Cited by 356Cardiac electrophysiology and arrhythmiasCardiac pacing and defibrillation studiesCardiac Health and Mental Health

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Limitations of Ejection Fraction for Prediction of Sudden Death Risk in Patients With Coronary Artery Disease

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Buxton, Alfred E., Lee, Kerry L., Hafley, Gail E., Pires, Luis A., Fisher, John D., Gold, Michael R., Josephson, Mark E., Lehmann, Michael H., Prystowsky, Eric N.·2007·Journal of the American College of Cardiology

DOI 10.1016/j.jacc.2007.04.095

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Abstract

Objectives We determined the contribution of multiple variables to predict arrhythmic death and total mortality risk in patients with coronary disease and left ventricular dysfunction. We then constructed an algorithm to predict risk of mortality and sudden death.Background Many factors in addition to ejection fraction (EF) influence the prognosis of patients with coronary disease. However, there are few tools to use this information to guide clinical decisions.Methods We evaluated the relationship between 25 variables and total mortality and arrhythmic death in 674 patients enrolled in the MUSTT (Multicenter Unsustained Tachycardia Trial) study that did not receive antiarrhythmic therapy. We then constructed risk-stratification algorithms to weight the prognostic impact of each variable on arrhythmic death and total mortality risk.Results The variables having the greatest prognostic impact in multivariable analysis were functional class, history of heart failure, nonsustained ventricular tachycardia not related to bypass surgery, EF, age, left ventricular conduction abnormalities, inducible sustained ventricular tachycardia, enrollment as an inpatient, and atrial fibrillation. The model demonstrates that patients whose only risk factor is EF < or =30% have a predicted 2-year arrhythmic death risk <5%.Conclusions Multiple variables influence arrhythmic death and total mortality risk. Patients with EF < or =30% but no other risk factor have low predicted mortality risk. Patients with EF >30% and other risk factors may have higher mortality and a higher risk of sudden death than some patients with EF < or =30%. Thus, risk of sudden death in patients with coronary disease depends on multiple variables in addition to EF.

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BackgroundMethodInfluential
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A combined anatomic and electrophysiologic substrate based approach for sudden cardiac death risk stratification
Merchant, F. M., Zheng, H., Bigger, T., Steinman, R. C., Ikeda, T., Pedretti, R. F. E., Salerno‐Uriarte, J. A., Klersy, C., Chan, P. S., Bartone, C. L., et al. (2013) · American Heart Journal · doi:10.1016/j.ahj.2013.06.023 · Cited by 18
Sudden death in ischemic heart disease – 2017
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Self-citation
The role of heart rate variability, heart rate turbulence, and deceleration capacity in predicting cause-specific mortality in chronic heart failure
Al‐Zaiti, S. S., Pietrasik, G. M., Carey, M. G., Alhamaydeh, M., Canty, J. M., & Fallavollita, J. A. (2018) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2018.11.006 · Cited by 17
“However, using LVEF to target ICD therapy has been found to be very inefficient [3,4].”
Method
Review of cardiovascular imaging in The Journal of Nuclear Cardiology in 2014: Part 1 of 2: Positron emission tomography, computed tomography, and neuronal imaging
AlJaroudi, W. A., & Hage, F. G. (2014) · Journal of Nuclear Cardiology · doi:10.1007/s12350-014-0045-8 · Cited by 17
“In patients with heart failure, the traditional tools that risk stratify for sudden cardiac death such as left ventricular ejection fraction have proven suboptimal, emphasizing a non-uniform distribution of risk among patients.(14) The presence of autonomic dysfunction has been associated with serious arrhythmia.”
Background
Risk stratification for sudden cardiac death in North America – current perspectives
Buxton, A. E., Waks, J. W., Shen, C., & Chen, P. (2016) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2016.07.018 · Cited by 17
Self-citation
Cardiac Chamber Volumetric Assessment Using 3D Ultrasound - A Review
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Dutch outcome in implantable cardioverter-defibrillator therapy (DO-IT): registry design and baseline characteristics of a prospective observational cohort study to predict appropriate indication for implantable cardioverter-defibrillator
on behalf of the DO-IT investigators, van Barreveld, M., Dijkgraaf, M. G. W., Hulleman, M., Boersma, L. V. A., Delnoy, P. P. H. M., Meine, M., Tuinenburg, A. E., Theuns, D. A. M. J., van der Voort, P. H., et al. (2017) · Netherlands Heart Journal · doi:10.1007/s12471-017-1016-x · Cited by 16
Prediction of Life-Threatening Arrhythmias – Still an Unresolved Problem
Haugaa, K. H., Edvardsen, T., & Amlie, J. (2011) · Cardiology · doi:10.1159/000327093 · Cited by 16
Electrocardiographic predictors of sudden and non-sudden cardiac death in patients with ischemic cardiomyopathy
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“Atrial Fibrillation (AF): This confounder precluded the analysis of (1) minimum heart rate (minHR), (2) heart rate variability (HRV), (3) premature ventricular contractions (PVC), (4) QRS duration (QRSd), (5) QTc, (6) QT-RR slope, and (7) QRSTA.”
Influential
Volumetric Left Ventricular Ejection Fraction is Superior to 2-Dimensional Echocardiography for Risk Stratification of Patients for Primary Prevention Implantable Cardioverter-Defibrillator Implantation
Rayatzadeh, H., Patel, S. J., Hauser, T. H., Ngo, L. H., Shaw, J. L., Tan, A. Y., Buxton, A. E., ZIMETBAUM, P. J., Josephson, M. E., Appelbaum, E. A., et al. (2013) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2012.12.051 · Cited by 15
Self-citation
Therapy with an implantable cardioverter defibrillator (ICD) in patients with coronary artery disease and dilated cardiomyopathy: benefits and disadvantages
Schaer, B. A., Kühne, M., Koller, M. T., Sticherling, C., & Osswald, S. (2009) · Swiss Medical Weekly · doi:10.4414/smw.2009.12668 · Cited by 14
T-Wave Alternans Testing for Ventricular Arrhythmias
Narayan, S. M. (2008) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2007.11.001 · Cited by 13
“Many limitations of TWA may be obviated, in part, by its inclusion in a risk score (51).”
BackgroundMethod
Clinical Applications of Myocardial Innervation Imaging
Travin, M. I. (2015) · Cardiology Clinics · doi:10.1016/j.ccl.2015.06.003 · Cited by 13
Usefulness of Cardiac Sympathetic Nerve Imaging Using 123Iodine-Metaiodobenzylguanidine Scintigraphy for Predicting Sudden Cardiac Death in Patients With Heart Failure
Kasama, S., Takuji, T., & Kurabayashi, M. (2016) · International Heart Journal · doi:10.1536/ihj.15-508 · Cited by 13
Improvement of left ventricular ejection fraction in revascularized postmyocardial patients: indication for statistical fallacy
Reibis, R. K., Salzwedel, A., Bonaventura, K., Völler, H., & Wegscheider, K. (2017) · BMC Research Notes · doi:10.1186/s13104-017-2562-4 · Cited by 13
“Although additional risk factors were also shown to be of predictive value [6], the estimation of SCD risk in the present study is based on the left ventricular ejection fraction.”
Background
Risk Stratification for Sudden Cardiac Death after Acute Myocardial Infarction
Liew, R., & Chiam, P. T. L. (2010) · Annals of the Academy of Medicine Singapore · doi:10.47102/annals-acadmedsg.v39n3p237 · Cited by 13
Risk Assessment for Defibrillator Therapy
Anderson, K. P. (2007) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2007.05.038 · Cited by 13
Adverse Structural Remodeling of the Left Ventricle and Ventricular Arrhythmias in Patients With Depressed Ejection Fraction
Draper, T. S., Silver, J. S., & Gaasch, W. H. (2014) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2014.10.018 · Cited by 12
Does Myocardial Perfusion Imaging Provide Incremental Prognostic Information to Left Ventricular Ejection Fraction?
Mudrick, D. W., Velazquez, E. J., & Borges‐Neto, S. (2010) · Current Cardiology Reports · doi:10.1007/s11886-010-0093-x · Cited by 12
Myocardial denervation coincides with scar heterogeneity in ischemic cardiomyopathy: A PET and CMR study
de Haan, S., Rijnierse, M. T., Harms, H. J., Verberne, H. J., Lammertsma, A. A., Huisman, M. C., Windhorst, A. D., van Rossum, A. C., Allaart, C. P., & Knaapen, P. (2015) · Journal of Nuclear Cardiology · doi:10.1007/s12350-015-0316-z · Cited by 12
The prognostic value of discordant T waves in lead aVR: A simple risk marker of sudden cardiac arrest in ischemic cardiomyopathy
Al‐Zaiti, S. S., Fallavollita, J. A., Canty, J. M., & Carey, M. G. (2015) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2015.06.013 · Cited by 12
“, both V5 and V6)9; (2) more extensive disease with myocardial scarring involving the apex;5 and (3) spatial-temporal changes in ventricular repolarization;5 T wave inversion in V5-V6, Selvester scores,12 and spatial QRS-T angle13 were evaluated for all patients and used as control analyses.”
Method
Different Substrates of Non-Sustained Ventricular Tachycardia in Post-infarction Patients With and Without Left Ventricular Dilatation
Bella, G. D., Passino, C., Aquaro, G. D., Rovai, D., Strata, E., Arrigo, F., Emdin, M., Lombardi, M., & Pingitore, A. (2009) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2009.09.001 · Cited by 12
“In addition, in the Multicenter Unsustained Tachycardia Trial, the presence of nonsustained VT and other variables increased the risk of sudden death in patients with LV ejection fraction O30%, resulting higher than that of patients with ejection fraction !30% but without other risk factors.(12) Other parameters propo…”
Background
Role of risk stratification and genetics in sudden cardiac death
Rai, V., & Agrawal, D. K. (2016) · Canadian Journal of Physiology and Pharmacology · doi:10.1139/cjpp-2016-0457 · Cited by 14
Cumulative effects of common genetic variants on risk of sudden cardiac death
Huertas‐Vázquez, A., Nelson, C. P., Sinsheimer, J. S., Reinier, K., Uy‐Evanado, A., Teodorescu, C., Ayala, J., Hall, A. S., Gunson, K., Jui, J., et al. (2015) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2015.03.001 · Cited by 11
“Implantable defibrillators are effective in treatingmalignant tachyarrhythmias but their impact in primary prevention of SCD could be significantly enhanced by improvements in risk stratification [4–7].”
Background
Delayed intrinsicoid deflection: Electrocardiographic harbinger of heart disease
Aiken, A. V., Goldhaber, J. I., & Chugh, S. S. (2022) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12940 · Cited by 11
Recognizing Life-Threatening Causes of Syncope
Khoo, C., Chakrabarti, S., Arbour, L. T., & Krahn, A. D. (2012) · Cardiology Clinics · doi:10.1016/j.ccl.2012.10.005 · Cited by 12
Heart rate turbulence predicts ICD-resistant mortality in ischaemic heart disease
Marynissen, T., Floré, V., Heidbüchel, H., Nuyens, D., Ector, J., & Willems, R. (2013) · EP Europace · doi:10.1093/europace/eut303 · Cited by 11
Primary Prevention Implantable Cardiac Defibrillator Trials
Sroubek, J., & Buxton, A. E. (2017) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2017.08.006 · Cited by 11
“A MUSTT substudy analyzed 674 trial participants.(21) This included 200 patients with inducible arrhythmias randomized to no antiarrhythmic ther-”
MethodSelf-citation
Primary prevention with the ICD in clinical practice: not as straightforward as the guidelines suggest?
Bracke, F. A. L. E., Dekker, L., van der Voort, P. H., & Meijer, A. (2009) · Netherlands Heart Journal · doi:10.1007/bf03086228 · Cited by 11
Programmed Ventricular Stimulation
Buxton, A. E. (2014) · Circulation · doi:10.1161/circulationaha.113.007747 · Cited by 11
“However, lessons from previous trials warn us that risk stratification cannot rely on single tests alone, but require consideration of multiple risk factors.(9,18,19) Finally, there is one other critical observation of the current study that bears on current guidelines for primary prevention of SCD.”
Self-citation
The coin toss: Implications for risk stratification for sudden cardiac death
Goldberger, J. J. (2010) · American Heart Journal · doi:10.1016/j.ahj.2010.04.006 · Cited by 11
“Unlike the performance of a diagnostic test, whose result can be compared with a criterion standard for diagnostic accuracy, the assessment of risk or prognosis attempts to predict a future event and is often characterized by a predicted event rate.(7) Important”
Method
Application of a mortality risk score in a general population of patients with an implantable cardioverter defibrillator (ICD)
Schaer, B. A., Kühne, M., Blatter, D., Osswald, S., & Sticherling, C. (2014) · Heart · doi:10.1136/heartjnl-2013-305002 · Cited by 10
Electrophysiology testing for risk stratification of patients with ischaemic cardiomyopathy: a call for action
Katritsis, D. G., Zografos, T. A., & Hindricks, G. (2017) · EP Europace · doi:10.1093/europace/eux305 · Cited by 10
Strain Imaging and Ventricular Arrhythmia
Bjerregaard, C. L., Skaarup, K. G., Lassen, M. C. H., Biering‐Sørensen, T., & Olsen, F. J. (2023) · Diagnostics · doi:10.3390/diagnostics13101778 · Cited by 9
Predictive Value of Global Longitudinal Strain by Left Ventricular Ejection Fraction
Medvedofsky, D. A., Arany‐Lao‐Kan, G., McNitt, S. A., Lang, R. M., Tung, R. H., Solomon, S. D., Merkely, B. P., Goldenberg, I., & Kutyifa, V. (2023) · ESC Heart Failure · doi:10.1002/ehf2.14193 · Cited by 8
The role of radionuclide imaging in heart failure
Gulati, V., Ching, G., & Heller, G. V. (2013) · Journal of Nuclear Cardiology · doi:10.1007/s12350-013-9776-1 · Cited by 9
Contrast ‑ in cardiac magnetic resonance imaging
Patel, N. B., Kolakalapudi, P., & Arora, G. (2018) · Echocardiography · doi:10.1111/echo.13845 · Cited by 9
CHA 2 DS 2 ‐VASc Score and the Risk of Ventricular Tachyarrhythmic Events and Mortality in MADIT‐CRT
Nof, E., Kutyifa, V., McNitt, S. A., Goldberger, J. J., Huang, D. T.-C., Aktaş, M. K., Spencer, R., Goldenberg, I., & Beinart, R. (2019) · Journal of the American Heart Association · doi:10.1161/jaha.119.014353 · Cited by 9
Role of Cardiac Imaging in Evaluating Risk for Sudden Cardiac Death
Macatangay, C., Viles-González, J. F., & Goldberger, J. J. (2017) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2017.08.001 · Cited by 8
Advances in Imaging and Heart Failure: Where are we Heading?
Adigopula, S., & Grapsa, J. (2018) · Cardiac failure review · doi:10.15420/cfr.2018.5.2 · Cited by 8
Arrhythmic burden among asymptomatic patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator
Sabbag, A., Glikson, M., Suleiman, M. A., Boulos, M., Goldenberg, I., Beinart, R., & Nof, E. (2019) · Heart Rhythm · doi:10.1016/j.hrthm.2019.03.030 · Cited by 8
The prognostic impact of pre-implantation hyponatremia on morbidity and mortality among patients with left ventricular dysfunction and implantable cardioverter-defibrillators
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Muerte súbita cardiaca. Estratificación de riesgo, prevención y tratamiento
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Burden of Ventricular Arrhythmias in Cardiac Resynchronization Therapy Defibrillation and Implantable Cardioverter-Defibrillator Recipients with Recovered Left Ventricular Ejection Fraction: The Additive Role of Speckle-Tracking Echocardiography
Carluccio, E., Biagioli, P., Mengoni, A., Zuchi, C., Lauciello, R., Jacoangeli, F., Bardelli, G., Oliva, V., & Ambrosio, G. (2021) · Journal of the American Society of Echocardiography · doi:10.1016/j.echo.2021.09.009 · Cited by 8
Primary Prevention Implantable Cardiac Defibrillators: A Townsville District Perspective
Engstrom, N., Dobson, G. P., Ng, K. K., & Letson, H. L. (2020) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2020.577248 · Cited by 8
The role of implantable cardioverter defibrillators in high-risk CABG patients identified early post-cardiac surgery
Nageh, M. F., Kim, J. J., Chung, J., & Yao, J. F. (2010) · EP Europace · doi:10.1093/europace/euq351 · Cited by 7
“The limited predictive values of LVEF and PES are consistent with findings from previous studies in IHD patients.(23,25)”
Result
Metabolomics Profiling Predicts Ventricular Arrhythmia in Patients with an Implantable Cardioverter Defibrillator
Yang, S., Zhao, J., Liu, X., Wang, J., Gu, M., Cai, C., Niu, H., Chen, L., & Hua, W. (2023) · Journal of Cardiovascular Translational Research · doi:10.1007/s12265-023-10413-6 · Cited by 8
“However, several recent reports have demonstrated that a subpopulation of patients may not benefit from ICD intervention; although their LVEF is markedly reduced, their risk of SCD is low [7, 8].”
The Year in Review of Clinical Cardiac Electrophysiology
Marcus, G. M., Keung, E. C., & Scheinman, M. M. (2013) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2012.09.062 · Cited by 7

Authors: Buxton, A. E., Lee, K. L., Hafley, G. E., Pires, L. A., Fisher, J. D., Gold, M. R., Josephson, M. E., Lehmann, M. H., & Prystowsky, E. N.
Affiliations: Brown University (US)
Duke Medical Center (US)
Albert Einstein College of Medicine (US)
Medical University of South Carolina (US)
Beth Israel Deaconess Medical Center (US)
University of Michigan (US)
Corresponding author: Buxton, Alfred E.
ORCID: Buxton, Alfred E.
Lee, Kerry L.
Fisher, John D.
Gold, Michael R.
Lehmann, Michael H.
Prystowsky, Eric N.
Venue: Journal of the American College of Cardiology
Publisher: Elsevier BV
Published: 2007-09
Volume: 50
Issue: 12
Pages: 1150-1157
ISSN: 0735-1097 (ISSN-L)
DOI: 10.1016/j.jacc.2007.04.095
OpenAlex: W29926391
Cited by: 356
References: 25
Citations by year: 2026: 7 · 2025: 2 · 2024: 4 · 2023: 9 · 2022: 9 · 2021: 11 · 2020: 11 · 2019: 16 · 2018: 24 · 2017: 27 · 2016: 24 · 2015: 28 · 2014: 23 · 2013: 40 · 2012: 21
FWCI: 17.79
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 2145 d)
Locations: Journal of the American College of Cardiology (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health (5u01hl045726-06)
National Heart, Lung, and Blood Institute (UO1HL45700, UO1-HL45726, HL45700, U01HL045700)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
Keywords: ejection fraction, sudden cardiac death, arrhythmic death, coronary artery disease, left ventricular dysfunction, risk stratification, mortality prediction, non-sustained ventricular tachycardia, atrial fibrillation, heart failure
MeSH terms: Aged, Anti-Arrhythmia Agents, Cause of Death, Coronary Artery Disease, Female, Heart Arrest, Humans, Male, Middle Aged, Predictive Value of Tests, Probability, Sensitivity and Specificity, Stroke Volume, Confidence Intervals, Chi-Square Distribution, Proportional Hazards Models, Death, Sudden, Cardiac, Defibrillators, Implantable, Tachycardia, Ventricular, Risk Assessment

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Limitations of Ejection Fraction for Prediction of Sudden Death Risk in Patients With Coronary Artery Disease

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