Relations between heart failure, ejection fraction, arrhythmia suppression and mortality: analysis of the Cardiac Arrhythmia Suppression Trial.

OBJECTIVES We studied the relations between heart failure, ejection fraction, arrhythmia suppression and mortality. BACKGROUND Both left ventricular ejection fraction and functional class of heart failure are strongly associated with mortality after acute myocardial infarction. Both are also related to the presence of ventricular arrhythmias and have been identified as factors related to the ability to suppress ventricular arrhythmias. Little has been reported about the relations between these two factors and arrhythmia suppression or mortality. METHODS Baseline data from the Cardiac Arrhythmia Suppression Trial were used to define several categories of heart failure and to relate both the resulting categories and ejection fraction to arrhythmia suppression and mortality using logistic and survival regression analytic methodologies. RESULTS Regardless of the prospective baseline definition of heart failure used, the data consistently showed that heart failure was a more powerful predictor of subsequent congestive heart failure events and arrhythmia suppression and was equally powerful in predicting death. However, each variable provided incremental information when included in the prediction model. Heart failure and ejection fraction appeared to be independent predictors of death. Interactions were observed: A low ejection fraction was more predictive of failure of arrhythmia suppression in patients with than without evidence of heart failure before or at baseline; a low ejection fraction was more predictive of subsequent congestive heart failure events in patients without than with evidence of heart failure before or at baseline. CONCLUSIONS Although heart failure as a prognostic feature appears to be somewhat superior to ejection fraction, both are powerful predictors of arrhythmia suppression and cardiac events in patients with ventricular arrhythmia after myocardial infarction. Each provides incremental prediction.

[1]  L. Horowitz,et al.  Prognosis in severe heart failure: relation to hemodynamic measurements and ventricular ectopic activity. , 1983, Journal of the American College of Cardiology.

[2]  J P Miller,et al.  The relationships among ventricular arrhythmias, left ventricular dysfunction, and mortality in the 2 years after myocardial infarction. , 1984, Circulation.

[3]  D. Wyse,et al.  Events in the Cardiac Arrhythmia Suppression Trial (CAST): mortality in patients surviving open label titration but not randomized to double-blind therapy. , 1991, Journal of the American College of Cardiology.

[4]  L. Horowitz,et al.  Relation of acute antiarrhythmic drug efficacy to left ventricular function in coronary artery disease. , 1988, The American journal of cardiology.

[5]  W. Littler,et al.  Factors influencing survival and mode of death in severe chronic ischaemic cardiac failure. , 1987, British heart journal.

[6]  T. Cesario.  Introduction—Cardiovascular disease in the elderly: Etiology, diagnosis, prevention and treatment , 1989 .

[7]  B. Pitt,et al.  Sudden death in the year following myocardial infarction. Relation to ventricular premature contractions in the late hospitals phase and left ventricular ejection fraction. , 1977, The American journal of medicine.

[8]  A. Hallstrom,et al.  Interaction of Baseline Characteristics With The Hazard of Encainide, Flecainide, and Moricizine Therapy in Patients With Myocardial Infarction: A Possible Explanation for Increased Mortality in the Cardiac Arrhythmia Suppression Trial (CAST) , 1994, Circulation.

[9]  W. Rogers,et al.  Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. , 1989, The New England journal of medicine.

[10]  J. Myles,et al.  Avoiding interpretive pitfalls when assessing arrhythmia suppression after myocardial infarction: insights from the long-term observations of the placebo-treated patients in the Cardiac Arrhythmia Pilot Study (CAPS) , 1991, Journal of the American College of Cardiology.

[11]  J. Kjekshus.  Arrhythmias and mortality in congestive heart failure. , 1990, The American journal of cardiology.

[12]  H L Greene,et al.  Classification of deaths after myocardial infarction as arrhythmic or nonarrhythmic (the Cardiac Arrhythmia Pilot Study). , 1989, The American journal of cardiology.

[13]  J. Kalbfleisch,et al.  The Statistical Analysis of Failure Time Data , 1980 .

[14]  J. Mahmarian,et al.  The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-benefit ratio. , 1989, American heart journal.

[15]  J. Goldberg,et al.  Ventricular premature beats and mortality after myocardial infarction. , 1977, The New England journal of medicine.

[16]  Jerome Cornfield,et al.  A Statistical Problem Arising from Retrospective Studies , 1956 .

[17]  F. Tristani,et al.  Ejection Fraction, Peak Exercise Oxygen Consumption, Cardiothoracic Ratio, Ventricular Arrhythmias, and Plasma Norepinephrine as Determinants of Prognosis in Heart Failure , 1993, Circulation.

[18]  J. Fleiss,et al.  Risk stratification and survival after myocardial infarction. , 1983, The New England journal of medicine.

[19]  T. Levine,et al.  Lack of correlation between exercise capacity and indexes of resting left ventricular performance in heart failure. , 1981, The American journal of cardiology.

[20]  M. Weir,et al.  The Cardiac Arrhythmia Suppression Trial Investigators: Preliminary Report: Effect of Encainide and Flecainide on Mortality in a Randomized Trial of Arrhythmia Suppression After Myocardial Infarction. , 1990 .

[21]  W. Rogers,et al.  Mortality following ventricular arrhythmia suppression by encainide, flecainide, and moricizine after myocardial infarction. The original design concept of the Cardiac Arrhythmia Suppression Trial (CAST). , 1993, JAMA.

[22]  J. Goldberg,et al.  Ventricular Premature Complexes and Sudden Death After Myocardial Infarction , 1981, Circulation.

[23]  Jerzy Neyman,et al.  Proceedings of the Third Berkeley Symposium on Mathematical Statistics and Probability : held at the Statistical Laboratory, University of California, December, 1954, July and August, 1955 , 1958 .

[24]  B Lown,et al.  Predictors of antiarrhythmic drug efficacy in patients with malignant ventricular tachyarrhythmias. , 1987, American heart journal.

[25]  E. Kaplan,et al.  Nonparametric Estimation from Incomplete Observations , 1958 .

[26]  E. Braunwald,et al.  Congestive heart failure : current research and clinical applications , 1982 .

[27]  David R. Cox,et al.  Regression models and life tables (with discussion , 1972 .

[28]  Cardiac Arrhythmia Pilot Study Investigators.  Effects of encainide, flecainide, imipramine and moricizine on ventricular arrhythmias during the year after acute myocardial infarction: the CAPS. , 1988, The American journal of cardiology.