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Incidence, Predictive Factors, and Prognostic Significance of Supraventricular Tachyarrhythmias in Congestive Heart Failure^*

^* From the Department of Medicine, University of Iowa College of Medicine, Iowa City, and LaSalle Cardiology and Galesburg Cottage Hospital (Mr. Mathew), Galesburg, IL; National Heart, Lung, and Blood Institute (Dr. Hunsberger), National Institutes of Health, Bethesda, MD; Division of Cardiology (Dr. Fleg), Johns Hopkins Bayview Medical Center, Baltimore, MD; VA Medical Center (Ms. Mc Sherry and Dr. Williford), Perry Point, MD; and Division of Cardiology (Dr. Yusuf), McMaster University, Hamilton, Ontario, Canada.

Correspondence to: James Mathew, Department of Cardiology, Galesburg Cottage Hospital, 695 N. Kellogg St, Galesburg, IL 61401

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion Conclusion References

 
Background: The incidence, predictive factors, morbidity, and mortality associated with the development of supraventricular tachyarrhythmias (SVTs) in patients with congestive heart failure (CHF) are poorly defined.

Methods: In the Digitalis Investigation Group trial, patients with CHF who were in sinus rhythm were randomly assigned to digoxin (n = 3,889) or placebo (n = 3,899) and followed up for a mean of 37 months. Baseline factors that predicted the occurrence of SVT and the effects of SVT on total mortality, stroke, and hospitalization for worsening CHF were determined.

Results: Eight hundred sixty-six patients (11.1%) had SVT during the study period. Older age (odds ratio [OR], 1.029 for each year increase in age; p = 0.0001), male sex (OR, 1.270; p = 0.0075), increasing duration of CHF (OR, 1.003 for each month increase in duration of CHF; p = 0.0021), and a cardiothoracic ratio of > 0.50 (OR, 1.403; p = 0.0001) predicted an increased risk of experiencing SVT. Left ventricular ejection fraction, New York Heart Association functional class, and treatment with digoxin vs placebo were not related to the occurrence of SVT. After adjustment for other risk factors, development of SVT predicted a greater risk of subsequent total mortality (risk ratio [RR] = 2.451; p = 0.0001), stroke (RR = 2.352; p = 0.0001), and hospitalization for worsening CHF (RR = 3.004; p = 0.0001).

Conclusion: In CHF patients in sinus rhythm, older age, male sex, longer duration of CHF, and increased cardiothoracic ratio predict an increased risk for experiencing SVT. Development of SVT is a strong independent predictor of mortality, stroke, and hospitalization for CHF in this population. Prevention of SVT may prolong survival and reduce morbidity in CHF patients.

Key Words: atrial fibrillation • congestive heart failure • digoxin • stroke • supraventricular arrhythmia

	Introduction

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Congestive heart failure (CHF) is a common precursor for development of supraventricular tachyarrhythmias (SVTs), particularly atrial fibrillation.^{1 2} Nevertheless, the incidence of SVT in patients with CHF and the factors that predict its development are poorly understood. Furthermore, the role of development of SVT as an independent risk factor for death and stroke in patients with CHF is controversial.^{1 2 3 4} However, these studies either included relatively few cases of SVT or they were not conducted in CHF patients who were in sinus rhythm at baseline. Data on the risk of hospitalization for worsening CHF associated with the development of SVT in patients with CHF are limited. The Digitalis Investigation Group (DIG) trial provides an opportunity to examine the incidence of SVT, the risk factors for its occurrence, and the risk of death, stroke, and hospitalization for worsening CHF associated with the development of SVT in a large heterogeneous population of patients with CHF and sinus rhythm. Therefore, we tested the hypotheses that (1) risk factors at baseline may predict the development of SVT in patients with CHF and sinus rhythm, and (2) the development of SVT in patients with CHF and sinus rhythm may predict an increased risk of subsequent morbidity and mortality.

	Materials and Methods

TOP Abstract Introduction Materials and Methods Results Discussion Conclusion References

 
Eligibility and Randomization
Details of rationale, design, baseline characteristics, and main outcome of the DIG study have been published previously.^{5 6} The DIG study was a large, simple double-blind, placebo-controlled clinical trial on the effect of digoxin on mortality and hospitalization in heart failure. Briefly, patients with CHF who were in sinus rhythm at baseline were eligible for enrollment. Patients with CHF and a left ventricular ejection fraction of 0.45 (n = 6,800) were enrolled into the main trial; patients with CHF and a left ventricular ejection fraction of > 0.45 (n = 988) were enrolled into an ancillary trial conducted parallel to the main study. The diagnosis of CHF was based on current or past symptoms and signs of CHF, or radiologic evidence of pulmonary congestion. Exclusion criteria included cor pulmonale, complex congenital heart diseases, and recognizable noncardiac causes of CHF. Patients who were already receiving digoxin were eligible for enrollment after a washout period.

From February 1991 through August 1993, a total of 7,788 patients were enrolled into the DIG trial (3,889 patients to digoxin and 3,899 patients to placebo). Randomization was stratified according to left ventricular ejection fraction ( 0.45 or > 0.45). The recommended initial dose of the study drug was calculated according to a published algorithm.⁷ The investigators were permitted to modify the dose of the study drug from 0.125 to 0.500 mg/d on the basis of factors such as previous use of digoxin and concomitant use of medications that might interact with digoxin pharmacokinetics. Investigators were strongly encouraged to prescribe angiotensin-converting enzyme inhibitors to the patients. Follow-up visits were scheduled at 4 weeks and 16 weeks after randomization and every 4 months thereafter. At each follow-up visit, data on clinical events, functional status, hospitalizations, and side effects were recorded. Discontinuation of treatment with study drug and treatment with open-label digoxin were permitted if the patients remained symptomatic despite optimization of other forms of treatment. The mean duration of follow-up was 37 months (range, 28 to 58 months).

Outcome and Definitions
For the current analysis, data from the main trial and the ancillary trial were combined. The main justification for combining patients with left ventricular ejection fraction 0.45 and > 0.45 is that left ventricular dysfunction and CHF is a spectrum with a continuum of risk and presentations. Further, one would expect the effect of most risk factors to be at least directionally similar. SVTs were defined as sustained SVT that required hospitalization or drug treatment. The DIG study was the prototype of a large, simple clinical trial. One of the basic features of a large, simple trial is that the information collected is consistent with usual clinical practice and readily available without sophisticated and expensive investigations. The results of the study are, therefore, applicable to a large spectrum of patients in clinical practice. SVT included atrial fibrillation, but the investigators were not required to specify the type of SVT. Diagnosis of SVT was based on clinical grounds and on ECG. Routine ambulatory (Holter) monitoring was not done. The first onset of sustained SVT was counted. No distinction was made between patients with intermittent SVT and those with permanent SVT. The outcomes measured to determine the prognostic significance of SVT were total mortality, cardiac mortality, stroke, and hospitalization for worsening CHF. The diagnosis of stroke was made clinically by the investigators. No attempt was made to classify strokes into embolic or other types.

Study Organization
The study was organized and conducted by a steering committee representing the National Heart, Lung, and Blood Institute, the Department of Veterans Affairs Cooperative Studies Program, and cardiologists from the United States and Canada. Patients were recruited at 302 clinical centers in the United States and Canada. The study was approved by the institutional review board at each institution, and all patients gave written informed consent.

Statistical Analysis
Baseline characteristics in patients who experienced SVT were compared with those of subjects who remained free of SVT by unpaired t tests or ² tests.

Independent predictors of SVT were determined by logistic regression analysis with the following baseline covariates; age (in years), sex (male vs female), duration of CHF (in months), left ventricular ejection fraction ( 0.45 vs > 0.45), cardiothoracic ratio (> 0.50 vs 0.50), New York Heart Association (NYHA) functional class (class III/IV vs class I/II), cause of CHF (nonischemic vs ischemic), history of hypertension (present vs absent), history of valvular heart disease (present vs absent), and treatment assignment (digoxin vs placebo). Using left ventricular ejection fraction as a discrete variable was consistent with the method used in the main outcome paper. When the analyses were repeated using left ventricular ejection fraction as a continuous variable, the results were essentially unchanged; risk ratios (RRs) and 95% confidence intervals (CIs) according to these analyses are also reported in appropriate places. An assumption of this model is that there are no first-order interactions. This assumption was tested and confirmed.

The relationship between SVT and a particular outcome (death, stroke, and hospitalization for worsening CHF) was determined using a Cox proportional hazards model. Because the time of onset of SVT and the duration of SVT are different for each patient, SVT was included as a time-dependent variable. In this model, the independent effect of SVT on each of these outcomes was determined by adjusting for treatment, age, sex, left ventricular ejection fraction, NYHA class, cardiothoracic ratio, history of hypertension, history of diabetes mellitus, history of valvular heart disease, and cause of CHF. The assumption of no first-order interactions in the Cox model was also tested and confirmed. Results of these analysis are presented as RRs and 95% CIs. For all analyses, a two-tailed p < 0.05 was required for significance.

	Results

TOP Abstract Introduction Materials and Methods Results Discussion Conclusion References

 
Table 1 summarizes the baseline characteristics of the total DIG study cohort and compares these characteristics in the subset that experienced SVT with those of the remaining patients (sample sizes for the current analysis were slightly lower because of missing values, but the baseline percentages were unchanged). Patients who had SVT were older and had a longer duration of CHF. A greater proportion of patients who experienced SVT had a cardiothoracic ratio > 0.50 and were in NYHA functional class III/IV.

View larger version (12K): [in this window] [in a new window] [Download PPT slide]   Figure 1.. Time to developing SVT in CHF patients.

View larger version (13K): [in this window] [in a new window] [Download PPT slide]   Figure 2.. Effect of SVT on all-cause mortality in CHF patients.

View larger version (15K): [in this window] [in a new window] [Download PPT slide]   Figure 3.. Effect of SVT on fatal or nonfatal stroke in CHF patients.

View larger version (14K): [in this window] [in a new window] [Download PPT slide]   Figure 4.. Effect of SVT on hospitalization for worsening CHF.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion Conclusion References

Morbidity and Mortality Associated With SVT
Data on the effect of atrial fibrillation on mortality and stroke in patients with CHF have been contradictory. In a study of 390 patients with CHF, Middlekauff et al¹² found that 1-year actuarial survival was 52% in patients who were in atrial fibrillation compared with 70% in patients who were in sinus rhythm. However, analysis of data from the Veterans Administration heart failure trials showed that patients with CHF who were in atrial fibrillation did not have an increased risk of death, stroke, or hospitalization for CHF compared with those in sinus rhythm.³ In community-based studies, however, atrial fibrillation was found to be associated with an increased risk of mortality⁸ and stroke.¹³ Data on the risk of hospitalization associated with the development of SVT in patients with CHF are limited. Carson et al³ reported that in the Veterans Administration heart failure trials, patients with CHF who were in atrial fibrillation did not have an increased risk of hospitalization for CHF, compared with patients in sinus rhythm. In contrast, a retrospective analysis of data from the Studies of Left Ventricular Dysfunction trials showed that patients with symptomatic or asymptomatic left ventricular dysfunction who were in atrial fibrillation at baseline had an increased risk of all-cause mortality as well as of death or hospitalization for CHF, compared with patients in sinus rhythm at baseline.⁴ It is worth noting, however, that to our knowledge, there are no previous studies that determined the morbidity and mortality associated with the development of SVT in a cohort of CHF patients who were in sinus rhythm at baseline.

This study demonstrates that SVT is a common complication in patients with CHF. Treatment with digoxin does not prevent the development of SVT in patients with CHF who are in sinus rhythm. The study further shows that the occurrence of SVT in patients with CHF is associated with a significantly increased risk of mortality, stroke, and hospitalization for worsening CHF. The increased risk of these adverse outcomes in CHF patients who develop SVT is independent of other prognostic factors including age, left ventricular ejection fraction, NYHA functional class, and cause of CHF. Thus, SVT in CHF patients is a common problem that presages substantial morbidity and mortality.

Significance and Implications of the Present Findings
This study shows that an enlarged heart is a strong, independent predictor of the occurrence of SVT in patients with CHF. Therefore, measures to prevent or minimize cardiac enlargement may reduce the risk of developing SVT in CHF patients. Angiotensin-converting enzyme inhibitors, for example, may be beneficial in this regard. Angiotensin-converting enzyme inhibitors minimize the enlargement of the left ventricle in patients who have left ventricular dysfunction after myocardial infarction.¹⁴ Data from the Studies of Left Ventricular Dysfunction trials show that angiotensin-converting enzyme inhibitors reduce the progression of left ventricular dilation in patients with asymptomatic left ventricular dysfunction.¹⁵

To our knowledge, there have been no trials to evaluate the efficacy of any intervention to prevent the development of SVT. One of the obstacles for designing such a trial has been the difficulty in defining a group at high risk for this end point.¹⁶ The present study helps to identify CHF patients who are at high risk for the development of SVT. Future trials to evaluate the effect of interventions to prevent the development of SVT in CHF populations may, therefore, focus on older patients with long-standing CHF and an increased cardiothoracic ratio. Given the independent prognostic importance of SVT, prevention of SVT may be a potential mechanism by which morbidity and mortality may be reduced in CHF patients. Such approaches may be indirect (for example, preventing cardiac enlargement) or direct (for example, the use of antiarrhythmic agents). Data from the Survival and Ventricular Enlargement trial and from the Studies of Left Ventricular Dysfunction trials show that angiotensin-converting enzyme inhibitors prevent enlargement of the heart in patients with left ventricular dysfunction with or without myocardial infarction.^{14 15} Beta-blockers and angiotensin-converting enzyme inhibitors may prevent the development of SVT in patients with CHF.^{17 18}

Whether aggressive intervention and treatment to convert SVT to sinus rhythm and to maintain sinus rhythm in CHF patients who develop SVT will reduce the risk of mortality and stroke in patients with CHF is not known. The use of type I antiarrhythmic drugs for atrial fibrillation has been associated with an increased risk of death, presumably because of proarrhythmic effects of these drugs.^{19 20} The ongoing Atrial Fibrillation Follow-up of Rhythm Management Study sponsored by the National Heart, Lung, and Blood Institute is designed to test the hypothesis that conversion to sinus rhythm and maintenance of sinus rhythm may reduce the risk of morbidity and mortality associated with atrial fibrillation in patients deemed to be at increased risk for stroke or death.

Stroke in patients with CHF complicated by SVT is usually attributed to systemic embolus.^{21 22 23} Randomized trials have demonstrated the beneficial effect of treatment with warfarin and perhaps aspirin on stroke in patients with chronic atrial fibrillation.^{23 24 25 26 27} Although the specific type of SVT was not identified in our patients who experienced SVT, atrial fibrillation is thought to be the most common SVT that complicates CHF. Because the development of SVT forewarns an increased risk of stroke, and because treatment with warfarin is known to reduce the risk of stroke in patients with chronic atrial fibrillation, anticoagulation therapy should be seriously considered in CHF patients with SVT.

Limitations
The limitations of the present study include the lack of data on the specific type of SVT, on previous history of stroke, and on the use of anticoagulant, antiplatelet, or antiarrhythmic drugs. Further, the effect of angiotensin-converting enzyme inhibitors on the development of SVT or its effect on morbidity and mortality in patients who develop SVT could not be determined because the vast majority of patients in the current study were treated with these agents as encouraged in the study protocol. It is possible that those patients who were detected to have SVT may have been sicker, particularly because treatment of CHF may reduce the risk of arrhythmias. This is likely to have biased the results. However, the patients were examined at regular intervals, and development of any sustained SVT that required an intervention was reported whether or not the patient was hospitalized. Therefore, the definitions used for SVT in this analysis would identify all clinically relevant SVT, even if the patients were not sick enough to be hospitalized. It is possible that intermittent episodes of SVT with no clinical event may have gone undetected just as occurs in usual clinical practice. Furthermore, even with the use of routine 24-h ambulatory (Holter) monitoring, all arrhythmias in patients in a long-term study cannot be detected. The post hoc nature of the analysis is another limitation. Nevertheless, this is by far the largest study examining the incidence and prognostic significance of SVT in patients with CHF and, therefore, has higher statistical power than previous studies.

	Conclusion

TOP Abstract Introduction Materials and Methods Results Discussion Conclusion References

 
In a large, heterogeneous population of patients with CHF and sinus rhythm, older age, male sex, longer duration of CHF, and increased cardiothoracic ratio are significant risk factors for the development of SVT. Development of SVT in patients with CHF is a strong and independent predictor of death, stroke, and hospitalization for worsening CHF. Treatment with digoxin does not reduce the risk of development of SVT in patients with CHF. Further studies to determine the effect of interventions to prevent SVT in patients with CHF and to minimize the risk of morbidity and mortality associated with SVT in this setting are warranted.

	Acknowledgements

 
The authors thank Ruby N. Stubbs-Stamps, Shari L. Berry, Michael Wold, Stephanie E. Pritchett, and Shanti M. Mathew for assistance in preparation of the manuscript. A complete list of the DIG investigators and institutional affiliations has been published previously.⁶

	Footnotes

 
Abbreviations: CHF = congestive heart failure; CI = confidence interval; DIG = Digitalis Investigation Group; NYHA = New York Heart Association; OR = odds ratio; RR = risk ratio; SVT = supraventricular tachyarrhythmia

Presented in part at the 47th Annual Scientific Sessions of the American College of Cardiology, Atlanta, GA, March 31, 1998.

Received for publication October 26, 1999. Accepted for publication May 2, 2000.

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TOP Abstract Introduction Materials and Methods Results Discussion Conclusion References

 

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