlike western countries where HF is predominantly a disease of elderly, in India, it affects relatively a younger age group. The two large studies published on acute coronary syndromes (ACSs) also show that Indian patients with acute coronary events were much younger than the western population. The larger of the two studies is the Kerala ACS registry (25,748 patients).[6] The mean age of the patients in that study was 60.4 ± 12.1 years. The mean age of the patients in the CREATE (Treatment and outcomes of ACSs in India) registry of 20468 patients was 57.5 ± 12.1 years.[7] In India, CAD, diabetes, hypertension, valvular heart diseases, and primary muscle diseases are the leading causes for HF. The most recent study on HF in India, AFAR study (Acute failure registry study) concluded that the in hospital mortality was 30.8%, with postdischarge 6-month major adverse event (re-hospitalization/mortality combined) and mortality rates at 39.5% and 26.3%, respectively.[8] Rheumatic heart disease is still a common cause of HF in Indians.[9] HF may occur de novo or as decompensation of an existing chronic HF. The burden of HF in India appears high, and estimates of prevalence range from 1.3 to 4.6 million, with an annual incidence of 491,600–1.8 million. However, reliable data are lacking because of inadequate surveillance systems. The best way to prevent the projected rise of HF in India is by effective and a comprehensive (primordial through tertiary) prevention.[10] Despite similar diagnostic rates and adherence to performance measures as compared to western literature, 6-month mortality and 6-month re-hospitalization rates in the patients were 26.3% and 39.5%, respectively, which may reflect the severity of illness presentation in this cohort.[8]

Acute decompensated HF is caused by a variety of precipitating factors and studies world over have shown that most of them are preventable.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21]

The 2005 guidelines of the ESC,[22] the 2012 ESC guidelines have defined and categorized HF with changing definitions, and The 2013 American College of Cardiology Foundation and AHA (ACCF/AHA) guidelines for the management of HF has classified types of HF into stages and compared them with New York Heart Association Functional Classifications. But still, there is no widely accepted nomenclature for HF syndromes requiring hospitalization. Patients are described as having “acute HF,” “acute HF syndromes,” or “acute(ly) decompensated HF,” while the third has gained greatest acceptance. Data from HF registries have clarified the profile of patients with HF requiring hospitalization.[23],[24],[25],[26] Characteristically, such patients are elderly or near-elderly, equally male or female, and typically have a history of hypertension, as well as other medical comorbidities, including chronic kidney disease, hyponatremia, hematologic abnormalities, and chronic obstructive pulmonary disease.[23],[25],[27],[28],[29],[30],[31],[32] A relatively equal percentage of patients with acute decompensated HF have impaired (a better-understood entity) versus preserved left ventricular systolic function.[26],[33],[34]

This study addresses the need to identify the precipitating, premorbid/comorbid, and other predisposing factors (with their relative frequency) leading to acute decompensated HF in chronic stable patients with known systolic ventricular dysfunction (Ejection fraction ≤40%).


  Materials and Methods Top


This 1-year study was a prospective study conducted on the patients admitted under a tertiary care unit in north India. Patients included in the study had chronic stable left ventricular systolic dysfunction and developed acute decompensated HF, all were on standard HF medications, which include at least two groups of medications mentioned: ACEI/ARB, diuretics, or digoxin.

Inclusion criteria (defining acute decompensated heart failure)

Treated patients with a known left ventricular systolic dysfunction (Ejection fraction ≤40%) since at least 6 months, with symptoms and signs, which have remained generally unchanged for at least a month, were labeled as “chronic stable left ventricular systolic dysfunction.” When this chronic stable HF deteriorated acutely within a span of 15 days and lead to hospital admission, a diagnosis of “Acute decompensated HF” was made (hence, patients with duration of fresh symptoms varying from 1 to 15 days before admission were included). All patients included in the study were previously well compensated and stable with individualized standard treatment protocols and dietary management.

Initial and serial evaluation of the HF patients was done as per the recommendations of the 2013 ACCF/AHA guidelines.[1]

Patients with cor pulmonale were excluded from the study.

Method of collection of data

A careful history, examination, and serial diagnostic tests were performed as per chosen guidelines and recorded on a pro forma. Data recorded included age, sex, height, weight, electrocardiogram (ECG), detailed echocardiography findings, and various [Table 1].
Table 1: Precipitating factors leading to acute decompensated heart failure in patients with chronic stable left ventricular systolic dysfunction

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The routine investigations and others were performed to evaluate these patients-complete blood count, (using Beckman Coulter Auto analyzer, USA) urinalysis, serum electrolytes (calcium, magnesium, phosphorus [using COBAS 6000, Auto Analyzer, Roche Diagnostics, USA] - if required as per clinical status of the patient were done), renal function tests, glucose, fasting lipid profile (if required), liver function tests, and (Thyroid-stimulating hormone, T 3, T 4 – if required), chest X-ray, a 12-lead ECG (using GE Healthcare), a two-dimensional (2D) echocardiography (Using Philips), BNP (using Home Products ELISA Ray BIO ® EIA, kits, Human BNP EIA, Norcross, GA, USA), or N-terminal pro-B-type natriuretic peptide (NT-pro BNP) – if required, biomarkers of myocardial injury or fibrosis – if required, coronary angiography – if required, Others (if need be). Further evaluation for various infections (sputum culture/sensitivity, blood culture/sensitivity, urine culture/sensitivity, etc., were also done), glycosylated hemoglobin levels (if required), and other tests as per clinical requirement. Patients were graded into mild, moderate, and severe anemia according to their hemoglobin values as per WHO Classification of Anemia.[35] Further evaluation was done on the basis on peripheral blood film, iron studies, and other clinical parameters to assess for the type of anemia. Hypertension among patients was graded on the basis of JNC VII guidelines.[36] Precipitating Factors leading to acute decompensated HF with focus on the last 15 days before admission were studied. Their relative frequencies and presence of comorbid factors with attributable rates were quantified. The data collected were analyzed using descriptive and inferential analysis.


  Results Top


This study was conducted in a Tertiary Unit in North India over a period of 1 year and a total of 150 patients who met the inclusion criteria, were included in the study of which 66% were males and 34% were females. The mean age of the patients was 63.3 years (±standard deviation 11.1). Of total 150, 96 patients were diabetic, and 54 were nondiabetics. About 18.8% of diabetics had an uncontrolled diabetic status at presentation [Table 2].
Table 2: Baseline characteristics of patients

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Most of the patients had more than one precipitating factor leading to acute decompensated HF. The factors leading to acute decompensated HF have been illustrated in [Table 3] and [Figure 1].
Table 3: Factors leading to acute decompensated heart failure (n=150)

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Figure 1: Factors leading to acute decompensated heart failure.

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Anemia, noncompliance, and new onset myocardial ischemia (major culprits)

Anemia was the most common factor, and as per WHO Classification of Anemia, 116 patients out of 150 were anemic – 42 were mild anemics, 69 were moderate, and 5 were severely anemic. Mean hemoglobin in males was 11.6 g/dl (±standard deviation 1.9) and mean hemoglobin in females was 10.6 g/dl (±1.7). Anemia of chronic disease was the most common identified type, i.e., 43 patients (37%), iron deficiency anemia was seen in 32 patients (27.6%), megaloblastic anemia in one patient (0.9%), and nutritional anemia in 1.7%. Anemia was normocytic normochromic in 38 patients (32.8%) although type of anemia could not be ascertained in these [Figure 2].
Figure 2: Type of anemia.

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Although 142 (94.7%) patients were aware of the low salt and water restriction still dietary indiscretion was found in 67 patients, i.e., 44.7%. When noncompliance to drugs was added (18.7%) to this, the noncompliance to treatment regimen amounted to 63.4%.

Seventy-one patients (47.3%) of acute decompensated heart failure (ADHF) were found to have new onset myocardial ischemia (with evidence of fresh ECG changes confirmed by echocardiography or coronary angiography).

Other factors

A total of 64 patients out of 150 (42.7%) patients of acute decompensated HF had worsening valvular dysfunction (moderate to severe) as compared to previous 2D ECHO findings. Mitral valve insufficiency was the most common finding (53 patients had moderate and 7 had severe mitral regurgitation). Multiple valvular involvement was seen in many patients. Moderate-to-severe aortic regurgitation was seen in five patients.

Infections contributed significantly to ADHF (35.3% total), and most common infections leading to ADHF were respiratory (35.8%) and urinary tract infections (32.1%), diabetic foot was present in 15.1%. Multiple infections were seen in (3.8%) 2 patients [Table 4].
Table 4: Infections

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Among iatrogenic factors (28% total), recent intake of NSAIDs was the most common (54.8%), others were chlorpheniramine (16.7%), calcium channel blockers (14.3%), NSAIDs taken along with Calcium channel blockers and chlorpheniramine accounted for 7.1% and 2.3% cases, respectively [Figure 3].
Figure 3: Iatrogenic factors (42 patients out of 150).

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Arrhythmias were seen in a total of 30 patients of ADHF – Atrial fibrillation (53.3%) was the most common arrhythmia followed by ventricular tachycardia (20%), complete heart block was seen in 16.7% patients of arrhythmia, and ventricular fibrillation was 10%.

Uncontrolled hypertension was a significant contributor to HF, with most of the patients having Stage I hypertension (76.4%). Stage II hypertension was 17.6% (as per JNC VII guidelines) and one patient was in a state of hypertensive crisis.

Opium (6.7%) and tobacco (1.3%) were the most commonly used toxic products in patients in ADHF and 22 patients were active heavy alcohol consumers.

Although psychosocial factors contributed to deteriorating clinical status in most of the patients with acute decompensated HF significant stressors with depression or anxiety neurosis were seen in 9.3% of the patients.

Among endocrine factors, thyroid dysfunction was observed in a total of 13 patients (8.7%). Uncontrolled hypothyroidism was seen in 46.1% patients and uncontrolled hyperthyroidism in 15.4% of patients with thyroid dysfunction. Rest of them were controlled.

Climate effect

Out of total 150 patients, 50% admissions were in quarter of October to December, 22.7% admissions occurred between January and March [Figure 4]. Hence, a total of 72.7% admissions were done in winters. Moreover, in summers, 17.3% between July and September and only 10% admissions in April–June quarter.
Figure 4: Admissions in different quarters of the year.

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Configuring the findings according to diabetic status and gender of the patients lead to some interesting conclusions [illustrated in [Figure 5] and [Figure 6]]. Anemia was much more common in females (moderate–to-severe anemia was present in 68.6% females as compared to 39.4% in males, P < 0.001).
Figure 5: Precipitating factors according to diabetic status

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Figure 6: Precipitating factors according to gender (Male, n = 99) (Female, n = 51).

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  Discussion Top


This study included 150 Patients with ADHF admitted during all seasons of the year in north India, i.e., from January 1, 2014 to December 31, 2014. The mean age of patients in this study group (63 years ± standard deviation 11.1) was much less as compared to the western population. This gives further weightage to the opinion that coronary disease, as well as HF, is seen at a younger age in Indian population.

Moderate-to-severe anemia was found to be the factor in 63.8% of the patients. Anemia was much more common in females (moderate-to-severe anemia was present in 68.6% as compared to 39.4% in males). Reduced hemoglobin levels are associated with sodium and water retention, reduction of renal blood flow and glomerular filtration rate. Many suggest that anemia causes neurohormonal activation even in the absence of any organic heart disease. All these effects are possibly because of anemia related changes in blood viscosity, oxygen tension in the microvasculature, and nitric oxide availability.[37] Anemia of chronic disease was most commonly seen type of anemia, i.e., in 37% of anemics. Since 64% of subjects were diabetic, underlying renal dysfunction or chronic kidney disease could be a possible attributing factor for the same.

New onset myocardial ischemia was the next most common factor leading to acute decompensated HF, a huge number, i.e., 71 patients had evidence of new onset myocardial ischemia 47.3% (interestingly both kind of patients with or without prior history of myocardial ischemia were seen in this subset).

Dietary indiscretion was seen in 45.3% of the patients. And when noncompliance to drugs was also taken into account (18.7%), noncompliance to the treatment regimen attributed to 64% of all the decompensations.

Mitral valve insufficiency was the most common valvular dysfunction. Infections contributed to acute decompensated HF in 35.3% patients, and it was found that incidence of infections in diabetic group of patients was much higher as compared to nondiabetics (42.7% and 22.2%, respectively) with a significant P = 0.002 [Figure 3], tabulating data as per diabetic status]. Underlying immunocompromised state could be a possible reason for higher rate of infections in diabetics. Among iatrogenic factors NSAIDs, antihistaminics, calcium channel blockers were the most commonly seen agents. The NSAIDs have been thought to cause dose-related increases in sodium and water retention. They may also impair renal function in patients with a decreased effective circulating volume by inhibiting prostaglandin synthesis.[38],[39] Both these factors may precipitate HF. The scientific statement released by American heart association lists a whole lot of drugs that may cause or exacerbate HF.[40] A larger and a fully dedicated study is required to study iatrogenic factors which also include newer oral hypoglycemic drugs such as dipeptidyl peptidase-4 inhibitors and older ones like biguanides and thiazolidinediones.

Among arrhythmias, atrial fibrillation was the most common arrhythmia leading to acute decompensated HF. Uncontrolled hypertension was seen in 11.3% of the patients, and most of the patients were in Stage 1 hypertension (JNC 7 guidelines).[36] Thyroid dysfunction was present in 8.7% patients, and uncontrolled thyroid status was seen in 5.3% of the patients. Uncontrolled hypothyroidism was the most common factor out of these. Thyroid hormones have metabolic and thermoregulatory tissue effects. They regulate cardiac performance by acting on the heart and vascular system. And hence, not only uncontrolled but controlled thyroid dysfunction had a bearing on HF.[41] Illicit drugs (such as opium and cocaine) also seemed to be involved in few patients. This study also shows that psychosocial factors such as depression and anxiety can have a lot of bearing in precipitation of HF (in known LV dysfunction patients). Active heavy alcohol consumption was observed in 22 patients.

Fonarow et al. published a study done during 2003–2004, where 259 US hospitals in OPTIMIZE-HF registry submitted data on 48 612 patients, respiratory involvement (pneumonia), myocardial ischemia, and arrhythmias were the leading causes of HF in 15.3%, 14.7%, and 13.5% patients, respectively.[12] In the Euro HF Survey II, 3580 patients hospitalized for acute HF were recruited by 133 centers in 30 European countries, and it was observed that coronary heart disease, hypertension, and atrial fibrillation were the most common underlying conditions. Moreover, arrhythmias, valvular dysfunction, and ACS were each present as precipitating factor in one-third of the cases.[21] In most of the early studies done the world over, a range of 21%–64% of patients had noncompliance as the precipitating factor of HF exacerbation, sometimes leading to hospitalization.[13],[14],[15],[16],[17] Michalsen et al. had similar observations in a study done in Berlin, Germany.[18] Diaz et al. published in a study on South American population that noncompliance with diet was identified in 52% of the patients, lack of adherence to the prescribed medications amounted to 30% and other factors such as infections, arrhythmias, and ACS were seen in 29%, 25%, and 22% of the patients, respectively.[19] Hence, our results were much similar to all the studies done previously on HF with anemia and noncompliance being major factors.

The study revealed that higher rates of admissions with acute decompensated HF were seen in winters (October to December and January to March). Low temperatures in winters increase peripheral vasoconstriction, which may lead to pulmonary edema as a consequence of left ventricular failure. In patients with symptomatic congestive heart failure, cold exposure decreases exercise capacity and increases the already raised systemic adrenergic activation. The results are similar to one of the earliest studies conducted by Stewart S et al. in Scotland between 1990 and 1996 where it was concluded that significantly more admissions occurred in winters as compared to summers (P< 0.0001). Most of the admissions in winters were also attributed to respiratory infections, hence an extra vigilance in patients with HF is advisable in winter, as is immunization against pneumococcus and influenza.[20] Hence, most of the factors leading to decompensated HF are preventable.


  Conclusion Top


Anemia and noncompliance with drugs were most common precipitating factors leading acute decompensated HF in North Indian population. This study shows that most of the factors precipitating HF in Indian Population were preventable. Anemia needs frequent monitoring and correction. Noncompliance needs to be dealt with more stringently regular phone reminders for treatment/diet correction after discharge may be used for effective management of HF patients. All possible metabolic factors should be adequately monitored, and treatment adjustments be made in a timely manner. Every patient needs a more intensive regular follow-up and adequate diet pattern for prevention of acute decompensated HF. Systematic patient education and treatment can reduce the burden, risk of ADHF, and re-hospitalization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


This article has been cited by
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