CHRISMED Journal of Health and Research

: 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

Faith Mariam John1, Anisha Joy1, Nevine Joseph Nellimala1, K Muruga Bharathy1, Turaka Vijay Prakash1, Kevin John John1, Alice Joan Mathuram1, Sowmya Sathyendra1, OC Abraham1, I Ramya1, Visalakshi Jayaseelan2, Thambu David Sudarsanam1,  
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

Correspondence Address:
K Muruga Bharathy
Department of Internal Medicine, Unit-2, Christian Medical College and Hospital, Vellore, Tamil Nadu


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.

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;8:125-130

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 2022 Jan 18 ];8:125-130
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Full Text


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.


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


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.


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}

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}{Table 2}

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}


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.


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.


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.


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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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