Where Patients With Mild To Moderate Heart Failure Die
Where Patients With Mild To Moderate Heart Failure Die
Background: Common locations of death in patients with congestive heart failure (CHF) are unknown. In the SCD-HeFT, mortality of patients with CHF was assessed after randomization to an implantable cardioverter/defibrillator (ICD), amiodarone, or placebo. The aim of this study was to evaluate the location of deaths in SCD-HeFT.
Methods: Among SCD-HeFT patients whose location of death was identified, we used logistic regression to assess the relationship of randomized treatment arm and other baseline predictors with the location of death. Cause of death was adjudicated by a therapy-blinded events committee.
Results: In SCD-HeFT, 666 (26%) of 2521 patients died. Of the 604 (91%) for whom location of death was known, 58% died in hospital and 29% died at home. Patients randomized to receive an ICD were less likely to die at home than patients randomized to placebo (P = .002). Fewer patients randomized to ICDs died; even fewer randomized to ICDs died at home. Age, sex, etiology of heart failure, left ventricular ejection fraction, and New York Heart Association functional class were not associated with location of death. Sudden cardiac death represented 52% of all out-of-hospital deaths but in hospital deaths exceeded out-of-hospital deaths.
Conclusion: Deaths in SCD-HeFT, a well-treated CHF population, were most often in hospital. ICDs were associated with lower total and sudden death rates at home and in hospital. Development of methods to identify which patients will not respond to optimal treatment, including an ICD, remain a challenge.
Patients with congestive heart failure (CHF) are at risk of death due to cardiac arrhythmias, worsening heart failure, and noncardiac causes, but the location where these patients die is not known. Sudden, unexpected, out-of-hospital, death is considered a common cause of death in the United States and likely explains deaths of many patients with heart failure, despite medical therapy. Yet, although many deaths may be out of hospital due to arrhythmic causes, some arrhythmic deaths occur in the hospital. Predictors for in hospital mortality exist based on admission characteristics of hospitalized patients, but no data predict the location of death in an outpatient heart failure population.
One common presumption is that an implantable cardioverter/defibrillator (ICD) or an antiarrhythmic drug may trade a quick and painless death for a lingering, perhaps even miserable, death. Furthermore, ICDs can be associated with limitation in activities including driving. The SCD-HeFT, a large National Institutes of Healthsponsored, multicenter, extended follow-up clinical trial evaluated the mortality of patients with chronic CHF (New York Heart Association [NYHA] functional class II and III), who had left ventricular ejection fractions ≤0.35 and were treated with standard heart failure medications. Patients were randomized as outpatients to receive a single-lead ICD, amiodarone, or a placebo pill (double blind with amiodarone). SCD-HeFT offered the opportunity to assess the impact of adjunctive arrhythmia treatment strategies (vs placebo) on the location and mode of death in this ambulatory chronic heart failure population.
The purpose of this study was to examine the place of death (in hospital, at home, or elsewhere) in SCD-HeFT. We hypothesized that most deaths in SCD-HeFT occurred in the hospital but that the location of death could not be predicted reliably by clinically available parameters. We further hypothesized that at-home deaths were even less frequent in patients randomized to receive an ICD.
Abstract and Introduction
Abstract
Background: Common locations of death in patients with congestive heart failure (CHF) are unknown. In the SCD-HeFT, mortality of patients with CHF was assessed after randomization to an implantable cardioverter/defibrillator (ICD), amiodarone, or placebo. The aim of this study was to evaluate the location of deaths in SCD-HeFT.
Methods: Among SCD-HeFT patients whose location of death was identified, we used logistic regression to assess the relationship of randomized treatment arm and other baseline predictors with the location of death. Cause of death was adjudicated by a therapy-blinded events committee.
Results: In SCD-HeFT, 666 (26%) of 2521 patients died. Of the 604 (91%) for whom location of death was known, 58% died in hospital and 29% died at home. Patients randomized to receive an ICD were less likely to die at home than patients randomized to placebo (P = .002). Fewer patients randomized to ICDs died; even fewer randomized to ICDs died at home. Age, sex, etiology of heart failure, left ventricular ejection fraction, and New York Heart Association functional class were not associated with location of death. Sudden cardiac death represented 52% of all out-of-hospital deaths but in hospital deaths exceeded out-of-hospital deaths.
Conclusion: Deaths in SCD-HeFT, a well-treated CHF population, were most often in hospital. ICDs were associated with lower total and sudden death rates at home and in hospital. Development of methods to identify which patients will not respond to optimal treatment, including an ICD, remain a challenge.
Introduction
Patients with congestive heart failure (CHF) are at risk of death due to cardiac arrhythmias, worsening heart failure, and noncardiac causes, but the location where these patients die is not known. Sudden, unexpected, out-of-hospital, death is considered a common cause of death in the United States and likely explains deaths of many patients with heart failure, despite medical therapy. Yet, although many deaths may be out of hospital due to arrhythmic causes, some arrhythmic deaths occur in the hospital. Predictors for in hospital mortality exist based on admission characteristics of hospitalized patients, but no data predict the location of death in an outpatient heart failure population.
One common presumption is that an implantable cardioverter/defibrillator (ICD) or an antiarrhythmic drug may trade a quick and painless death for a lingering, perhaps even miserable, death. Furthermore, ICDs can be associated with limitation in activities including driving. The SCD-HeFT, a large National Institutes of Healthsponsored, multicenter, extended follow-up clinical trial evaluated the mortality of patients with chronic CHF (New York Heart Association [NYHA] functional class II and III), who had left ventricular ejection fractions ≤0.35 and were treated with standard heart failure medications. Patients were randomized as outpatients to receive a single-lead ICD, amiodarone, or a placebo pill (double blind with amiodarone). SCD-HeFT offered the opportunity to assess the impact of adjunctive arrhythmia treatment strategies (vs placebo) on the location and mode of death in this ambulatory chronic heart failure population.
The purpose of this study was to examine the place of death (in hospital, at home, or elsewhere) in SCD-HeFT. We hypothesized that most deaths in SCD-HeFT occurred in the hospital but that the location of death could not be predicted reliably by clinically available parameters. We further hypothesized that at-home deaths were even less frequent in patients randomized to receive an ICD.