Diabetes Does Not Affect Ventricular Repolarization and Sudden Cardiac Death Risk in Patients with Dilated Cardiomyopathy

Background: We studied the effects of diabetes on ventricular repolarization parameters and sudden cardiac death in patients with dilated cardiomyopathy (DCM).
Methods: We enrolled 132 consecutive patients in New York Heart Association (NYHA) heart failure functional classes II or III and left ventricular ejection fraction <40% without evidence of coronary artery disease. In 45 patients (34%), diabetes was diagnosed according to standard criteria (study group), and the remaining 87 (66%) had no diabetes (controls). All patients underwent a 5-minute high-resolution electrocardiogram recording for determination of QT variability (QTV) index and were followed for 1 year thereafter.
Results: At baseline, the two groups did not differ in age, gender, left ventricular ejection fraction, NYHA functional class, or plasma brain natriuretic peptide levels. Similarly, QTV index did not differ between the study group (−0.51 ± 0.55) and controls (−0.48 ± 0.51; P = 0.48). During follow-up, 18 patients (14%) died of cardiac causes. Of the 18 deaths, eight were attributed to heart failure, and 10 to sudden cardiac death. Mortality was higher in the study group (10/45, 20%) than in controls (8/87, 10%) (P = 0.03). The same was true of the heart failure mortality (6/45 [13%] vs 2/87 [2%], P = 0.01), but not of the sudden cardiac death rate (3/45 [7%] vs 7/87 [8%], P = 0.78). By multiple variable analyses, diabetes predicted total and heart failure mortality, and a high QTV predicted sudden cardiac death.
Conclusions: Diabetes appears to increase the risk of heart failure in patients with DCM without affecting ventricular repolarization parameters and sudden cardiac death risk.     

Use of a wearable defibrillator in terminating tachyarrhythmias in patients at high risk for sudden death: results of the WEARIT/BIROAD

The automatic ICD improves survival in patients with a history of sudden cardiac arrest. However, some patients do not meet the guidelines for ICD implantation or are unable to receive an implantable device. This study tested the hypothesis that these patients could benefit from a wearable cardioverter defibrillator. Patients with symptomatic heart failure and an ejection fraction of <0.30 (WEARIT Study) or patients having complications associated with high risk for sudden death after a myocardial infarction or bypass surgery not receiving an ICD for up to 4 months (BIROAD Study) were enrolled into two studies. After a total of 289 patients had been enrolled in the trial (177 in WEARIT and 112 in BIROAD), prespecified safety and effectiveness guidelines had been met. Six (75%) of eight defibrillation attempts were successful. Six inappropriate shock episodes occurred during 901 months of patient use (0.67% unnecessary shocks per month of use). Twelve deaths occurred during the study 6 sudden deaths: 5 not wearing and 1 incorrectly wearing the device). Most patients tolerated the device although 68 patients quit due to comfort issues or adverse reactions.The results of the present study suggest that a wearable defibrillator is beneficial in detecting and effectively treating ventricular tachyarrhythmias in patients at high risk for sudden death who are not clear candidates for an ICD and may be useful as a bridge to transplantation or ICD in some patients.     

Neurohormonal risk stratification for sudden death and death owing to progressive heart failure in chronic heart failure

BACKGROUND: This study tested various neurohormones for prediction of heart failure death (death owing to progressive deterioration of ventricular function; HFD). Moreover, B-type natriuretic peptide (BNP) as a predictor of sudden death (SD; as reported previously) and the best predictor of HFD were combined for a simple risk stratification model. DESIGN: BNP, the N-terminal fragment of BNP (N-BNP), and of the atrial natriuretic peptide (N-ANP) and big endothelin levels were obtained from 452 patients with a left ventricular ejection fraction 130 pg mL(-1) and N-ANP < 6300 fmol mL(-1) (Group B, n = 177; 18%; P = 0.0001) and patients with BNP > 130 pg mL(-1) and N-ANP > 6300 fmol mL(-1) (Group C, n = 50; 19%; P = 0.0001). Analyzing 293 survivors and 31 patients with HFD, fewer patients died in Group A (n = 109; 0%; P = 0.0001) and Group B (n = 153; 6%; P = 0.0001) as compared with patients of Group C (n = 62; 34%). CONCLUSION: Prognostic power of neurohormones depends on the mode of death. The combined determination of BNP and N-ANP identifies patients with minimal risk of death, elevated SD but low HFD risk as well as elevated SD and HFD risk.     

Causes of Death in Patients with Unipolar Single Chamber Ventricular Pacing: Prevalence and Circumstances in Dependence on Arrhythmias Leading to Pacemaker Implantation

Cardiac pacing improves the prognosis of patients with severe impulse formation and conduction disturbance, though sudden death can occur frequently in paced patients. In the present study, we analyzed the causes and the circumstances of 378 deaths in 2,243 paced patients followed over a 5-year period. Sudden cardiac death occurred in 71 of these 378 patients (18.7%), 56 patients died of stroke (15%), heart failure was the cause of death in 91 subjects (24%). We analyzed the causes of death in two groups with respect to the arrhythmia that had led to pacemaker implantation. The prevalence of cardiac sudden death was higher in patients with AV block than in patients with sick sinus syndrome, while stroke was more frequent in patients with sick sinus syndrome, particularly those with both fast and slow components. Atrial fibrillation is common in patients with sick sinus syndrome and is an important well-known risk factor for stroke. Death from heart failure was frequently reported in our population, but in our study group only a few patients had heart failure at the moment of pacemaker implantation. We conclude that sudden death is a common event in paced patients and the disturbance that led the patient to pacemaker implantation was also a factor in the cause of death.     

Cardioverter Defibrillator Therapy as a Bridge to Heart Transplantation

The prognosis of patients with severely impaired left ventricular function is poor, with an annual mortality rate of about 50%, and the majority die from sudden cardiac death. Heart transplantation is an accepted therapy for patients with end-stage heart disease; however, about 30% of candidates for transplantation die from sudden cardiac death while on the waiting list. It has been shown that implantable Cardioverter defibrillator (ICD) therapy has a low surgical mortality and is highly effective in the prevention of sudden death. Therefore, prophylactic ICD implantation may prevent sudden death in patients with end-stage heart disease while on the waiting list, and it is highly probable that patients with an ICD have a greater chance of survival until a donor heart becomes available. However, this hypothesis still has to be proven by prospective studies.     

Long-Term Follow-Up of Patients with Nonischemic Dilated Cardiomyopathy and Ventricular Tachyarrhythmias Treated with Implantable Cardioverter Defibrillators

We analyzed our 10-year cumulative experience of 40 consecutive patients with idiopathic dilated Cardiomyopathy and associated ventricular tachyarrhythmias, treated with implantable Cardioverter defibrillators. Dilated Cardiomyopathy was defined as left ventricular ejection fraction (EF) ≤50% with no defineable etiology. Patient characteristics included: 24 male, mean age 52 years, mean EF = 33%, New York Heart Association Class I–III, presenting syndrome—cardiac arrest (n = 28), syncope/near syncope (n = 12). At 2.5 years mean follow-up, there were 16 deaths: one operative, three sudden, two incessant ventricular tachycardia/ventricular fibrillation (VT/VF), six heart failure, and four noncardiac. The actuarial mortality at 1 and 4 years was 0% and 14% for sudden death, 11% and 34% for cardiac death. The projected mortality was 52% and 78% for same time intervals (P < 0.01). No useful baseline variable predicted who would or would not receive an ICD shock in follow-up. ICD therapy appears effective in reducing sudden death mortality in this high risk population.     

Insulin-treated type 2 diabetes is associated with a decreased survival in heart failure patients after cardiac resynchronization therapy

Background: Cardiac resynchronization therapy (CRT) improves cardiac performance and survival in patients with congestive heart failure. Recent observations suggest that diabetes is associated with a worse outcome in these patients. The aim of the study was to investigate the effect of diabetes and insulin treatment on outcome after CRT. Methods: Diabetic status and insulin treatment were assessed in 447 patients who underwent CRT (males 80.8%, mean age 65.7 ± 9.7 years, ejection fraction 29.9 ± 6.11%). Patients were stratified in three groups according to the presence or absence of diabetes and insulin treatment. Results: Nondiabetic patients were 366 (79.6%), noninsulin‐treated diabetic patients 62 (13.9%), insulin‐treated diabetic patients 29 (6.5%). The estimated death rate was 5.15 per 100 patients‐year in the nondiabetic group, 8.63 in noninsulin‐treated diabetics (HR 1.59, P = 0.240), and 15.84 in insulin‐treated diabetics (HR 3.05, P = 0.004). Cardiac mortality accounted for 81% of deaths in nondiabetic patients and for 56% of deaths in diabetic patients. Diabetic patients tended to have a worse recovery of left ventricular ejection fraction over time (P = 0.057) and of the distance at 6‐minute walking test (6MWT) (P = 0.018). Conclusions: Insulin‐treated diabetes is associated with a worse functional recovery and a higher mortality in patients with advanced heart failure after CRT. While cardiac death accounts for the majority of deaths in nondiabetic patients, a relevant proportion of the mortality in diabetic patients seem to result from noncardiac causes.     

Device therapy in Chagas disease heart failure

Chagas disease is the principal cause of chronic heart failure in areas where the disease is endemic. The medical treatment is the same recommended for non-Chagas disease patients. There is no evidence-based medicine support for device therapy in Chagas disease heart failure. Cardiac resynchronization therapy is recommended for Chagas disease heart failure patients with intraventricular conduction disturbances, mainly for those with left bundle branch block, and in advanced congestive heart failure refractory to targeted medical treatment, although this therapy is still polemic in Chagas disease heart failure. Implantable cardioverter–defibrillator (ICD) therapy is indicated to Chagas disease patients with left ventricular ejection fraction <30% for primary prevention of sudden cardiac death. ICD therapy is offered to patients for secondary prevention of sudden cardiac death. Patients with moderate left ventricular dysfunction and inducible arrhythmia at electrophysiological testing should receive ICD therapy.     

Female gender is associated with a better outcome after cardiac resynchronization therapy

Background: Some studies have suggested that women respond differently to cardiac resynchronization therapy (CRT). We sought to determine whether female gender influences long‐term clinical outcome, symptomatic response as well as echocardiographic response after CRT. Methods and Results: A total of 550 patients (age 70.4 ± 10.7 yrs [mean ± standard deviation]) were followed up for a maximum of 9.1 years (median: 36.2 months) after CRT‐pacing (CRT‐P) or CRT‐defibrillation (CRT‐D) device implantation. Outcome measure included mortality as well as unplanned hospitalizations for heart failure or major adverse cardiovascular events (MACE). Female gender predicted survival from cardiovascular death (hazard ratio [HR]: 0.52, P = 0.0051), death from any cause (HR: 0.52, P = 0.0022), the composite endpoints of cardiovascular death /heart failure hospitalizations (HR: 0.56, P = 0.0036) and death from any cause/hospitalizations for MACE (HR: 0.67, P = 0.0214). Female gender predicted death from pump failure (HR: 0.55, P = 0.0330) but not sudden cardiac death. Amongst the 322 patients with follow‐up echocardiography, left ventricular (LV) reverse remodelling (≥15% reduction in LV end‐systolic volume) was more pronounced in women (62% vs 44%, P = 0.0051). In multivariable Cox proportional hazards analyses, the association between female gender and cardiovascular survival was independent of age, LV ejection fraction, atrial rhythm, QRS duration, CRT device type, New York Heart Association (NYHA) class, and LV reverse remodelling (adjusted HR: 0.48, P = 0.0086). At one year, the symptomatic response rate (improvement by ≥1 NYHA classes or ≥25% increase in walking distance) was 78% for both women and men. Conclusions: Female gender is independently associated with a lower mortality and morbidity after CRT. (PACE 2011; 82–88)     

Lipid-lowering therapy and outcomes in heart failure

Lipid-lowering therapy, particularly with statins, reduces the risk of cardiovascular mortality; however, there is uncertainty about their efficacy in patients with heart failure, including those without coronary artery stenosis. A clinical database was studied to determine whether lipid-lowering therapy is associated with improved survival in persons with heart failure-with or without concomitant coronary artery stenosis. During an 8-year period, 6060 people with a history of heart failure underwent coronary angiography. At the time of angiography, 1216 received a lipid-lowering agent. During a median follow-up of 4.7 years, 7.1 deaths per 100 person-years occurred among users of lipid-lowering therapy, compared with 7.8 per 100 person-years among nonusers (adjusted hazard ratio 0.87, 95% confidence interval 0.77-0.97). Use of lipid-lowering therapy was associated with a reduced risk of death in patients with heart failure. Current evidence supports statin use in individuals with recognized heart failure and concomitant coronary heart disease, dyslipidemia, or diabetes mellitus. More data are needed before statins can be recommended in those with isolated heart failure.     

Antiarrhythmic therapy in patients with heart failure

In patients with severe chronic heart failure, many deaths are sudden due to life-threatening ventricular arrhythmias. Supraventricular arrhythmias such as paroxysmal or chronic atrial fibrillation may also cause serious complications in those patients due to acute loss of atrial contraction, pump failure during rapid ventricular response and embolic events. Two therapeutic strategies are currently available for therapy and prevention of malignant ventricular arrhythmias and subsequent sudden arrhythmic death: antiarrhythmic drug therapy and implantable defibrillators. However, selection of the most beneficial strategy for the individual patient to reduce the risk of sudden death remains a major challenge in cardiology. Betablockers exert a favorable antiarrhythmic action without increasing proarrhythmia, thus betablockers may serve as a basic medication in patients at risk for sudden death. However, the general use of antiarrhythmic drug therapy for symptomatic ventricular arrhythmias is not recommended, as these drugs have been shown to increase mortality in patients with severe congestive heart failure due to proarrhythmic or negative inotropic effects (e.g. class Ia antiarrhythmics). Even class III antiarrhythmic drugs such as amiodarone, which has been studied sufficiently in patients with left ventricular dysfunction, is not effective enough for significant reduction of cardiac mortality in patients with symptomatic ventricular arrhythmias and depressed ventricular function (e.g. EMIAT, CAMIAT). But as a positive result of available studies, amiodarone does not increase mortality in those patients. Dofetilide has also not been shown to prolong life significantly by suppressing malignant ventricular arrhythmias (DIAMOND-Study). In patients with symptomatic ventricular arrhythmias or aborted sudden death, ICD therapy has been proven to be superior to antiarrhythmic drug therapy in cardiac mortality reduction as a secondary prevention strategy (e.g. AVID, CASH, CIDS). For primary prevention of sudden arrhythmic death in high risk patients, 2 studies (MADIT, MUSST) have already demonstrated favorable results, decreasing mortality by ICD therapy in selected patient populations with partly-reduced ventricular function and unsustained but inducible ventricular tachycardias. This topic is, however, undergoing further evaluation by ongoing trials (e.g. MADIT II, SCD-HeFT). From available data, antiarrhythmic drug therapy in high risk patients is not justified on a routine basis, whereas ICD therapy as a secondary and perhaps primary prevention strategy will significantly reduce cardiac mortality in patients with severe heart failure. Sotalol, a class III antiarrhythmic agent, has recently been shown to reduce ICD-shock delivery which indicates that concomitant drug therapy in patients with an ICD device already implanted may be beneficial in terms of reducing ICD discharges due to ventricular and supraventricular tachycardias. In patients with paroxysmal atrial fibrillation and congestive heart failure, restitution of sinus rhythm is the primary therapeutic goal which can be safely achieved by amiodarone and dofetilide (DIAMOND). In the latter, continuous monitoring of the patient is mandatory because of increased risk of torsade de pointes arrhythmias during the first days of drug administration. In patients with chronic atrial fibrillation rate control and anticoagulation with warfarin is the primary therapeutic option, which can be achieved with either drug treatment (Digoxin, betablockers, amiodarone) or by His bundle ablation with subsequent pacemaker insertion.     

Indications for Pacing in Patients with Congenital Heart Disease

Background: Advances in pacing technology have increased indications for antibradycardia pacing and new indications have appeared for treatment of atrial tachycardia and cardiac failure in patients with congenital heart disease (CHD).
Methods and Results: Implantation of a pacemaker is mandatory for symptomatic children with complete atrio-ventricular block (CAVB). In asymptomatic neonates and infants, prophylactic pacing is indicated when the ventricular rhythm is <55 beats per minute (bpm) or 70 bpm in case of significant cardiac malformations. Beyond one year of age, PM implantation is recommended in children with an average heart rate <50 bpm or long pauses on 24-hour recordings. Post-operative block that persists 7 days after cardiac surgery is a class I indication for pacing. Postoperative heart block may also be transient, but patients with residual conduction abnormalities and a long HV interval have a high risk of late sudden death and should be paced. After cardiac surgery, atrial pacing may also be considered, in patients with severe sinus bradycardia and symptoms, or in those requiring antiarrhythmic drugs for tachy-bradycardia syndrome; in case of failure of antiarrhythmic drugs, antitachycardia atrial pacing now appears to be safe and efficacious. Finally, cardiac resynchronization therapy may apply to children with congenital heart block and cardiomyopathy, as well as to the population with CHD. Methods and results are described in the section dedicated to resynchronization.
Conclusion: Cardiac pacing indications have extended beyond prevention of sudden death and pacemaker implantation is now indicated to improve quality of life of patients with CHD and as a bridge to cardiac transplantation.     

Management of Nonsustained Ventricular Tachycardia Guided By Electrophysiological Testing

Two hundred eighty patients with spontaneous nonsusfained ventricular tachycardia were treated based on the results of electrophysiological testing. Seventy-nine patients had no evidence of structural heart disease, 134 had coronary artery disease, 43 had idiopathic dilated cardiomyopathy, and 24 patients had miscellaneous types of heart disease. Sustained monomorphic ventricular tachycardia was induced during electrophysiological testing in the drug free state in 52 of 280 patients (19%). Ventricular tachycardia was induced more frequently in patients with coronary artery disease (32%) than in any of the other groups (P < 0.001). The patients with inducible sustained monomorphic ventricular tachycardia underwent a mean of 1.9 ± 1.3 drug trials. Twenty-five patients had the induction of ventricular tachycardia suppressed by pharmacological therapy and were treated with the drug judged to be effective during electropharmacological testing. Twenty-seven patients continued to have inducible sustained monomorphic ventricular tachycardia despite antiarrhythmic therapy and were discharged on the drug that made induced ventricular tachycardia best tolerated. Forty-five of 280 patients (16.1%) died during a mean follow-up period of 19.6 ± 14.4 months, There were 15 sudden cardiac deaths, 21 nonsudden cardiac deaths, 6 noncardiac deaths, and 3 deaths that could not be classified. Sudden cardiac death mortality was lowest in the patients without structural heart disease (0% at 2 years), intermediate in the patients with coronary artery disease and miscellaneous heart disease (4% al 2 years), and highest in the patients with idiopathic dilated cardiomyopathy (13% at 2 years; P < 0.01 for pairwise comparisons). No patient treated with a drug that had suppressed the induction of sustained ventricular tachycardia died suddenly during the follow-up period whereas four of 27 patients who were discharged on “ineffective antiarrhythmic drugs” and 11 of 228 patients without inducible sustained ventricular tachycardia experienced sudden cardiac death during the follow-up period. By multivariate analysis, ejection fraction and inducible ventricular tachycardia during the predischarge eiectrophysiological test were independent predictors of sudden cardiac death. In conclusion, in patients with spontaneous nonsustained ventricular tachycardia: (1) Arrhythmia inducibility varies depending on the underlying heart disease. Ventricular tachycardia is most often inducible in patients with coronary artery disease and least often in patients without structural heart disease; (2) With the exception of patients with idiopathic dilated cardiomyopathy, management of patients with nonsustained ventricular tachycardia guided by electrophysiological testing appears to result in a low incidence of sudden cardiac death although effects on total mortality are less impressive; and (3) Patients with idiopathic dilated cardiomyopathy and patients with other heart diseases who continue to have inducible ventricular tachycardia despite antiarrhythmic drug therapy are at substantial risk of sudden cardiac death.     

Long-Term Outcomes of CRT-PM Versus CRT-D Recipients

Objective: To compare the rates of all-cause mortality in recipients of cardiac resynchronization therapy devices without (CRT-PM) versus with defibrillator (CRT-D).
Methods: Between February 1999 and July 2004, 233 patients (mean age = 69 ± 8 years, 180 men) underwent implantation of CRT-PM or CRT-D devices. New York Heart Association (NYHA) heart failure functional class II was present in 11%, class III in 69%, and class IV in 20% of patients; mean left ventricle ejection fraction (LVEF) was 26.5 ± 6.5 %, 48% presented with idiopathic dilated cardiomyopathy and 49% with ischemic heart disease. Cox multiple variable regression analysis was performed in search of predictors of death.
Results: The clinical characteristics of the 117 CRT-PM and 116 CRT-D recipients were similar, except for LVEF (28.2 ± 6.2% vs 25.0 ± 6.5%, respectively; P < 0.001), and ischemic versus nonischemic etiology of heart failure (41% vs 56%, respectively P = 0.02). Over a mean follow-up of 58 ± 15 months, no significance difference in overall mortality rate was observed between the two study groups. Male sex, NYHA functional class IV, and atrial fibrillation at implant were significant predictors of death.
Conclusions: There was no difference in long-term survival rate among patients with CRT-D versus CRT-PM, although CRT-D more effectively lowered the sudden death rate. Male sex, NYHA functional class IV, and atrial fibrillation predicted the worst prognosis.     

Prognostic Value of Heart Rate Variability in Patients Awaiting Cardiac Transplantation

Time and frequency domain parameters of heart rate variability (HRV) were determined in patients with severe end stage heart failure awaiting cardiac transplantation (HTX). These parameters were then correlated with mortality to investigate the performance of HRV in discriminating between groups with high and low risk of death. The standard deviation of five consecutive RR intervals (SDANN) was found to be the parameter with the greatest sensitivity (90%) and specificity (91%). Patients with SDANN values of < 55 msec had a twenty-fold increased risk of death (90% confidence limits: 4–118, P < 0.001). The results furthermore suggest that measurements of HRV are superior to other prognostic markers such as left ventricular ejection fraction, pulmonary artery wedge pressure, cardiac index, and serum sodium levels. We conclude that HRV is a powerful, noninvasive tool to assess the risk of death in candidates for HTX. HRV measurements can therefore be used as a supplement to other markers of risk to determine the optimal therapeutic strategy in patients with severe congestive heart failure.     

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance

Background

Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT).

Methods

559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR).

Results

Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group.

Conclusions

Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.     

Blood alcohol levels in Finnish victims of non-ischaemic sudden cardiac death

IntroductionNon-ischaemic heart disease (NIHD) is the underlying pathology in∼20% of all sudden cardiac deaths (SCDs). Heavy drinking is known to be associated with SCD due to ischaemic heart disease, but studies on association of recent alcohol consumption and SCD in patients with NIHD are scarce. We evaluated the blood alcohol levels of autopsy verified non-ischaemic SCD victims.MethodsStudy population was derived from the Finnish Genetic Study of Arrhythmic Events (Fingesture) (n = 5869, mean age 65 ± 12, 79% males). All deaths occurred in Northern Finland during 1998–2017. All victims underwent a medico-legal autopsy. Subjects of SCD due to ischaemic heart disease were excluded.ResultsA total of 1301 (mean age 57 ± 12, 78% males) victims of SCD due to NIHD were included in the study. The blood ethanol level was elevated in 543 (42%) subjects, out of which the blood alcohol level was ≥0.10%in 339 (62%) subjects and ≥0.15%in 252 (46%) subjects. Male SCD victims had alcohol in blood more frequently compared to females (45% versus 31%, p < .001).ConclusionElevated blood alcohol level is common in SCD victims due to NIHD, especially in males. Recent alcohol consumption might contribute to the subsequent SCD in many non-ischaemic SCD victims.

KEY MESSAGES

• Elevated blood alcohol level is common in victims of sudden cardiac death due to non-ischaemic heart disease, especially in males.
• Recent alcohol consumption may contribute to the subsequent death in many nonischemic sudden cardiac death victims.

     

Permanent Cardiac Pacing After Open Heart Surgery: Congenital Heart Disease

A retrospective review of 6,004 patients who underwent open repair of congenital heart defects revealed that 132 patients (2.2%) required permanent cardiac pacing postoperatively. The indications for pacing were early atrioventricular (AV) block in 55%, late onset AV block in 31%, and sick sinus syndrome in 14%. A ventricular septal defect (VSD) was the most common congenital anomaly present alone or in association with other lesions in 67% of the patients. Atrial surgery accounted for 21% of the patients requiring pacing. Ten-year patient survival was found to be 66% (+/- 6%). Thirty-five percent of the deaths were sudden and unexpected, presumably due to an arrhythmia. Reoperation for pacing system failure has occurred too frequently (12% per year). The most common causes for reoperation were battery failure (44%) and exit block (25%).     

Application of the Seattle Heart Failure Model in patients on cardiac resynchronization therapy

Background: The Seattle Heart Failure Model (SHFM) is a multimarker risk assessment tool able to predict outcome in heart failure (HF) patients. Aim: To assess whether the SHFM can be used to risk‐stratify HF patients who underwent cardiac resynchronization therapy with (CRT‐D) or without (CRT) an implantable defibrillator. Methods and Results: The SHFM was applied to 342 New York Heart Association class III‐IV patients who received a CRT (23%) or CRT‐D (77%) device. Discrimination and calibration of SHFM were evaluated through c‐statistics and Hosmer‐Lemeshow (H‐L) goodness‐of‐fit test. Primary endpoint was a composite of death from any cause/cardiac transplantation. During a median follow‐up of 24 months (25th–75th percentile [pct]: 12–37 months), 78 of 342 (22.8%) patients died; seven patients underwent urgent transplantation. Median SHFM score for patients with endpoint was 5.8 years (25th–75th pct: 4.25–8.7 years) versus 8.9 years (25th–75th pct: 6.6–11.8 years) for those without (P < 0.001). Discrimination of SHFM was adequate for the endpoint (c‐statistic always ranged around 0.7). The SHFM was a good fit of death from any cause/cardiac transplantation, without significant differences between observed and SHFM‐predicted survival. Conclusion: The SHFM successfully stratifies HF patients on CRT/CRT‐D and can be reliably applied to help clinicians in predicting survival in this clinical setting. (PACE 2012; 35:88–94)     

Poor prognosis for patients with chronic kidney disease despite ICD therapy for the primary prevention of sudden death

INTRODUCTION: Chronic kidney disease (CKD) has been independently associated with increased cardiovascular mortality. Little is known about the benefit of implantable cardioverter defibrillator (ICD) therapy for prevention of sudden death in this large, high-risk population. We sought to evaluate the impact of CKD on survival in patients who received an ICD for primary prevention of sudden death. METHODS AND RESULTS: In this retrospective study of patients who underwent ICD implantation for primary prevention of sudden death, patients were stratified by CKD, defined as serum creatinine > or = 2 mg/dL or dialysis use. Primary endpoint was mortality. CKD was identified in 35 of 229 patients (15.3%). There were 33 deaths during a follow-up period of 18.0 +/- 15.2 months: 17 of 35 CKD patients and 16 of 194 patients without CKD (48.6% vs 8.2%, P < 0.00001 by log-rank). One-year survival for patients with and without CKD was 61.2% and 96.3%, respectively. Cox regression analysis controlling for age, sex, comorbidities, ejection fraction, and medications proved CKD to be the strongest independent predictor of death (hazard ratio 10.5; 95% confidence interval 4.8-23.1; P = 0.0001). This risk was dependant on severity of CKD; a 10 mL/min reduction in creatinine clearance was associated with a 55% increase in hazard of death (P < 0.0001). CONCLUSIONS: In patients receiving an ICD for primary prevention of sudden death, CKD significantly reduced long-term survival. This poor prognosis may limit the impact of primary prevention ICD therapy in this patient population.