Evidence-based medications likely contributed to decreased rates of sudden death in heart failure

Background

A meta-analysis showed that the rate of sudden death in HFrEF patients has fallen over the past two decades, suggesting a cumulative benefit of evidence-based medications on sudden death.

Main results

• Out of 40,195 eligible patients, 77% were men, 62% had an ischemic cause of HF and 8.9% died suddenly.
• The annual rate of sudden death fell over time, from 6.5% in the earliest trial (RALES, completed in 1998) to 3.3% in the most recent trial (PARADIGM-HF, completed in 2014). The P value for trend was 0.02.
• An exception to the fall of sudden death rates over time was the CORONA trial (completed in 2007), with a rate of sudden death of 5.2%. In this study the rate of death from any cause was also outside the declining trend for other trials, probably because only patients ≥60 years with ischemic HF were enrolled.
• The rate of sudden death was lower in the experimental-therapy groups than in the control groups in all the trials, with the exceptions of Val-HeFT and GISSI-HF. With adjustment for randomized group (groups combined per study), with the trial as a random effect, there was a decline in risk of sudden death of 44% over the 19 years (HR 0.56, 95% CI 0.33-0.93, P=0.03).
• The reduction in risk over time was attenuated with further adjustment for baseline covariates (adjusted HR 0.90, 95% CI 0.61-1.32, P=0.60), although the randomized group remained associated with a lower risk of sudden death (HR 0.86, 95% CI 0.81-0.92, P<0.001).
• At 90 days after randomization, the cumulative incidence rates of sudden death ranged from 2.4% (95% CI 1.6-3.1) in RALES to 1.0% (95% CI 0.8-1.3) in the PARADIGM-HF trial. In each trial, the cumulative incidence of sudden death at 180 days was approximately double that at 90 days, with a similar general trend towards lower rates in more recent trials.
• The cumulative risk of sudden death during follow-up increased significantly according to the length of time between the diagnosis of HF and randomization in the nine trials that had this information available (31,866 patients; 79% of the total study sample).
• In each trial, a higher rate of sudden death was observed in the subgroup of patients with a lower ejection fraction.

Conclusion

References

Find this article online at NEJM