Heart failure: syncope increased the risk of dying in severe cases.

Clinical bottom line (level 2b)

  1. A third of patients with severe heart failure were dead within one year.
  2. Half died suddenly.
  3. Patients with the following risk factors were at increased risk of dying:
    • syncope
    • low serum sodium
    • no ACE inhibitors
Middlekauff et al: Journal of the American College of Cardiology 1993; 21: 110-116
Expires July 2003

The study

Retrospective cohort study with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: university hospital, USA

491 patients (aged mean 50 years, 80% male) severe heart failure (mean left ventricular ejection fraction 20%)

Excluded if
  • history of cardiac arrest
  • haemodynamic instability prevented discharge



    • Factors studied:
  • death, sudden death
  • syncope
  • low serum sodium
  • no ACE inhibitors




    • 96 followed for one year
    Outcomes studied:
  • death
  • sudden death
  • death from progressive heart failure

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    death one year 154/491 31%
    (27% to 36%)
    sudden death one year 69/491 14%
    (11% to 17%)
    death from progressive heart failure one year 66/491 13%
    (10% to 17%)

    prognostic factor for
    sudden death     		time to outcome unadjusted RR
    (95% CI)    		 p-value
    syncope one year 13.0
    ( to )     		0.00001
    low serum sodium one year 5.80
    ( to )     		0.01
    no ACE inhibitors one year 5.2
    ( to )     		0.02

    Comments

    1. Retrospective analysis of a large group of very unusual sub-group (30% transplanted). This may make the results less certain.

    Citation

    1. Middlekauff HR, Stevenson WG, Stevenson LW, et al: Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. Journal of the American College of Cardiology 1993; 21: 110-116
    Contributor: Bob Phillips and Clare Wotton, July 2000
    Reviewer:

    Clinical Question.
    Patient heart failure
    Intervention or Exposure risk factors
    Outcome death