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CLINICAL RESEARCH: SAFETY ISSUE

Mode of Death in Advanced Heart Failure

The Comparison of Medical, Pacing, and Defibrillation Therapies in Heart Failure (COMPANION) Trial

Peter Carson, MD, FACC^_*,_*, Inder Anand, MD, FACC, Christopher O’Connor, MD, FACC, Brian Jaski, MD, FACC, Jonathan Steinberg, MD, FACC^||, Amy Lwin, RN^¶, JoAnn Lindenfeld, MD, FACC^#, Jalil Ghali, MD, FACC^_**, Jodi H. Barnet, MS, Arthur M. Feldman, MD, PhD, FACC and Michael R. Bristow, MD, PhD, FACC^#

^_* Veterans Affairs Medical Center, Washington, DC
Division of Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
Division of Cardiology, Duke University, Durham, North Carolina
Advanced Heart Failure and Cardiac Transplant Programs, Sharp Memorial Hospital, San Diego, California
^|| Division of Cardiology, St. Luke’s-Roosevelt Hospital, New York, New York
^¶ Clinical Cardiovascular Research, Gaithersburg, Maryland
^# Division of Cardiology, University of Colorado, Denver, Colorado
^_** Louisiana State University Medical Center, Shreveport, Louisiana
University of Wisconsin, Madison, Wisconsin
Jefferson Medical College, Philadelphia, Pennsylvania

Manuscript received March 1, 2005; revised manuscript received August 24, 2005, accepted September 8, 2005.

^_* Reprint requests and correspondence: Dr. Peter E. Carson, Division of Cardiology, Veterans Affairs Medical Center, 50 Irving Street NW, Washington, DC 20422 (Email: Peter.Carson{at}med.va.gov).

OBJECTIVES: The aim of this study was to evaluate the mode of death in patients with advanced chronic heart failure (HF) and intraventricular conduction delay treated with optimal pharmacologic therapy (OPT) alone or OPT with biventricular pacing to provide cardiac resynchronization therapy (CRT) or CRT + an implantable defibrillator (CRT-D).

BACKGROUND: Limited data are available on mode of death in advanced HF. No data have existed on mode of death in these patients who also have an intraventricular conduction delay and are treated with CRT or CRT-D.

METHODS: Using prespecified definitions and source materials, seven cardiologists assessed mode of death among the 313 deaths that occurred in the Comparison of Medical, Pacing, and Defibrillation Therapies in Heart Failure (COMPANION) trial.

RESULTS: A primary cardiac cause was present in 78% of deaths. Pump failure (44.4%) was the most common mode of death followed by sudden cardiac death (SCD) (26.5%). Compared with OPT, CRT-D significantly reduced the number of cardiac deaths (38%, p = 0.006), whereas CRT alone was associated with a non-significant 14.5% reduction (p = 0.33). Both CRT and CRT-D tended to reduce pump failure deaths (29%, p = 0.11 and 27%, p = 0.14, respectively). The CRT-D significantly reduced SCD (56%, p = 0.02), but CRT alone did not.

CONCLUSIONS: Pump failure deaths are the predominant mode of death in patients with advanced HF and are modestly reduced by both CRT and CRT-D. Only CRT-D reduced SCD and thus produced a favorable effect on cardiac mortality.

Abbreviations and Acronyms   CI = confidence interval   COMPANION = Comparison of Medical, Pacing, and Defibrillation Therapies in Heart Failure trial   CRT = cardiac resynchronization therapy   CRT-D = cardiac resynchronization therapy with defibrillator   HF = heart failure   HR = hazard ratio   ICD = implantable cardioverter-defibrillator   NYHA = New York Heart Association   OPT = optimal pharmacologic therapy   SCD = sudden cardiac death

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