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Sudden Death in Patients With Coronary Heart Disease Without Severe Systolic Dysfunction
Neal A Chatterjee1,2, M Vinayaga Moorthy1, Julie Pester1
1Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
Sudden and/or arrhythmic death (SAD) is a major cause of mortality in coronary heart disease patients without severe systolic dysfunction. Risk stratification needs to consider factors like LVEF, age, and NYHA class to identify high-risk individuals.
Area of Science:
- Cardiology
- Preventive Cardiology
- Clinical Research
Background:
- Sudden and/or arrhythmic death (SAD) is a significant concern in coronary heart disease (CHD) patients, particularly those without severe systolic dysfunction.
- Current strategies for preventing sudden death are limited in this specific patient population.
- Understanding competing causes of death is crucial for developing targeted prevention trials.
Purpose of the Study:
- To estimate the contemporary incidence of SAD versus other causes of death in CHD patients without severe systolic dysfunction.
- To identify high-risk subgroups within this population who could benefit from future SAD prevention strategies.
- To analyze the relationship between clinical risk factors and modes of death.
Main Methods:
- A prospective observational cohort study involving 5761 participants across 135 clinical sites in the US and Canada.
- Participants had coronary heart disease but did not meet criteria for primary prevention implantable cardioverter-defibrillator therapy (LVEF >35% or NYHA class I with LVEF >30%).
- Baseline clinical risk factors including age, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) heart failure class were assessed.
Main Results:
- Over a median follow-up of 3.9 years, the cumulative incidence of SAD was 2.1% and non-SAD was 7.7%.
- SAD constituted 56% of cardiovascular deaths, but noncardiac death was the most common cause of overall mortality.
- Highest SAD incidence was observed in patients with LVEF 30%-40% (4.9%) and NYHA class III/IV heart failure (5.1%). Moderately reduced LVEF (40%-49%) was linked to higher SAD risk, while NYHA class II and older age were associated with non-SAD.
Conclusions:
- SAD accounts for a substantial proportion of mortality in contemporary CHD patients without severe systolic dysfunction.
- Left ventricular ejection fraction, age, and NYHA class are key factors differentiating SAD from non-SAD.
- Future risk stratification efforts must incorporate both absolute and proportional risks of SAD across diverse clinical subgroups.
Importance:
The majority of sudden and/or arrhythmic deaths (SAD) in patients with coronary heart disease occur in those without severe systolic dysfunction, for whom strategies for sudden death prevention are lacking.
Objective:
To provide contemporary estimates of SAD vs other competing causes of death in patients with coronary heart disease without severe systolic dysfunction to search for high-risk subgroups that might be targeted in future trials of SAD prevention.
Design, Setting, And Participants:
This prospective observational cohort study included 135 clinical sites in the United States and Canada. A total of 5761 participants with coronary heart disease who did not qualify for primary prevention implantable cardioverter defibrillator therapy based on left ventricular ejection fraction (LVEF) of more than 35% or New York Heart Association (NYHA) heart failure class (LVEF >30%, NYHA I).
Exposures:
Clinical risk factors measured at baseline including age, LVEF, and NYHA heart failure class.
Main Outcomes And Measures:
Primary outcome of SAD, which is a composite of SAD and resuscitated ventricular fibrillation arrest.
Results:
The mean (SD) age of the cohort was 64 (11) years. During a median of 3.9 years, the cumulative incidence of SAD and non-SAD was 2.1% and 7.7%, respectively. Sudden and/or arrhythmic death was the most common mode of cardiovascular death accounting for 114 of 202 cardiac deaths (56%), although noncardiac death was the primary mode of death in this population. The 4-year cumulative incidence of SAD was lowest in those with an LVEF of more than 60% (1.0%) and highest among those with LVEF of 30% to 40% (4.9%) and class III/IV heart failure (5.1%); however, the cumulative incidence of non-SAD was similarly elevated in these latter high-risk subgroups. Patients with a moderately reduced LVEF (40%-49%) were more likely to die of SAD, whereas those with class II heart failure and advancing age were more likely to die of non-SAD. The proportion of deaths due to SAD varied widely, from 14% (18 of 131 deaths) in patients with NYHA II to 49% (37 of 76 deaths) in those younger than 60 years.
Conclusions And Relevance:
In a contemporary population of patients with coronary heart disease without severe systolic dysfunction, SAD accounts for a significant proportion of overall mortality. Moderately reduced LVEF, age, and NYHA class distinguished SAD and non-SAD, whereas other markers were equally associated with both modes of death. Absolute and proportional risk of SAD varied significantly across clinical subgroups, and both will need to be maximized in future risk stratification efforts.
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