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CHD without severe systolic dysfunction increases risk for sudden, arrhythmic deaths
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The major cause of death among patients with CHD without severe systolic dysfunction was sudden and/or arrhythmic death, according to a study published in JAMA Cardiology.
PRE-DETERMINE study
Neal A. Chatterjee, MD, MSC, research fellow in medicine at Massachusetts General Hospital, and colleagues analyzed data from 5,761 patients (mean age, 64 years; 76% men) from the PRE-DETERMINE study with CHD and a history of MI and/or mild to moderate left ventricular dysfunction. These patients also did not meet the guideline criteria for implantable cardioverter defibrillator implantation based on NYHA HF class or LV ejection fraction. Patients with a life expectancy of less than 6 months, current or planned ICD or a history of cardiac arrest not associated with acute MI were excluded from the study.
Information on clinical characteristics, demographics, lifestyle habits, medical history, medications and cardiac test results were collected at baseline. Patients completed questionnaires over the phone or mail every 6 months on ICD implantation, intervening cardiac arrest and other CV endpoints.
The primary endpoint was sudden and/or arrhythmic deaths.
During a median follow-up of 3.9 years, the cumulative incidence of sudden and/or arrhythmic death was 2.1% (95% CI, 1.8-2.6) vs. 7.7% for nonsudden and/or arrhythmic death (95% CI, 7-8.5). The most common cause of CV death was sudden and/or arrhythmic death (56%), although most deaths in this cohort were noncardiac.
Patients with LVEF greater than 60% had the lowest 4-year cumulative incidence of sudden and/or arrhythmic death (1%). Those with an LVEF between 30% and 40% (4.9%; 95% CI, 3-7.6) and patients with class III or IV HF (5.1%; 95% CI, 2.6-8.9) had the highest incidence. The high-risk subgroups had a similar cumulative incidence of nonsudden and/or arrhythmic death.
Increased risk for death
An LVEF between 40% and 49% was more associated with sudden and/or arrhythmic death (HR = 3.68; 95% CI, 2.05-6.6) compared with nonsudden and/or arrhythmic death (HR = 1.98; 95% CI, 1.51-2.6). Patients with advancing age and class II HF had an increased risk for nonsudden and/or arrhythmic death.
Sudden and/or arrhythmic death occurred in 14% of patients with NYHA class II HF and in 49% of those younger than 60 years.
“Looking ahead, identification of markers that uniquely discriminate [sudden and/or arrhythmic death] from non-[sudden and/or arrhythmic death] will be required to maximize absolute and proportional risk in subpopulations targeted for sudden death prevention,” Chatterjee and colleagues wrote.
“Because [sudden arrhythmic death] is the only type of sudden death rescued by automatic external defibrillators and ICDs and is the intended focus of genetic association and risk studies of [sudden cardiac death], it is essential to distinguish [sudden arrhythmic death] from nonarrhythmic causes,” Zian H. Tseng, MD, MAS, professor of medicine at the University of California, San Francisco, wrote in a related editorial. “While comprehensive autopsies are not practical in most clinical trials and population, cohort or genetic association studies, understanding the limits of current criteria used to define [sudden cardiac death] and [sudden arrhythmic death] is important for interpreting results.” – by Darlene Dobkowski
Disclosures: The PRE-DETERMINE study was supported by the NHLBI, St. Jude Medical and St. Jude Medical Foundation. Chatterjee and Tseng report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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