Maximum potential benefit of implantable defibrillators in preventing sudden death after hospital admission because of heart failure

Abstract

Implantable defibrillators are recommended for the prevention of sudden cardiac death in patients with heart failure. However, criteria to identify those who would benefit most from this therapy are lacking. We assessed the maximum potential benefit of preventing sudden death in patients with repeated hospital admissions because of heart failure. Using a cohort assembled from an administrative database, we identified 14,374 patients admitted to hospital for the first time because of heart failure between Jan. 1, 2000, and Dec. 31, 2004. We followed subsequent admissions related to heart failure as well as mortality and causes of death to Mar. 31, 2006. We regarded all out-of-hospital cardiac deaths as sudden deaths. We calculated the maximum potential benefit of preventing sudden death by subtracting the observed survival after each hospital admission from the hypothetical survival whereby all out-of-hospital cardiac deaths were assumed to be preventable. The mean age of the cohort was 77 years, 45% were women, 11% had cerebrovascular disease, and 21% had chronic kidney disease. Out-of-hospital cardiac deaths constituted 13.7% (1226/8967) of all deaths during 32,055 person-years of follow-up. The median survival declined with each subsequent hospital admission related to heart failure. The hypothetical prevention of all out-of-hospital deaths prolonged life by 0.63 (95% confidence interval [CI] 0.49 to 0.77) years after the first hospital admission. This potential benefit dropped to 0.28 (95% CI 0.10 to 0.46) years after 3 hospital admissions related to heart failure. Among patients less than 65 years old, and older patients without kidney disease, dementia or cancer, more than 50% survived longer than 2 years until they had 2 or 3 hospital admissions related to heart failure. The use of implantable defibrillators to prevent sudden death would provide limited benefit among older patients with comorbidities and among patients with multiple hospital admissions related to heart failure.