219 J I M D C   2 0 1 7  219 

Open Access 
F u l l  L e n g t h  A r t i c l e  

 Precipitants of Acute Decompensated Heart Failure and their 

Correlation with the Severity of Decompensation in a Resource Poor 

Country 

Sidra Zahoor 1, Muhammad Shafique Arshad 2, Asad Riaz 3, Muhammad Farhan 4 
1 Resident, Department of Cardiology, Pakistan Institute of Medical Sciences, Islamabad 

2 Associate Professor, Department of Cardiology, Pakistan Institute of Medical Sciences, Islamabad 
3 Resident, Department of Cardiology, Pakistan Institute of Medical Sciences, Islamabad 
4 Resident, Department of Cardiology, Pakistan Institute of Medical Sciences, Islamabad  

(Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad) 

A B S T R A C T  

Objective: 1. To determine the frequency of various factors (patient related, disease related and physician related), 

causing immediate precipitation of congestive cardiac failure in a tertiary care hospital. 2. To establish correlation 

between these variables and severity of decompensated heart failure. 

Patients and Methods: This cross-sectional study was carried out over a period of March-August, 2016. All patients 

admitted to cardiology ward and Coronary Care Unit (CCU) of Pakistan Institute of Medical Sciences during the study 

period were enrolled in the study using consecutive sampling technique. An arbitrarily predetermined sample size of 115 

patients was taken. Precipitants were classified as patient related, disease related and physician related. Data was 

recorded and analyzed using SPSS version 22. Qualitative variables were reported as percentages and quantitative 

variables by using mean ± standard deviation. Spearman correlation coefficient was used to determine the correlation 

between variables and outcome measures. 

Results: A total of 115 patients were enrolled in this study. The mean age of the population was 51.13±13.6 years. 

Among these 38.3% of the population was obese. The patients remained admitted to the hospital for the index episode 

of decompensation for a mean period of 4.14±1.2 days. Infections were found to be the leading precipitant contributing 

to 57.6% of all decompensation episodes. This was followed by drug non-compliance (17.4%) and arrhythmias (8.7%). 

Ischemia was noted in 5.2%. Heart failure severity at presentation was found to correlate significantly with the presence 

of hypertension (Spearman coefficient 0.62, p-value 0.04), baseline hemoglobin (Spearman coefficient -0.58, p-value 

0.03), creatinine levels (Spearman coefficient 0.71, p-value 0.05) and precipitant of heart failure (Spearman coefficient 

0.257, p-value 0.007). 

Conclusion: A sizeable majority of heart failure hospitalizations can be prevented by inculcating measures directed at 

effective infection control at community and health care level and educating patients regarding recognition of early signs 

of infection that may target the most important immediate precipitant for acute decompensated heart failure. 

Key words: Correlation, Decompensation, Heart failure, Severity. 

Author`s Contribution 
1
 Conception, synthesis, planning of research 

and manuscript writing 
2 

Interpretation and discussion 
3
 Data analysis, interpretation and 

manuscript writing, 
4 

Active participation in 
data collection  

Address of Correspondence 
Sidra Zahoor 
Email: sidrazahoor@hotmail.com 

Article info. 
Received:  April 7, 2017 
Accepted:  September 17,2017 

Cite this article. Zahoor S, Arshad M. S, Riaz A, Farhan M. Precipitants of Acute 
Decompensated Heart Failure and their correlation with the Severity of Decompensation in a 
Resource Poor Country. JIMDC.2017;6(4): 

 

Funding Source: Nil 
Conflict of Interest: Nil 

O R I G I N A L  A R T I C L E  



 

                           220 J I M D C   2 0 1 7  220 

I n t r o d u c t i o n  
 

Coinciding with diminutive rates of death from coronary 

artery disease, a parallel rise in mortality from heart failure 

is being observed, which now has taken over as the 

leading cause of cardiovascular mortality.1 Despite the 

advances in therapeutic options for congestive cardiac 

failure, decompensations requiring hospitalization or 

those leading to death are not uncommon.2 The 

prevalence rates are also known to increase in an 

exponential fashion with increasing age; and up-to 10% of 

the people aged 65 years or more are affected by this 

illness.3 It is now the most common cause of 

hospitalization in people of more than 65 years of age.4 

The diagnosis significantly alters the quality of life and 

overall survival, with mortality rates being as high as the 

average mortality rates for the patients with malignancies. 

One -year survival of patients with NYHA (New York 

Heart Association) IV heart failure has been documented 

to be a mere 50%.5 The socioeconomic impact of this 

illness is immense and a major share of that is contributed 

by the in-hospital stay of the patients with heart failure. 

The US health care facilities encounter over 1 million 

hospitalizations each year with a primary diagnosis of 

heart failure 2 and it costs an approximate $34 billion to 

the country’s economy each year.6 A similar trend has 

been noted in the developing world like Pakistan where 

health care facilities continue to be scarce and under 

equipped, and even when present, a lack of access to 

health care for majority of the population makes diseases 

requiring constant medical attention a growing problem. 

No studies reporting the overall incidence and prevalence 

of heart failure are present and the burden of this illness is 

grossly underestimated owing to under reporting and an 

enormous undiagnosed pool of the heart failure iceberg. 

One single center study carried out in 2008-2010 reported 

heart failure as a cause of 22.87% of all hospitalizations 

with an average hospital stay of 4.97 days. 7 In addition, 

hospitalization for heart failure is a documented predictor 

for readmission and death in the post discharge period 

(20% mortality rate after hospitalization).8 Readmission 

rates may range from 27-47% for up-to 6 months 

following the index discharge.9,10 

Many clinical and lifestyle factors are postulated to 

precipitate decompensation of heart failure. These include 

drug non-compliance, myocardial ischemia, arrhythmias, 

infection, anemia, alcohol, pregnancy, worsening 

hypertension, acute valvular insufficiency and use of 

drugs like calcium antagonists, beta-blockers, NSAIDs, 

thiazolidinedione, and class I anti-arrhythmic drugs. The 

impact of these variables on the course of illness may 

both be transient or permanent. Studies conducted in the 

affluent world have identified behavioral factors as the 

primary culprit in altering the clinical course of heart 

failure adversely; of which non-compliance to sodium 

restriction is the major contributor.11  Another study found 

inadequate medical treatment in the outpatient 

department as the major factor leading to 

decompensation.12 However, suboptimal infection control 

practices, over prescription of antibiotics and a low level 

of health education has led to the observation that 

infections may be the primary and the most common 

precipitating factors culminating into decompensated 

heart failure and at times; death, in Pakistan. All of these 

factors are largely modifiable and a correct identification 

may prompt the primary care physicians and cardiologists 

to address these issues systematically, with increased 

vigilance leading to an improved clinical course and 

reduced economic impact of heart failure on Pakistan’s 

already failing economy. 

P a t i e n t s  a n d  M e t h o d s  

This cross-sectional study was carried out from March-

August, 2016. Sample size was determined through WHO 

sample size calculator using 95% Confidence interval, 

80% power of test and anticipated population proportion 

8.1%.3 Calculated sample size was 115 patients. Patients 

admitted to cardiology ward and Coronary Care Unit 

(CCU) of Pakistan Institute of Medical Sciences were 

enrolled in the study using consecutive sampling. Acute 

decompensated heart failure was defined as any sudden 

or gradual onset of symptoms suggestive of heart failure 

warranting unscheduled OPD visits, emergency room 

visits or hospital admissions. Patients were considered 

eligible to enter into the study if they had a previous or 

current diagnosis of heart failure due to any cause and if 

the primary admitting diagnosis was acute 

decompensated heart failure. Patients with severe  



 

                           221 J I M D C   2 0 1 7  221 

psychiatric illnesses, severe dementia, malignancies or 

patients with an anticipated survival of less than a week 

were excluded from the study. All patients provided 

written informed consent. The hospital’s ethical review 

board approved the study. Presenting symptoms and 

examination findings were noted and NYHA classification 

for dyspnea at the time of presentation was used to 

gauge the severity of the index hospital visit. Pertinent lab 

data were acquired which included ECG, 

echocardiogram, blood complete picture, renal and liver 

functions tests, electrolytes, chest X ray and pregnancy 

test (if applicable). Trained hospital physicians conducted 

the interview during admission using an objectively 

structured questionnaire.  

Figure 1: Distribution of study population according 

to clinical diagnosis (n=115) 

Data was recorded and analyzed using SPSS version 

22.0. Qualitative variables were reported as percentages 

and quantitative variables by using mean ± standard 

deviation. Spearman correlation coefficient was used to 

determine the correlation between variables and outcome 

measures. A p-value of <0.05 was considered to be 

statistically significant.  

R e s u l t s  

A total of 115 patients were included in this study after 

screening for inclusion and exclusion criteria and 

obtaining written informed consent. The baseline 

characteristics of this population are described in table 1. 

The mean age of the population was 51.13±13.6 years. 

Percentage of obesity was 38.3. Mean hemoglobin was 

found to be 13.47±2.12 g/dL and the mean creatinine was 

1.92±0.99 mg/dL. The patients remained admitted to the 

hospital for the index episode of decompensation for a 

mean period of 4.14±1.2 days (maximum 8 days).  

Out of 115, maximum number of patients (n=53) were 

diagnosed to have idiopathic dilated cardiomyopathy. The 

distribution of patients according to their clinical diagnosis 

is as shown in Figure 1. In total 34.8% of the patients had 

a NYHA III dyspnea at the time of admission and 65.2% 

had NYHA IV dyspnea at presentation. The patients had 

an average of 2.14±1.4 admissions over the preceding 6 

months for this illness (maximum 6). The trends of 

precipitants of heart failure that were observed on 

analysis are shown in table 2.  

Table 2: Trends in distribution of immediate 
precipitants of heart failure decompensation in 
study participants (n=115) 

Immediate precipitant Number (%) 

Respiratory tract infection 46(40) 

Urinary Tract infections 11(9.6) 

Other infections (e.g. cellulitis) 8(07) 

Anaemia 8(07) 

Myocardial Ischemia 6(5.2) 

Uncontrolled hypertension 6(5.2) 

Arrhythmia 10(8.7) 

Drug non compliance 20(17.4) 

Table 1: Baseline characteristics of the study 

population (n=115) 

Parameter Status Frequency Percentage 

Hypertension Non 

Hypertensive 

45 39.1 

Hypertensive 70 60.9 

Diabetes Non Diabetic 63 54.8 

Diabetic 52 45.2 

Smoking No 73 63.5 

Yes 42 36.5 

Dyslipidaemia No 84 73 

Yes 31 27 

Lifestyle Sedentary 53 46.1 

Active 62 53.9 

Socioeconomic 

status 

Upper 8 7 

Middle 34 29.6 

Lower 73 63.5 



 

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Heart failure severity at presentation was found to 

correlate significantly with the presence of hypertension, 

baseline hemoglobin levels, baseline creatinine levels and 

precipitant of heart failure (Table 3). The number of 

hospitalizations over preceding 6 months correlated 

significantly with lifestyle and heart failure precipitant. The 

length of index hospital stay was also found to correlate 

significantly with age (Table 3). 

Table 3: Correlation of heart failure 

severity/hospitalization with different variables of 

study (n=115) 
Parameters Variables Correlation 

Coefficient 

p-value 

Heart failure 

severity at 

presentation 

Hypertension 0.62 0.04 

Hemoglobin 

levels 

-0.58 0.03 

Creatinine 

levels 

0.71 0.05 

Nature of heart 

failure 

precipitant 

0.257 0.007 

Number of 

hospitalizations 

for heart failure 

over past 6 

months 

Lifestyle 0.186 0.047 

Nature of heart 

failure 

precipitant 

0.199 0.033 

Length of index 

hospitalization 

Age 0.210 0.022 

D i s c u s s i o n  

Heart failure represents a growing health related problem 

globally with more than 20 million people affected world 

over.6 An exponential rise in incidence with age has also 

been reported and this impact is further amplified on 

account of heart failure being the most common reason 

for hospitalization in the elderly.4  All hospitalizations for 

decompensated heart failure are associated with 

substantial increase in mortality, morbidity and risk of re-

hospitalization as compared to clinically stable heart 

failure.13,14 In this light, targeting modifiable precipitants of 

decompensation may lead to significant improvement in 

overall mortality, morbidity and quality of life of heart 

failure patients. The present study was instituted with this 

aim that may prove to be a stepping stone for enhanced 

health care delivery for patients affected with heart failure. 

The mean patient age in the present cohort was 51.13 

years in contrast to a higher mean age of 73.1 years in a 

similar istudy.15 This difference may have arisen due to a 

higher prevalence of post myocarditis dilated 

cardiomyopathy in our population which tends to affect 

younger age groups. Majority of patients presented with 

NYHA IV symptom severity in our study consistent with 

similar findings noted in another study carried out on a 

resource rich population.16 Ninety-nine percent patients 

had a history of at least one previous hospital admission 

over the last 6 months comparable albeit higher than a 

value of 72.6% in the aforementioned study.16 

The present study identified infection as the major 

immediate precipitant of decompensated heart failure 

accounting for 56.6% of all hospitalizations (respiratory 

infection being the most common one) followed by drug 

noncompliance, arrhythmia and anaemia. Previous 

studies carried out in resource rich populations have 

documented ischemia, drug non-compliance, dietary 

sodium excess, arrhythmias but no such study except 

OPTIMIZE-HF identified infection as the major factor, and 

in that too, it constituted only 15% of total 

decompensation events in contrast to 55.6% in ours.15-18 

This reflects the role of poor infection control practices in 

our population along with suboptimal antibiotic prescribing 

practices giving rise to more frequent and rampant 

infections. This is also one of the major modifiable factors 

implicated in heart failure hospitalizations. To the best of 

our knowledge, correlation of patient and disease related 

factors with severity of heart failure at presentation, length 

of hospital stay and number of hospitalization has not 

been studied previously. 

C o n c l u s i o n  

A sizeable majority of heart failure hospitalizations can be 

prevented by inculcating measures directed at effective 

infection control at health care level and educating 

patients regarding recognition of early signs of infection 

that may target the most important immediate precipitant 

for acute decompensated heart failure. 



 

                           223 J I M D C   2 0 1 7  223 

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