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Aims Implantable cardioverter‐defibrillator (ICD) therapy reduces mortality in patients with heart failure and current guidelines advise implantation of ICDs in patients with a life expectancy of >1 year. We examined trends in all‐cause mortality in patients who underwent primary or secondary prevention ICD placement in the Veterans Affairs (VA) Health System. Methods and results US veterans receiving a new ICD placement for primary or secondary prevention of sudden cardiac death between January 2007 and January 2015, who had heart failure with reduced ejection fraction (HFrEF) were included in the analysis. We assessed all‐cause mortality 1 year post‐ICD implantation. ICD implantation and HFrEF diagnosis were established with associated ICD‐9 codes. The VA death registry was utilized to identify mortality rates following ICD placement. Results were subsequently age‐stratified. There were 17 901 veterans with HFrEF with ICD placement nationwide. There was no statistically significant difference in 1‐year mortality from 2007 (13.1%) to 2014 (13.4%, P > 0.05). There was a significant increase in 1‐year mortality in patients in the oldest age quartile (81.6 years, 32.3% mortality) compared to the youngest quartile (55.5 years, 7% mortality). The finding of diverging clinical outcomes extended to the 30‐day but also 8‐year mark. Conclusions Our data suggest there is a high 1‐year mortality in aging HFrEF patients undergoing primary and secondary prevention ICD placement. This highlights the importance of developing better predictive models for mortality in our ICD eligible patient population.

Patients with HFrEF taking carvedilol had improved survival as compared to metoprolol succinate. The data supports the need for furthering testing to determine optimal choice of beta blockers in patients with heart failure with reduced ejection fraction.

This study aimed to compare the effect of β-blocker dose and heart rate (HR) on mortality in patients with heart failure with reduced ejection fraction (HFrEF). The Veteran Affairs databases were queried to identify all patients diagnosed with HFrEF based on International Classification of Diseases Ninth Revision codes from 2007 to 2015 and β-blocker (carvedilol or metoprolol succinate) use. 36,168 patients on low dose β blocker were then matched with 36,168 patients on high dose β-blocker using propensity score matching. The impact of β-blocker dose and HR was assessed on overall mortality using Cox proportional hazard model. After dividing average HR into separate quartiles and adjusting for patient characteristics, high β-blocker dose was associated with lower overall mortality as compared with a low dose of β blocker (hazard ratio 0.75, 95% confidence interval 0.73 to 0.77, p <0.01) independent of the HR achieved. The results held for all 4 quartiles of average HR. A higher β-blocker dose or a lower HR were independently and jointly associated with lower mortality for all quartiles of HR. In conclusion, higher dose of β-blocker therapy and a lower achieved HR were independently associated with a reduction in mortality in HFrEF patients.

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