This study sought to determine whether survival and risk of sudden death have improved
for patients with advanced heart failure referred for consideration for heart transplantation
as advances in medical therapy were systematically implemented over an 8-year period.
Recent survival trials in patients with mild to moderate heart failure and patients
after a myocardial infarction have shown that angiotensin-converting enzyme inhibitors
are beneficial, type I antiarrhythmic drugs can be detrimental, and amiodarone may
be beneficial in some groups. The impact of advances in therapy may be enhanced or
blunted when applied to severe heart failure.
One-year mortality and sudden death were determined in relation to time, baseline
variables and therapeutics for 737 consecutive patients referred for heart transplantation
and discharged home on medical therapy from 1986 to 1988, 1989 to 1990 and 1991 to
1993. Medical care was directed by a single team of physicians with policies established
by consensus. From 1986 to 1990, the hydralazine/isosorbide dinitrate combination
or angiotensin-converting enzyme inhibitors were the initial vasodilators, and class
I antiarrhythmic drugs were allowed. After 1990, captopril was the initial vasodilator,
given to 86% of patients compared with 46% of patients before 1989. After mid-1989,
class I agents were routinely withdrawn, and amiodarone was used for frequent ventricular
ectopic beats or atrial fibrillation (53% of patients after 1990 vs. 10% before 1989).
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 variables in multivariate proportional hazards models, total mortality
and sudden death were lower after 1990.
The large reduction in mortality, particularly in sudden death, from advanced heart
failure since 1990 may reflect an enhanced impact of therapeutic advances shown in
large randomized trials when they are incorporated into a comprehensive 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 transplantation.