Published Online
on March 1, 2004

A more recent version of this article appeared on March 23, 2004

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Submitted on August 22, 2003
Revised on October 30, 2003
Accepted on January 5, 2004

Heart Failure and the Risk of Shocks in Patients With Implantable Cardioverter Defibrillators. Results From the Triggers Of Ventricular Arrhythmias (TOVA) Study

William Whang MD, MS^*, Murray A. Mittleman MD, DrPH, David Q. Rich MPH, Paul J. Wang MD, Jeremy N. Ruskin MD, Geoffrey H. Tofler MD, James E. Muller MD, Christine M. Albert MD, MPH, and for the TOVA Investigators

From the Cardiovascular Division, (W.W., J.N.R., J.E.M., C.M.A.) Massachusetts General Hospital, Cardiovascular Division (D.Q.R., M.A.M.), Beth Israel Deaconess Medical Center, and the Division of Preventive Medicine (C.M.A.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass; Stanford University Medical Center (P.J.W.), Stanford, Calif; and the Royal North Shore Hospital (G.E.H.), Sydney, Australia.

^* To whom correspondence should be addressed. E-mail: wwhang{at}partners.org.

Background--Left ventricular ejection fraction (LVEF) predicts device discharges in patients with implantable cardioverter-defibrillators (ICDs). The relationship between severity of congestive heart failure (CHF) and ICD discharges is less clear.

Methods and Results--We prospectively analyzed the association between CHF and risk of appropriate ICD discharges in the Triggers Of Ventricular Arrhythmias (TOVA) study, a cohort study of ICD patients conducted at 31 centers in the United States. Reported shocks were confirmed for sustained ventricular tachycardia (VT) or fibrillation (VF) by analysis of stored electrograms. Proportional hazards models included CHF categorized by New York Heart Association class. Baseline CHF was present among 502 (44%) of 1140 patients; 170 (34%) had class I, 230 (46%) had class II, 97 (19%) had class III, and only 5 (1%) had class IV symptoms. During median follow-up of 212 days, 92 patients experienced 1 or more appropriate ICD discharges. Class III CHF was associated in a statistically significantly manner with ICD discharge for VT/VF (hazard ratio 2.40, 95% CI 1.16 to 4.98), even with adjustment for LVEF. The combination of LVEF <0.20 and class III symptoms resulted in a particularly high risk of shocks for VT/VF (hazard ratio 3.90, 95% CI 1.28 to 11.92).

Conclusions--Class III CHF, an easily accessible clinical measure, is an independent risk factor, along with LVEF, for ventricular arrhythmias that require shock therapy among ICD patients. Whether patients with class III CHF benefit to a greater degree from ICDs and whether aggressive treatment of CHF in ICD patients may prevent ventricular arrhythmias remains to be determined.

Key words: heart failure • tachyarrhythmias • defibrillation • cardioversion

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