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Seattle Heart Failure and Proportional Risk Models Predict Benefit From Implantable Cardioverter-Defibrillators.

ABSTRACT: BACKGROUND:Recent clinical trials highlight the need for better models to identify patients at higher risk of sudden death. OBJECTIVES:The authors hypothesized that the Seattle Heart Failure Model (SHFM) for overall survival and the Seattle Proportional Risk Model (SPRM) for proportional risk of sudden death, including death from ventricular arrhythmias, would predict the survival benefit with an implantable cardioverter-defibrillator (ICD). METHODS:Patients with primary prevention ICDs from the National Cardiovascular Data Registry (NCDR) were compared with control patients with heart failure (HF) without ICDs with respect to 5-year survival using multivariable Cox proportional hazards regression. RESULTS:Among 98,846 patients with HF (87,914 with ICDs and 10,932 without ICDs), the SHFM was strongly associated with all-cause mortality (p < 0.0001). The ICD-SPRM interaction was significant (p < 0.0001), such that SPRM quintile 5 patients had approximately twice the reduction in mortality with the ICD versus SPRM quintile 1 patients (adjusted hazard ratios [HR]: 0.602; 95% confidence interval [CI]: 0.537 to 0.675 vs. 0.793; 95% CI: 0.736 to 0.855, respectively). Among patients with SHFM-predicted annual mortality ?5.7%, those with a SPRM-predicted risk of sudden death below the median had no reduction in mortality with the ICD (adjusted ICD HR: 0.921; 95% CI: 0.787 to 1.08; p = 0.31), whereas those with SPRM above the median derived the greatest benefit (adjusted HR: 0.599; 95% CI: 0.530 to 0.677; p < 0.0001). CONCLUSIONS:The SHFM predicted all-cause mortality in a large cohort with and without ICDs, and the SPRM discriminated and calibrated the potential ICD benefit. Together, the models identified patients less likely to derive a survival benefit from primary prevention ICDs.

SUBMITTER: Bilchick KC

PROVIDER: S-EPMC5502749 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Seattle Heart Failure and Proportional Risk Models Predict Benefit From Implantable Cardioverter-Defibrillators.

Bilchick Kenneth C KC Wang Yongfei Y Cheng Alan A Curtis Jeptha P JP Dharmarajan Kumar K Stukenborg George J GJ Shadman Ramin R Anand Inder I Lund Lars H LH Dahlström Ulf U Sartipy Ulrik U Maggioni Aldo A Swedberg Karl K O'Conner Chris C Levy Wayne C WC

Journal of the American College of Cardiology 20170501 21

<h4>Background</h4>Recent clinical trials highlight the need for better models to identify patients at higher risk of sudden death.<h4>Objectives</h4>The authors hypothesized that the Seattle Heart Failure Model (SHFM) for overall survival and the Seattle Proportional Risk Model (SPRM) for proportional risk of sudden death, including death from ventricular arrhythmias, would predict the survival benefit with an implantable cardioverter-defibrillator (ICD).<h4>Methods</h4>Patients with primary pr ...[more]

PMID: 28545633

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Project description:BackgroundImplantable defibrillators are recommended for the prevention of sudden cardiac death in patients with heart failure. However, criteria to identify those who would benefit most from this therapy are lacking. We assessed the maximum potential benefit of preventing sudden death in patients with repeated hospital admissions because of heart failure.MethodsUsing a cohort assembled from an administrative database, we identified 14,374 patients admitted to hospital for the first time because of heart failure between Jan. 1, 2000, and Dec. 31, 2004. We followed subsequent admissions related to heart failure as well as mortality and causes of death to Mar. 31, 2006. We regarded all out-of-hospital cardiac deaths as sudden deaths. We calculated the maximum potential benefit of preventing sudden death by subtracting the observed survival after each hospital admission from the hypothetical survival whereby all out-of-hospital cardiac deaths were assumed to be preventable.ResultsThe mean age of the cohort was 77 years, 45% were women, 11% had cerebrovascular disease, and 21% had chronic kidney disease. Out-of-hospital cardiac deaths constituted 13.7% (1226/8967) of all deaths during 32,055 person-years of follow-up. The median survival declined with each subsequent hospital admission related to heart failure. The hypothetical prevention of all out-of-hospital deaths prolonged life by 0.63 (95% confidence interval [CI] 0.49 to 0.77) years after the first hospital admission. This potential benefit dropped to 0.28 (95% CI 0.10 to 0.46) years after 3 hospital admissions related to heart failure. Among patients less than 65 years old, and older patients without kidney disease, dementia or cancer, more than 50% survived longer than 2 years until they had 2 or 3 hospital admissions related to heart failure.InterpretationThe use of implantable defibrillators to prevent sudden death would provide limited benefit among older patients with comorbidities and among patients with multiple hospital admissions related to heart failure.

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Seattle Heart Failure and Proportional Risk Models Predict Benefit From Implantable Cardioverter-Defibrillators.

Publications

Seattle Heart Failure and Proportional Risk Models Predict Benefit From Implantable Cardioverter-Defibrillators.

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