CARDIOVASCULAR MEDICINE

Predicting sudden death in patients with mild to moderate chronic heart failure

M T Kearney¹, K A A Fox², A J Lee³, W P Brooksby⁴, A M Shah¹, A Flapan², R J Prescott³, R Andrews, P D Batin⁴, D L Eckberg⁵, N Gall¹, A G Zaman⁶, H S Lindsay⁷, J Nolan⁸

¹ King’s College, London, UK
² Department of Cardiology, University of Edinburgh, Edinburgh, UK
³ Medical Statistics Unit, University of Edinburgh
⁴ Pontefract and Wakefield Hospitals, UK
⁵ Medical College of Virginia at Virginia Commonwealth University, Virginia, USA
⁶ Freeman Hospital, Newcastle upon Tyne, UK
⁷ Bradford Royal Infirmary, Bradford, UK
⁸ North Staffordshire Cardiac Centre, UK

Correspondence to:
Correspondence to:
Dr M Kearney
Department of Cardiology, Kings College, Bessemer Road, London SE5 9PJ, UK; mark.kearney{at}kcl.ac.uk

Objectives: To explore the relation between non-invasive measures of cardiac function and sudden cardiac death, as well as the development and utility of an index integrating these variables to identify patients at increased risk of this mode of death.

Design: UK-HEART (United Kingdom-heart failure evaluation and assessment of risk trial) was a prospective study conducted between December 1993 and April 2000. The study was specifically designed to identify non-invasive markers of death and mode of death among patients with chronic heart failure.

Setting: 8 UK general hospitals.

Main outcome measures: Death and mode of death.

Results: 553 patients aged a mean (SD) of 63 (10) years, in New York Heart Association functional class 2.3 (0.02), recruited prospectively. After 2365 patient-years’ follow up, 201 patients had died (67 suddenly). Predictors of sudden death were greater cardiothoracic ratio, QRS dispersion, QT dispersion corrected for rate (QTc) across leads V1–V6 on the 12 lead ECG, and the presence of non-sustained ventricular tachycardia. The hazard ratio and 95% confidence intervals (CI) of sudden death for a 10% increase in cardiothoracic ratio was 1.43 (95% CI 1.20 to 1.71), for a 10% increase in QRS dispersion 1.11 (95% CI 1.04 to 1.19), for the presence of non-sustained ventricular tachycardia 2.03 (95% CI 1.27 to 3.25), and for a 10% increase in QTc dispersion across leads V1–V6 1.03 (95% CI 1.00 to 1.07) (all p < 0.04). An index derived from these four factors performed well in identifying patients specifically at increased risk of sudden death.

Conclusions: Results show that an index derived from three widely available non-invasive investigations has the potential to identify ambulant patients with chronic heart failure at increased risk of sudden death. This predictive tool could be used to target more sophisticated investigations or interventions aimed at preventing sudden death.

Abbreviations: CHF, chronic heart failure; CI, confidence interval; MADIT II, multicentre automatic defibrillator implantation trial II; NYHA, New York Heart Association; ROC, receiver operating characteristic; QTc, QT interval corrected for rate; UK-HEART, United Kingdom-heart failure evaluation and assessment of risk trial

Keywords: chronic heart failure; sudden death; risk stratification; arrhythmias; prognosis

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