European Heart Journal Advance Access originally published online on June 5, 2006
European Heart Journal 2006 27(16):1933-1941; doi:10.1093/eurheartj/ehl041
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Left ventricular outflow tract obstruction and sudden death risk in patients with hypertrophic cardiomyopathy
The Heart Hospital, University College London, 16–18 Westmoreland Street, London W1G 8PH, UK
Received 29 August 2005; revised 13 April 2006; accepted 4 May 2006; online publish-ahead-of-print 5 June 2006.
* Corresponding author. Tel: +44 208 573 8888 ext. 4801; fax: +44 208 573 8838. E-mail address: perry.elliott{at}uclh.org
See page 1895 for the editorial comment on this article (doi:10.1093/eurheartj/ehl130)
Aims Left ventricular outflow tract obstruction (LVOTO) is associated with reduced survival in patients with hypertrophic cardiomyopathy (HCM). The influence of LVOTO on survival from SD in relation to other recognized clinical risk markers is unknown.
Methods and results A total of 917 patients with HCM (554 males, 43±15 years) were studied; 288 (31.4%) had LVOTO at rest (
30 mmHg). During follow-up [median 61 (30;99) months], 54 (5.9%) patients died suddenly (SD), survived ventricular fibrillation, or had an appropriate ICD discharge; 25 (2.7%) died from heart failure or were transplanted; 17 (1.8%) died from other cardiovascular causes. Five-year survival from all-cause death or cardiac transplantation was lower in patients with LVOTO [86.5% (95% CI: 81.7–91.2) vs. 90.1% (95% CI: 87.3–92.8), P=0.006], with a trend towards higher all-cause death and transplantation with increasing LVOTO [(RR per 20 mmHg=1.24 (95% CI: 1.08–1.42), P=0.003)]. In patients with obstruction, there was a significant relation between 5-year survival from all-cause death and functional limitation (NYHA class I: 91.0%; NYHA class II: 83.3%; NYHA class III/IV: 82.6%, P=0.002). LVOTO was associated with reduced survival from SD and ICD discharge (SD/ICD) [91.4% (95% CI: 87.4–95.3) vs. 95.7% (95% CI: 93.8–97.6), P=0.0004]. Magnitude of LVOTO was related to a higher occurrence of SD/ICD [RR per 20 mmHg=1.36 (95% CI: 1.12–1.65), P=0.001]. There was no relation between survival from SD/ICD, LVOTO, and NYHA class. The annual rate of SD/ICD in patients with LVOTO and no risk factors was 0.37% (95%CI: 0.05–1.35). There was a trend towards lower survival from SD/ICD, with increasing numbers of risk factors in patients with and without LVOTO (P=0.002 and P=0.002, respectively). Multivariable analysis demonstrated that LVOTO was an independent predictor of SD/ICD, with a 2.4-fold (P=0.003) increase in the risk of SD/ICD.
Conclusion LVOTO is associated with an increased risk of SD/ICD that is related to the severity of obstruction and the presence of other recognized risk factors for SD. The low sudden death mortality in asymptomatic patients with LVOTO and no other SD risk markers suggests that aggressive interventions to reduce LVOTO are unwarranted in this group. Further studies are required to determine the most appropriate treatment strategies (ICD or gradient reduction) in patients with additional risk factors.
Key Words: Outflow tract obstruction • Prognosis • Hypertrophic cardiomyopathy
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