Therapies for patients with chronic heart failure caused by left ventricular systolic dysfunction have advanced substantially over recent decades. The cumulative effect of these therapies on ...mortality, mode of death, symptoms, and clinical characteristics has yet to be defined.
This study was a comparison of 2 prospective cohort studies of outpatients with chronic heart failure caused by left ventricular systolic dysfunction performed between 1993 and 1995 (historic cohort: n=281) and 2006 and 2009 (contemporary cohort: n=357). In the historic cohort, 83% were prescribed angiotensin-converting enzyme inhibitors and 8.5% were prescribed β-adrenoceptor antagonists, compared with 89% and 80%, respectively, in the contemporary cohort. Mortality rates over the first year of follow-up declined from 12.5% to 7.8% between eras (P=0.04), and sudden death contributed less to contemporary mortality (33.6% versus 12.7%; P<0.001). New York Heart Association class declined between eras (P<0.001). QTc dispersion across the chest leads declined from 85 ms (SD, 2) to 34 ms (SD, 1) and left ventricular end-diastolic dimensions declined from 65 mm (SD, 0.6) to 59 mm (SD, 0.5) (both P<0.001).
Survival has significantly improved in patients with chronic heart failure caused by left ventricular systolic dysfunction over the past 15 years; furthermore, sudden death makes a much smaller contribution to mortality, and noncardiac mortality is a correspondingly greater contribution. This has been accompanied by an improvement in symptoms and some markers of adverse electric and structural left ventricular remodeling.
Aims The efficacy of cardioversion (DCCV) for restoration of sinus rhythm (SR) in persistent atrial fibrillation (AF) is limited by a high relapse rate. Relapse may be reduced by amiodarone but no ...placebo-controlled trials of efficacy have been performed and the appropriate duration of therapy is unknown. Method and results In this double-blind study, 161 subjects with persistent AF were randomized to one of three groups—placebo (n=38); amiodarone 400mg BD for 2 weeks prior to DCCV and 200mg daily for 8 weeks followed by placebo for 44 weeks (n=62, short-term amiodarone); amiodarone 400mg BD for 2 weeks then 200mg daily for 52 weeks (n=61, long-term amiodarone). Spontaneous reversion to SR occurred before DCCV in 21% (26/123) patients on amiodarone and none of the 38 patients on placebo (absolute difference 21%, 95% confidence interval (CI): 10 to 29%, P=0.002). At 8 weeks following DCCV, 51% (63/123) patients on amiodarone remained in SR compared to 16% (6/38) taking placebo (difference—35% 95% CI: −48 to −18%, P<0.001). At 1 year, 49% (30/61) patients on long-term amiodarone were in SR compared to 33% (21/62) taking short-term amiodarone (difference—15%, 95% CI: −31 to 2%, P=0.085). There was no difference in adverse event rate or quality of life scores between groups. Conclusions Amiodarone pre-treatment before electrical DCCV for persistent AF allows chemical conversion in one-fifth of patients without altering the efficacy of subsequent DC conversion. Amiodarone is more effective than placebo in the maintenance of SR when continued for 8 weeks following successful DCCV. More patients taking long-term amiodarone remained in SR at 52 weeks, but more had serious adverse effects requiring discontinuation of therapy. Eight weeks of adjuvant therapy with amiodarone following successful DCCV may be the preferred option.
...even the patients with preserved systolic function have a 25% five year mortality. ...clinical heart failure itself has a poor long term prognosis, irrespective of electrocardiographically ...determined left ventricular systolic function.
Background:
Mortality in patients with mild to moderate chronic heart failure remains high. At present there is no easy way of identifying patients within this population at increased risk of death ...in the medium to long term.
Aims:
To develop a prognostic index to identify outpatients with mild to moderate chronic heart failure at increased risk of death.
Methods and results:
Five hundred and fifty‐three outpatients mean (S.D.) age 63(±10) years with symptoms of chronic heart failure (mean New York Heart Association functional class, 2.3(±0.5)), were recruited between December 1993 and April 1995. By April 2000, 201 patients had died. Using data from non‐invasive measurements of cardiac size, electrical and autonomic function, renal function and plasma biochemistry we identified eight independent predictors of mortality (all P<0.01). To develop a prognostic index, predictors were dichotomised by group median and awarded 0 or 1 point accordingly. Serum sodium≤140 mmol/l (1 point), creatinine≥111 μmol/l (1 point), cardiothoracic ratio≥0.52 (1 point), SDNN≤112 ms (1 point), maximum corrected QT interval≥487 ms (1 point), QRS dispersion≥42.7 ms (1 point), the presence of non‐sustained ventricular tachycardia (1 point) and voltage criteria for left ventricular hypertrophy on 12‐lead ECG (1 point). We calculated risk scores for patients by adding the points of each independent risk factor. In the low‐risk group (0–3 points) mortality at 5 years was 20% and in the high‐risk group (4–8 points) 53%. The area under the receiver–operator characteristic curve using dichotomised variables was 0.74 and for continuous model 0.78.
Conclusions:
Our prognostic index which uses eight non‐invasive measurements and a straightforward additive points system, has good discrimination and stratifies outpatients with chronic heart failure into high and low risk. This index may be useful in clinical care and risk stratification.
Background: Chronic heart failure is characterized by left ventricular dilation and abnormalities of cardiac autonomic function. Up to 20% of patients with chronic heyart failure have QRS ...prolongation, which can lead to asynchronous left ventricular contraction. We tested the hypotheses that in patients with chronic heart failure, QRS > 150 ms is a risk factor for additional abnormalities of ventricular morphology, heart rate variability, and increased mortality. Methods and Results: In 184 patients with left ventricular ejection fraction < 35%, QRS duration was > 150 ms in 53, and ≤ 150 ms in 131. We evaluated patients with baseline chest radiographs, echocardiograms, and Holter recordings. Patients with QRS duration above and below 150 ms were similar in age, sex, functional class, renal function, serum sodium, and ejection fraction. In patients with QRS > 150 ms, left ventricular end-diastolic and end-systolic diameters were greater than patients with QRS duration ≤150 ms (P <.01). Patients with QRS > 150 ms had less low frequency R-R interval spectral power (P <.04). At 5 years 60% of patients with QRS > 150 ms had died compared with 35% of patients with QRS ≤150 ms (P <.001). This increase in mortality was predominantly the result of an increase in progressive heart failure. Conclusions: Chronic heart failure patients with QRS duration > 150 ms have exaggerated disturbance of cardiac autonomic function, and left ventricular remodeling and significantly higher mortality than patients with QRS duration ≤ 150 ms.
Patients with chronic heart failure (CHF) have a continuing high mortality. Autonomic dysfunction may play an important role in the pathophysiology of cardiac death in CHF. UK-HEART examined the ...value of heart rate variability (HRV) measures as independent predictors of death in CHF.
In a prospective study powered for mortality, we recruited 433 outpatients 62+/-9.6 years old with CHF (NYHA functional class I to III; mean ejection fraction, 0.41+/-0.17). Time-domain HRV indices and conventional prognostic indicators were related to death by multivariate analysis. During 482+/-161 days of follow-up, cardiothoracic ratio, SDNN, left ventricular end-systolic diameter, and serum sodium were significant predictors of all-cause mortality. The risk ratio for a 41.2-ms decrease in SDNN was 1.62 (95% CI, 1.16 to 2.44). The annual mortality rate for the study population in SDNN subgroups was 5.5% for >100 ms, 12.7% for 50 to 100 ms, and 51.4% for <50 ms. SDNN, creatinine, and serum sodium were related to progressive heart failure death. Cardiothoracic ratio, left ventricular end-diastolic diameter, the presence of nonsustained ventricular tachycardia, and serum potassium were related to sudden cardiac death. A reduction in SDNN was the most powerful predictor of the risk of death due to progressive heart failure.
CHF is associated with autonomic dysfunction, which can be quantified by measuring HRV. A reduction in SDNN identifies patients at high risk of death and is a better predictor of death due to progressive heart failure than other conventional clinical measurements. High-risk subgroups identified by this measurement are candidates for additional therapy after prescription of an ACE inhibitor.
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