Mode of death from congestive heart failure: implications for clinical management

The care of the end-stage patient has not been extensively studied, and little is known about best care practices. Therefore, using new definitions for mode of death due to heart failure, we performed a retrospective chart review of records from a university-based heart failure disease management program to characterize the population of patients dying from heart failure and to define clinical predictors that identify patients who will likely die of metabolic and/or progressive causes. Of 74 deaths recorded over a 60-month period, 17.6% and 21.3% were deemed to be metabolic or progressive, respectively. Utilization of resources was considerable, and only a small number of patients died while in hospice. Patients who required continuous inotropic support and those with preexisting renal failure were at highest risk for non-sudden cardiac death. We conclude that prospective identification of patients at risk for metabolic and progressive heart failure death is possible. The numbers of these patients is likely to increase in an era of implantable cardioverter-defibrillators. Intervention studies designed to evaluate and improve strategies that emphasize symptom control should target this group.     

Mode of death in elderly and super‐elderly patients with acute heart failure: Insights from Japanese heart failure registry

BackgroundIn Japan, both the prevalence of the elderly and super‐elderly and those of acute heart failure (AHF) have been increasing rapidly.MethodsThis registry was a prospective multicenter cohort, which enrolled a total of 1253 patients with AHF. In this study, 1117 patients'' follow‐up data were available and were categorized into three groups according to age: <75 years old (nonelderly), 75–84 years old (elderly), and ≥ 85 years old (super‐elderly). The endpoint was defined as all‐cause death and each mode of death after discharge during the 3‐years follow‐up period.ResultsBased on the Kaplan–Meier analysis, a gradually increased risk of all‐cause death according to age was found. Among the three groups, the proportion of HF death was of similar trend; however, the proportion of infection death was higher in elderly and super‐elderly patients. After adjusting for potentially confounding effects using the Cox and Fine–Gray model, the hazard ratio (HR) of all‐cause death increased significantly in elderly and super‐elderly patients (HR, 2.60; 95% confidence interval [CI], 1.93–3.54 and HR, 5.04; 95% CI, 3.72–6.92, respectively), when compared with nonelderly patients. The highest sub‐distribution HR in detailed mode of death was infection death in elderly and super‐elderly patients (HR, 4.25; 95% CI, 1.75–10.33 and HR, 10.10; 95% CI, 3.78–27.03, respectively).ConclusionsIn this population, the risk of all‐cause death was found to increase in elderly and super‐elderly. Elderly patients and especially super‐elderly patients with AHF were at a higher risk for noncardiovascular death, especially infection death.     

Indications for implantable cardiac defibrillators in patients with congestive heart failure: Implications of the sudden cardiac death in heart failure trial

Sudden cardiac death (SCD) is a significant cause of mortality in patients suffering from heart failure and left ventricular dysfunction. Implantable cardioverter defibrillators have been shown to effectively reduce the incidence of SCD in this population. Recent clinical trials have redefined the indications and patient profiles for their use: from secondary prevention to primary prevention of SCD. In this article, we review the clinical trials contributing to the current practice guidelines, which include device therapy.     

Mode of death in patients with newly diagnosed heart failure in the general population

BACKGROUND: Early prognosis for incident (new) heart failure (HF) patients in the general population is poor. Clinical trials suggest approximately half of chronic HF patients die suddenly but mode of death for incident HF cases in the general population has not been evaluated. AIMS: To describe mode of death in the first six months after a new diagnosis in the general population. METHODS: Two-centre UK population-based study. RESULTS: 396 incident HF patients were prospectively identified. Overall mortality rates were 6% [3-8%], 11% [8-14%] and 14% [11-18%] at 1, 3 and 6months respectively. There were 59 deaths over a median follow-up of 10months; 86% (n = 51) were cardiovascular (CV) deaths. Overall, the mode of death was progressive HF in 52% (n = 31), sudden death (SD) in 22% (n = 13), other CV death in 12% (n = 7), and non-CV death in 14% (n = 8). On multivariable analysis, progressive HF deaths were associated with older age, lower serum sodium, systolic hypotension, prolonged QRS duration at baseline and absence of ACE inhibitor therapy at the time of discharge or death. CONCLUSION: Early prognosis after a new diagnosis of HF in the general population is poor and progressive HF, rather than sudden death, accounts for the majority of deaths.     

Five-year follow-up findings from a randomized controlled trial of cardiac rehabilitation for heart failure.

BACKGROUND: A follow-up study was carried out on the 5-year status of the surviving patients (n=179 at 6 months) of a 24-week randomized controlled trial comparing cardiac rehabilitation (CR) with heart failure outpatient clinic care (standard care). METHODS: In the original randomized controlled trial, 200 patients (60-89 years, 132 men) with New York Heart Association II/III heart failure confirmed by echocardiography had been randomized (2000-2001). At the 5-year follow-up, the initial trial measures (6-min walk test, Minnesota living with heart failure, EuroQol health-related quality of life, and routine biochemistry) were repeated if the patient was in a satisfactory condition. Data on deaths and admissions were obtained from the medical records department. RESULTS: Over half of the original participants (n=119, 59.5%) were alive at 5 years (mean age 75.2 years), and most (94%) attended the clinic for assessment. A sustained improvement from baseline for both groups in Minnesota living with heart failure, but not in EuroQol was observed, and the majority of the other measures had deteriorated. In contrast to the CR group, the standard care group showed a significant deterioration in walking distance (5 versus 11%; P<0.05). More patients in the CR group were taking regular exercise (71 versus 51%; P<0.05). No significant differences between the groups in health care utilization or survival were observed. CONCLUSION: A 24-week CR programme for patients with stable heart failure showed some long-term benefit at 5 years. Differences in the mean values of most of the functional and quality of life measures were evidently to the advantage of the CR group, which also showed a better exercise profile.     

Pathologic-anatomic findings in sudden heart death

Sudden cardiac death can be caused by a large variety of pathological conditions detected morphologically. In most cases it is the result of coronary sclerosis. A coronary thrombus is not only found in myocardial infarction, but also frequently occurs in unstable angina without infarction. In most instances these thrombi develop following rupture of an atheromatous plaque. A higher risk of sudden cardiac death is associated with abnormalities of the coronary ostia, most commonly an anomalous origin of the left coronary artery from the right sinus. HOCM is the most important cardiomyopathy causing sudden cardiac death in young athletes. Furthermore, myocarditis, pathological changes of the conduction system, and other rare conditions can lead to sudden cardiac death. A particular set of diseases contributes to sudden cardiac death in the young. Occasionally, disturbances in the texture of the ventricular septum can be found that have so far not been described in the literature. Acute arrhythmias hold a key position among the pathophysiological mechanisms leading to sudden cardiac death.     

Beta-blocker therapy for heart failure outside the clinical trial setting: findings of a community-based registry

Background

β-Blockers reduce morbidity and mortality rates in heart failure (HF) clinical trials, but it is unknown whether these findings persist in the community setting.

Methods

A registry was created to survey tolerability and outcomes during initiation and 1-year follow-up of β-blocker treatment with carvedilol in patients with HF treated by cardiologists (CARD) and primary care physicians (PCP) in the community.

Results

A total 4280 patients were enrolled (3121 by 259 CARD, 1159 by 129 PCP). Patient age averaged 67 ± 13 years; 35% were women and 12% were black. The left ventricular ejection fraction averaged 31 ± 12; New York Heart Association class was II-III in 86% and IV in 3%. Patients of PCP had higher left ventricular ejection fraction, were older, and more frequently were female, black, diabetic, hypertensive, and in New York Heart Association class III/IV. Minimal difficulty titrating carvedilol was noted by >80% of CARD and PCP. Significantly more CARD-treated patients reached carvedilol doses of 25 mg twice daily (49% vs 27%). Kaplan-Meier all-cause mortality rate was 8.5% at 1 year and did not differ between CARD-treated and PCP-treated patients (8.2% vs 9.3%, P = .254). At least one HF hospitalization occurred in 11% of patients during follow-up, compared with 28% in the preceding year.

Conclusions

Community-based physicians use carvedilol with success approaching that of clinical trials. Overall mortality rates and HF hospitalizations were in the same low range as in clinical trials. Thus, it appears that results of clinical trials with carvedilol for HF can be translated to the community setting.     

Mode of death in advanced heart failure: the Comparison of Medical, Pacing, and Defibrillation Therapies in Heart Failure (COMPANION) trial.

OBJECTIVES: The aim of this study was to evaluate the mode of death in patients with advanced chronic heart failure (HF) and intraventricular conduction delay treated with optimal pharmacologic therapy (OPT) alone or OPT with biventricular pacing to provide cardiac resynchronization therapy (CRT) or CRT + an implantable defibrillator (CRT-D). BACKGROUND: Limited data are available on mode of death in advanced HF. No data have existed on mode of death in these patients who also have an intraventricular conduction delay and are treated with CRT or CRT-D. METHODS: Using prespecified definitions and source materials, seven cardiologists assessed mode of death among the 313 deaths that occurred in the Comparison of Medical, Pacing, and Defibrillation Therapies in Heart Failure (COMPANION) trial. RESULTS: A primary cardiac cause was present in 78% of deaths. Pump failure (44.4%) was the most common mode of death followed by sudden cardiac death (SCD) (26.5%). Compared with OPT, CRT-D significantly reduced the number of cardiac deaths (38%, p = 0.006), whereas CRT alone was associated with a non-significant 14.5% reduction (p = 0.33). Both CRT and CRT-D tended to reduce pump failure deaths (29%, p = 0.11 and 27%, p = 0.14, respectively). The CRT-D significantly reduced SCD (56%, p = 0.02), but CRT alone did not. CONCLUSIONS: Pump failure deaths are the predominant mode of death in patients with advanced HF and are modestly reduced by both CRT and CRT-D. Only CRT-D reduced SCD and thus produced a favorable effect on cardiac mortality.     

Predictors of death from congestive heart failure in hypertrophic cardiomyopathy

In 309 patients with hypertrophic cardiomyopathy during long-term follow-up (mean 9.4 years), independent predictors of death from congestive heart failure (n = 15) were smaller electrocardiographic SV1 + RV5 and smaller echocardiographic fractional shortening at the initial evaluation. Our data may contribute to the construction of therapeutic strategies for the prevention of heart failure death in patients with hypertrophic cardiomyopathy.