IMPROVING SURVIVAL FOR PATIENTS WITH ADVANCED HEART-FAILURE - A STUDYOF 737 CONSECUTIVE PATIENTS

Objectives. This study sought to determine whether survival and risk o f sudden death have improved for patients with advanced heart failure referred for consideration for heart transplantation as advances in me dical therapy were systematically implemented over an 8-year period. B ackground. Recent survival trials in patients with mild to moderate he art failure and patients after a myocardial infarction have shown that angiotensin-converting enzyme inhibitors are beneficial, type I antia rrhythmic drugs can be detrimental, and amiodarone may be beneficial i n some groups. The impact of advances in therapy may be enhanced or bl unted when applied to severe heart failure. Methods. One-year mortalit y and sudden death were determined in relation to time, baseline varia bles and therapeutics for 737 consecutive patients referred for heart transplantation and discharged home on medical therapy from 1986 to 19 88, 1989 to 1990 and 1991 to 1993. Medical care was directed by a sing le team of physicians with policies established by consensus. From 198 6 to 1990, the hydralazine/isosorbide dinitrate combination or angiote nsin-converting enzyme inhibitors were the initial vasodilators, and c lass I antiarrhythmic drugs mere allowed. After 1990, captopril was th e initial vasodilator, given to 86% of patients compared with 46% of p atients before 1989. After mid-1989, class I agents were routinely wit hdrawn, and amiodarone was used for frequent ventricular ectopic beats or atrial fibrillation (53% of patients after 1990 vs. 10% before 198 9). Results. The total 1-year mortality rate decreased from 33% before 1989 to 16% after 1990 (p = 0.0001), and sudden death decreased from 20% to 8% (p = 0.0006). Adjusted for clinical and hemodynamic variable s in multivariate proportional hazards models, total mortality and sud den death were lower after 1990. Conclusions. The large reduction in m ortality, particularly in sudden death, from advanced heart failure si nce 1990 may reflect an enhanced impact of therapeutic advances shown in large randomized trials when they are incorporated into a comprehen sive approach in this population. This improved survival supports the growing practice of maintaining potential heart transplant candidates on optimal medical therapy until clinical decompensation mandates tran splantation.