Full text of DOI:10.1002/clc.4960250404

Clin. Cardiol. 25, 149–152 (2002)
Clinical Presentation, Hospital Length of Stay, and Readmission Rate in
Patients with Heart Failure with Preserved and Decreased LeftVentricular
Systolic Function
QAHTAN MALKI, M.D., NAGARAJA D. SHARMA, M.D.,ADNAN AFZAL, M.D., KARTHIK ANANTHSUBRAMANIAM, M.D.,ALI ABBAS, M.D.,
GORDON JACOBSON, M.S., SYED JAFRI, M.D.
Henry Ford Hospital, Detroit, Michigan, USA
Summary
Background: Congestive heart failure is the leading cause
of hospital admissions for adults in the United States. To our
knowledge, there are limited data comparing the clinical pres-
entation, hospital length of stay, and readmission in patients
with preserved and decreased left ventricular (LV) systolic
function.
Hypothesis:The goal of the study was to determine whether
there are differences in clinical presentation, hospital length of
stay, and readmission in patients with preserved (≥50%) and
reduced (< 50%) systolic function.
Methods: We prospectively evaluated 187 patients admit-
ted with congestive heart failure confirmed by the presence of
pulmonary vascular congestion on chest x-ray, and with re-
cent (< 6 months) documentation of LV systolic function by
two-dimensional echocardiography. History and physical
examination findings, patient demographics, comorbidities,
discharge medications, and length of hospital stay data were
documented. Readmission rate over a 6-month follow-up pe-
riod was also documented.
vs. 37%, p = 0.03),AfricanAmericans (79 vs. 60%, p = 0.007),
had a higher prevalence of previous stroke (17 vs. 5%, p =
0.03), and were more likely to carry no medical insurance at
the time of admission (14 vs. 2%, p = 0.01) and to be dis-
charged on digoxin (60 vs.30%, p < 0.001). There were no
significant differences in symptoms (exertional dyspnea, rest
dyspnea, orthopnea, or paroxysmal nocturnal dyspnea), or in
physical examination findings (S3, S4, elevated jugular ve-
nous pressure, rales, or peripheral edema).According to chest
x-ray, patients with EF <50% had more frequent cardio-
megaly (88 vs. 72% p = 0.008), but there were no differences
in the presence of pleural effusion or pulmonary vascular
congestion (p = NS). The mean length of stay was 5.9 and 5.2
days, respectively (p = 0.34). During the 6-month follow-up
period, the readmission rates were 33% (43 patients) and 26%
(15 patients), respectively (p = 0.36).
Conclusion: The clinical presentation, hospital length of
stay, and readmission rate for congestive heart failure are
similar in patients with preserved and decreased LV systolic
function.
Results: Of the 187 patients, 130 (70%) patients had an ejec-
tion fraction (EF) < 50%, and 57 (30%) patients had an EF
≥50%. Patients with EF < 50% were more likely to be men (54
Key words: heart failure, left ventricular systolic function,
ejection fraction, follow-up
Introduction
Heart failure remains the leading cause of hospital admis-
sions in adults in the U.S., with estimated costs exceeding 100
billion dollars annually.1, 2 Furthermore, the rate of readmis-
sion to the hospital within 90 days of hospital discharge is re-
ported to be as high as 45%.3–5 Previous studies suggest that
30 to 40% of patients with heart failure have preserved left
ventricular (LV) systolic function.1, 2, 6, 7 Therefore, targeting
this patient population and understanding the differences be-
tween patients with decreased and preserved systolic function
is of paramount importance in guiding therapeutic manage-
ment and clinical decision making. Since the pathophysiology
and thus the management are different in patients with heart
failure with preserved versus depressed LV systolic function,
early identification of these two subsets of patients will allow
The preliminary findings in this manuscript were presented at the
Heart Failure Society of America Annual Meeting, September 2000,
Boca Raton, Florida
Address for reprints:
Syed M. Jafri, M.D.
Henry Ford Hospital
Division of Cardiology K-14
2799 West Grand Blvd
Detroit, MI 48202, USA
E-mail: sjafri2@hfhs.org
Received: December 15, 2000
Accepted with revision: May 1, 2001

150
Clin. Cardiol. Vol. 25, April 2002
appropriate therapeutic strategies. To our knowledge, there are
limited prospective data comparing the clinical presentation,
hospital length of stay, and readmission rate of patients with
heart failure with preserved and decreased systolic function.8
The goal of our study was to determine whether there are dif-
ferences between patients with preserved (≥50%) and reduced
(< 50%) systolic function.
48%). The mean EF for the 57 patients with an EF of at least
50% was 54 ± 4% (median of 55%, range 50–65%).
Sociodemographics
As summarized in Table I, patients with decreased systolic
function (EF < 50%), were more likely to be men (54 vs.
37%, p = 0.03), African Americans (79 vs. 60%, p = 0.007),
had a higher prevalence of previous stroke (17 vs. 5%, p =
0.03), and were also more likely to carry no medical insur-
ance at the time of admission (14 vs. 2%, p = 0.01). There were
no statistically significant differences between the two groups
with regard to age, history of hypertension, diabetes, peripher-
al vascular occlusive disease, smoking status, and history of
myocardial infarction.
Methods
Henry Ford Hospital, Detroit, is a 900-bed urban hospital
with direct admissions from emergency rooms, suburban
clinics, and transfers from several community hospitals. This
study comprises the prospective evaluation of 198 consecu-
tive patients admitted to the hospital during a 6-month time
period with the admitting diagnosis of congestive heart fail-
ure. Patients were eligible for the study if they had both clini-
cal and radiographic evidence of pulmonary vascular conges-
tion not related to acute myocardial infarction. Only 187
patients (95%) with recent (< 6 months) documentation of LV
function by echocardiography were included in the analysis.
Detailed clinical data (history, physical examination, chest x-
ray, electrocardiogram [ECG]) were prospectively collected
by the study investigators. Data regarding patient demograph-
ics, comorbidity, discharge medications, and length of hospi-
tal stay and readmission data over a 6-month follow-up peri-
od were documented. Follow-up evaluation was performed
by means of a telephone questionnaire at 2, 4, and 6 months
after discharge.
History and Physical Examination Findings
There were no significant differences in symptoms (exer-
tional dyspnea, rest dyspnea, orthopnea, or paroxysmal noctur-
nal dyspnea) or in physical examination findings (S3, S4, jugu-
lar venous distention, rales, or peripheral edema). By chest
x-ray, patients with low EF had more often cardiomegaly (88
vs. 72% p = 0.008), but there were no differences in the pres-
ence of pleural effusion or pulmonary congestion (Table II).
Discharge Medications
Patients with decreased LV systolic function were more
likely to be prescribed digoxin at the time of discharge (60 vs.
30%, p < 0.001), whereas patients with preserved function
were more likely to be discharged on a calcium-channel block-
er (39 vs. 16%, p < 0.001). There was no significant difference
between the two study groups with regard to the use of diuret-
ics, beta blockers, or angiotensin-converting enzyme inhibi-
tors upon discharge.
StatisticalAnalysis
Patients with LV ejection fraction (EF) <50% were com-
pared with patients with EF ≥50% using standard tests of as-
sociation. The categorical variable comparisons were made
using the general chi-square test. The Fisher exact test was
used instead of the chi-square test if the expected number of
patients within any category was < 5. The numeric variable
comparisons were made using either the Student two-sample
t-test for equal variances or the Welch two-sample t-test for
unequal variances. The Wilcoxon rank sum test was used
rather than the t-test if the assumption of distributional nor-
mality was significantly violated. After further subdividing
the patients into four LVEF subgroups, one-way analysis of
variance (ANOVA) was used to compare the four groups re-
garding the logarithm-transformed hospital length of stay.
Furthermore, the chi-square test was used to compare the four
groups regarding the readmission status.All comparison test
results were two-sided. For this descriptive study, a signifi-
cance level of 0.05 was used throughout.
TABLE I Sociodemographics and risk factors
Variables
EF < 50% (%) EF≥50% (%)
pValue
Number of patients
Age
Gender (male)
Ethnicity (AA)
Hypertension
Diabetes
130
65 ± 13
54
79
84
57
69 ± 12
37
60
88
0.09
0.03a
0.07a
0.5
50
40
0.4
Previous MI
Previous CVA
Smoker
35
17
46
13
26
5
32
7
0.2
0.03a
0.06
0.5
PVOD
CRI, creatinine> 2.0
24
26
0.6
Results
a P value < 0.05 indicates statistical significance.
Of the 187 patients, 130 (70%) had an EF < 50%, and 57
(30%) had an EF ≥50%. The mean EF for the 130 patients
with an EF < 50% was 27 ± 10% (median of 25, range 10–
Abbreviations: AA =AfricanAmerican, MI = myocardial infarction,
CVA = cerebral vascular disease, PVOD = peripheral vascular occlu-
sive disease, CRI = chronic renal insufficiency.

Q. Malki et al.: Heart failure with preserved and decreased LV systolic function
151
TABLE II Comparison of the clinical history, physical examination,
and chest x-ray findings between patients with preserved (EF ≥50%)
and decreased left ventricular systolic function (EF< 50%)
length of stay of 6 days with a standard deviation (SD) of 5.8
days, a median of 4 days, and a range of 1 to 33 days; 58 pa-
tients with an EF 26–49% had a mean length of stay of 5.8
days with an SD of 5.6 days, a median of 4 days, and a range
of 1 to 25 days. The 49 patients with an EF 50–59% had a
mean length of stay of 5.3 days with an SD of 5.5 days, a me-
dian of 3 days, and a range of 1 to 33 days. Eight patients with
an EF ≥60% had a mean length of stay of 4.3 days with an SD
of 2.3 days, a median of 4.5 days, and a range of 1 to 8 days.
The difference in the length of hospital stay among these four
groups was not statistically significant (p = 0.8). Note that the
ANOVA was performed on the logarithm-transformed length
of stay, thereby conforming sufficiently to the assumption of
distributional normality.
The group percentages with regard to readmission rate
within the 6-month follow-up period (Fig. 2) are as follows:
40% (29/72) for patients with an EF of ≤25%, 24% (14/58) for
patients with an EF between 26 and 49%, 27% (13/49) for pa-
tients with an EF of at least 50 but <60, and 25% (2/8) for pa-
tients with an EF of at least 60%.A statistically significant dif-
ference among those percentages was not detected (p = 0.2).
However, there was a trend for increased readmission in the
very low EF group of ≤25% compared with the other groups
(40 vs. 26%).
EF< 50%
EF ≥50%
Variables
130 patients
57 patients
pValue
Exertional dyspnea, %
Rest dyspnea, %
Orthopnea, %
Admission HR
Admission SBP
Admission DBP
77.7
59
65
98 ± 23
149 ± 40
89 ± 23
77.2
51
51
0.9
0.3
0.45
0.3
0.1
0.9
0.6
0.3
0.8
0.7
94 ± 24
159 ± 41
86 ± 29
6.5 ± 2.8 cm
16
Jugular venous pressure 6.6 ± 2.7 cm
Admission S3 gallop, %
Admission S4 gallop, %
Rales at admission, %
Cardiomegaly, %
Pleural effusion, %
Pulmonary congestion, %
23
26
88
88
44
98
25
86
72
46
0.008 a
0.8
0.6
100
a P value <0.05 indicates statistical significance.
Abbreviations: PND = paroxysmal nocturnal dyspnea, HR = hear
rate, SBP = systolic blood pressure, DBP = diastolic blood pressure,
EF = ejection fraction.
Hospital Length of Stay and Readmission Rate
Discussion
The mean length of stay was 5.9 days, median of 4 days,
and a range of 1 to 33 days for patients with low EF < 50%. For
patients with preserved systolic function (EF ≥50%), the
mean length of hospital stay was 5.2 days, median of 4 days,
range of 1 to 33 days. The difference between the two groups
was not statistically significant (p = 0.34).
Of the 130 patients with an EF < 50%, 43 patients (33%)
were readmitted within 6 months of discharge. Of the 57 pa-
tients with an EF of ≥50%, 15 (26%) were readmitted. That
difference is not statistically significant (p = 0.36).
Heart failure is the most common discharge diagnosis
among men and women aged ≥65 years. Readmission con-
tributes to morbidity in these patients and is reported to occur
in 20 to 50% of patients within 14 days to 6 months after dis-
charge.3–5, 9, 10 Previous studies have documented patients
with heart failure at risk for readmission include male gender,3
prior admission,3, 10 prior heart failure,10 diabetes,9 comorbid-
ity,3 and low serum sodium.9 Acute heart failure caused by
myocardial infarction or severe hypertension10 also correlated
with readmission. Large observational studies of readmission
with heart failure did not include EF as a correlate for hospital
readmission.4 Chin, in a prospective evaluation of 257 patients
with heart failure to determine the correlates of early hospital
Further patients stratification based on LVEF into four
groups (EF < 25%, EF 26–49%, EF 50–59%, EF ≥60%),
showed the following results.With regard to hospital length of
stay, (Fig. 1), 72 patients with an EF of ≤25% had a mean
n =
72
n =
58
n =
49
n =
8
n=29/72
40
6
5
4
3
2
1
35
30
25
n=13/49
n =14/58
n=2/8
20
15
10
5
0
EF
EF
0
≤
25%
26 –
49%
50 –
59%
≥
60%
≤
25%
26 –
49%
50 –
59%
≥
60%
FIG. 1 Comparison of hospital length of stay (LOS) based on the
ejection fraction (EF). P value > 0.05.
FIG. 2 Comparison of readmission rates (RR) based on the ejec-
tion fraction (EF). P value > 0.05.

152
Clin. Cardiol. Vol. 25, April 2002
readmission found that EF did not correlate with the rate of
readmission.11 The results of our study suggest that the hospi-
tal length of stay and readmission rate are similar in patients
with heart failure with preserved and decreased LVEF.
The clinical entity of heart failure with preserved systolic
function is increasingly recognized and accounts for 30–40%
of all admissions to hospital with heart failure.1, 2, 6–8 Under-
standing the differences in the clinical characteristics between
these two subsets of patients with heart failure will help devel-
op strategies targeted to decrease hospital length of stay and
readmission rate.
> 40% for those with preserved function. Our analysis includ-
ed patients with EF between 40 and 50%, and we used 50% as
the cut-off for normal and abnormal systolic function, which
might explain the differences in our findings compared with
these studies. Also, the sample size may be a factor that ex-
plains these differences. However, our study shows that there
are no differences with regard to the length of stay and read-
mission rate, suggesting similar resource utilization between
the two groups.
Conclusion
The first question we wanted to address in this study was
whether clinical data can help differentiate patients with heart
failure with preserved and decreased systolic function. Pre-
vious studies have shown that in patients with coronary artery
disease, the presence of cardiomegaly on chest x-ray, ECG ev-
idence of transmural myocardial infarction, dyspnea, and rales
have a predictive accuracy of 81% for identifying normal or
abnormal EF. There are limited data, however, that looked
specifically at the differences in the clinical findings in patients
with preserved and decreased LV systolic function.12 We
found no significant differences in symptoms between the two
patient populations (exertional dyspnea, rest dyspnea, orthop-
nea, paroxysmal nocturnal dyspnea), nor in physical examina-
tion findings (S3, S4, jugular venous distension, rales, or pe-
ripheral edema).While the physical findings were similar, it is
possible that with a thorough evaluation of the point of maxi-
mal impulse and careful evaluation for the presence of S3 and
S4 gallops, experienced clinicians may be able to differentiate
these entities better than those reported in our analysis.
Our study analyzed the differences in hospitalized patients
with congestive heart failure exacerbation. Patients with LV
systolic dysfunction were more likely to be men, black, to have
a history of cerebral vascular events, and to have cardiomegaly
on chest x-ray. Our results show that among consecutively
hospitalized patients with heart failure, hospital length of stay
and readmission rates within 6 months of discharge from the
study institution were not statistically different between pa-
tients with preserved and reduced systolic function.
Our study concludes that the clinical presentation in heart
failure is similar in patients with preserved and decreased left
ventricular systolic function and cannot be reliably differenti-
ated by history, physical examination, and chest x-ray. The
hospital length of stay and readmission rates are similar in
these subsets of patients. Clinical trials are needed to identify
strategies to improve outcomes among the growing subsets of
patients with heart failure and preserved systolic function.
References
1. McDermott MM: Clinical characteristics and drug therapy in hos-
pitalized congestive heart failure patients with preserved vs. abnor-
mal left ventricular systolic function. Am J Med 1995;69:629–625
2. DoughertyAH: Congestive heart failure with normal systolic func-
tion. Am J Cardiol 1984;54:778–782
3. Krumholz HM: Readmission after hospitalization for congestive
heart failure among Medicare beneficiaries. Arch Intern Med 1997;
157:99–104
4. Gooding J: Hospital readmissions among the elderly. J Am Geriatr
Soc 1985;33:595–601
5. Rich MW: Effect of DRGs on three-month readmission rate of
geriatric patients with congestive heart failure. Am J Public Health
1988;78:680–682
6. McDermott MM: Systolic function, readmission rates, and survival
among consecutively hospitalized patients with congestive heart
failure. Am Heart J 1997;134,N4:728–736
7. Saufer R: Intact systolic left ventricular function in clinical conges-
tive heart failure. Am J Cardiol 1985;55:1032–1036
While the focus of pharmacologic strategies has been de-
voted entirely to heart failure with systolic dysfunction, there
is a distinct lack of clinical trials data to support therapeutic
strategies in patients with preserved systolic function.9, 10, 13, 14
McDermott, in his retrospective analysis of 412 patients
with congestive heart failure exacerbation, reported that pa-
tients with systolic dysfunction were more likely to be read-
mitted within 6 months than are those with preserved systolic
function.1 The cut-off for EF was > 50% or < 40%, respective-
ly; patients with EF 40–50% were excluded, compared with
our study which included all patients with the cut-off for EF of
< 50% and ≥50%, respectively. Harjai, in a retrospective
analysis of 443 consecutive patients admitted with congestive
heart failure, reported that patients with depressed LV systolic
function had higher resource utilization and readmission rates
following hospitalization for heart failure.8 The cut-off in his
study was ≤40% for patients with depressed LV function and
8. Harjai KJ: The independent effects of left ventricular ejection frac-
tion on short term outcomes and resource utilization following hos-
pitalization for heart failure. Clin Cardiol 1999;22(3):184–190
9. Rich MW:A multidisciplinary intervention to prevent the readmis-
sion of elderly patients with congestive heart failure. N Engl J Med
1995;333:1190–1195
10. Rich MW: Prevention of readmission in elderly patients with con-
gestive heart failure: Results of prospective, randomized pilot
study. J Gen Intern Med 1993;8:585–590
11. Chin MH: Correlates of early hospital readmission or death in
patients with congestive heart failure. Am J Cardiol 1997;79:
1640–1644
12. Thomas TJ: History, physical exam, ECG and CXR do not differ-
entiate normal from decreased systolic function in patients with
CHF (abstr 1998). J Am Coll Cardiol 1999:I-381
13. Ashton CM: The association between the quality of inpatient care
and early readmission. Ann Intern Med 1995;122:415–421
14. West JA: A comprehensive management system for heart failure
improves clinical outcomes and reduces medical resource utiliza-
tion. Am J Cardiol 1997;79:58–63