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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Limitations of Ejection Fraction for Prediction of Sudden Death Risk in Patients With Coronary Artery Disease

Lessons From the MUSTT Study

Alfred E. Buxton, MD, FACC^_*,_*, Kerry L. Lee, PhD, Gail E. Hafley, MS, Luis A. Pires, MD, John D. Fisher, MD, Michael R. Gold, MD^||, Mark E. Josephson, MD^#, Michael H. Lehmann, MD^_**, Eric N. Prystowsky, MD for the MUSTT Investigators

^_* Department of Medicine, Cardiology Division, Brown Medical School and Lifespan Academic Medical Center, Providence, Rhode Island
Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
St. John Hospital and Medical Center and Wayne State University School of Medicine, Detroit, Michigan
Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
^|| Medical University of South Carolina, Charleston, South Carolina
^# Beth Israel Deaconess Medical Center, Boston, Massachusetts
^_** Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
Care Group, Indianapolis, Indiana.

Manuscript received January 23, 2007; revised manuscript received April 17, 2007, accepted April 23, 2007.

^_* Reprint requests and correspondence: Dr. Alfred E. Buxton, Cardiology Division, Brown Medical School, 2 Dudley Street, Suite 360, Providence, Rhode Island 02905. (Email: alfred_buxton{at}brown.edu).

Objectives: We determined the contribution of multiple variables to predict arrhythmic death and total mortality risk in patients with coronary disease and left ventricular dysfunction. We then constructed an algorithm to predict risk of mortality and sudden death.

Background: Many factors in addition to ejection fraction (EF) influence the prognosis of patients with coronary disease. However, there are few tools to use this information to guide clinical decisions.

Methods: We evaluated the relationship between 25 variables and total mortality and arrhythmic death in 674 patients enrolled in the MUSTT (Multicenter Unsustained Tachycardia Trial) study that did not receive antiarrhythmic therapy. We then constructed risk-stratification algorithms to weight the prognostic impact of each variable on arrhythmic death and total mortality risk.

Results: The variables having the greatest prognostic impact in multivariable analysis were functional class, history of heart failure, nonsustained ventricular tachycardia not related to bypass surgery, EF, age, left ventricular conduction abnormalities, inducible sustained ventricular tachycardia, enrollment as an inpatient, and atrial fibrillation. The model demonstrates that patients whose only risk factor is EF 30% have a predicted 2-year arrhythmic death risk <5%.

Conclusions: Multiple variables influence arrhythmic death and total mortality risk. Patients with EF 30% but no other risk factor have low predicted mortality risk. Patients with EF >30% and other risk factors may have higher mortality and a higher risk of sudden death than some patients with EF 30%. Thus, risk of sudden death in patients with coronary disease depends on multiple variables in addition to EF.

Abbreviations and Acronyms   EF = ejection fraction   ICD = implantable cardioverter-defibrillator   IVCD = intraventricular conduction delay   LBBB = left bundle branch block   NSVT = nonsustained ventricular tachycardia   VT = ventricular tachycardia

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