Prognostic role of NYHA class in heart failure patients undergoing primary prevention ICD therapy

Abstract

Aims Concerns about the prognostic value of NYHA functional class (FC) in heart failure (HF) patients carrying a prophylactic implantable cardioverter defibrillator (ICD) are still present. We aimed to compare whether mortality and arrhythmic risk were different, in a cohort of HF patients undergoing ICD‐only implant, according to their FC. Methods and results HF patients with left ventricle ejection fraction (LVEF) ≤35%, undergoing first prophylactic ICD‐only implant were collected from a multicentre nationwide registry (2006–2015). Six hundred and twenty‐one patients were identified (101 patients in NYHA I; 411 in NYHA II; 109 in NYHA III). After a mean follow‐up of 4.4 years (±2.1), 126 patients died (20.3%). All‐cause mortality risk was higher in symptomatic patients: 13.9% in NYHA I patients, 18.3% in NYHA II patients (HR: 1.8, 95% CI 1.1–3.2), and 32.9% in NYHA III patients (HR: 3.9, 95% CI 2.1–7.3). Seventy‐eight out of all deaths were due to cardiovascular causes (12.6%). Cardiovascular mortality risk was also higher in symptomatic patients: 6.9% in NYHA I patients, 11% in NYHA II patients (HR: 2.2, 95% CI 1.1–4.9), and 23.9% in NYHA III (HR: 5.5, 95% CI 2.4–12.7). One hundred and seventeen patients received a first appropriate ICD therapy (19.4%). Arrhythmia free survival did not differ among study groups [20.8% in NYHA I patients, 18.7% in NYHA II (HR: 1.1, 95% CI 0.6–1.7) and 20.8% in NYHA III patients (HR: 1.3, 95% CI 0.7–2.5)]. NYHA class independently predicted cardiovascular mortality (NYHA III vs. NYHA I: HR, 4.7; 95% CI, 1.7–12.8, P = 0.002; NYHA II vs. NYHA I: HR, 2.1, 95% CI, 1.0–5.6, P = 0.05) but not all‐cause death (NYHA III vs. NYHA I: HR: 1.8, 95% CI 0.8–3.9, P = 0.11; NYHA II vs. NYHA I: HR, 1.1, 95% CI 0.6–2.2, P = 0.71;). Atrial fibrillation, chronic kidney disease, and diabetes emerged as predictors of both all‐cause death [(HR: 1.8, 95% CI 1.2–2.8, P = 0.005), (HR: 2.2, 95% CI 1.4–3.4, P < 0.001), (HR: 2.0, 95% CI 1.3–3.1, P = 0.001), respectively] and cardiovascular mortality [(HR: 1.8, 95% CI 1.1–3.1, P = 0.02), (HR: 3.1, 95% CI 1.8–5.4, P < 0.001), (HR: 1.7, 95% CI 1.1–3, P = 0.032), respectively]. Conclusions Mortality in HF patients undergoing prophylactic ICD implantation was higher in symptomatic patients. NYHA functional class along with other comorbidities might be helpful to identify a subgroup of ICD carriers with poorer prognosis and higher risk of cardiovascular death.

Antiarrhythmic effect of 9-week hybrid comprehensive telerehabilitation and its influence on cardiovascular mortality in long-term follow-up – subanalysis of the TELEREHabilitation in Heart Failure Patients randomized clinical trial

“…However, it should be noted that the multivariable analysis of the entire population (both HCTR and UC groups) identified independent factors associated with the worsening effect, namely, NYHA class III at baseline and diabetes mellitus. This is in line with the notion that high NYHA functional class is a marker of high-risk patients and was independently related to an increased risk of death from cardiovascular origin [ 5 , 17 ]. Briongos-Figuero et al found that cardiovascular mortality risk was highest in NYHA class III compared with NYHA I and NYHA II patients [ 17 ].…”

“…This is in line with the notion that high NYHA functional class is a marker of high-risk patients and was independently related to an increased risk of death from cardiovascular origin [ 5 , 17 ]. Briongos-Figuero et al found that cardiovascular mortality risk was highest in NYHA class III compared with NYHA I and NYHA II patients [ 17 ].…”

Oral procainamide as pharmacological treatment of recurrent and refractory ventricular tachyarrhythmias: A single-center experience

“…Procainamide, like most antiarrhythmic drugs, is known to reduce the systolic left ventricular function 20 : in our study, the patients' mortality rate during procainamide treatment was apparently higher than that in previous studies of patients with heart failure who had an ICD. 21 It is not clear whether procainamide may have contributed to the naturally occurring worsening of heart failure; however, this value could be more appropriately explained by the higher mortality rates of patients with a high ventricular arrhythmic burden, 22 such as the population of our study. In patients with sustained VTs, the response to intravenous procainamide does not reliably predict the response to oral procainamide 23 ; for this reason, only 26.5% of our patients experienced intravenous infusion of procainamide before the beginning of oral administration.…”

Influence of diabetes on mortality and ICD therapies in ICD recipients: a systematic review and meta-analysis of 162,780 patients

“…2 A). Data in 4 studies [ 10 , 14 , 29 , 31 ] were available for cardiac mortality. The pooled data found an increased risk of cardiac mortality in ICD recipients with diabetes (HR = 1.68, 95% CI 1.35–2.08, I 2 = 0%), shown in Fig.…”