Amiodarone in Patients with Congestive Heart Failure and Asymptomatic Ventricular Arrhythmia
Steven N. Singh, Ross D. Fletcher, Susan Gross Fisher, Bramah N. Singh, H. Daniel Lewis, Prakash C. Deedwania, Barry M. Massie, Cindy Colling, Diane Lazzeri, for The Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure
Background Asymptomatic ventricular arrhythmias in patientswith congestive heart failure are associated with increasedrates of overall mortality and sudden death. Amiodarone is nowused widely to prevent ventricular tachycardia and fibrillation.We conducted a trial to determine whether amiodarone can reduceoverall mortality in patients with congestive heart failureand asymptomatic ventricular arrhythmias.
Methods We used a double-blind, placebo-controlled protocolin which 674 patients with symptoms of congestive heart failure,cardiac enlargement, 10 or more premature ventricular contractionsper hour, and a left ventricular ejection fraction of 40 percentor less were randomly assigned to receive amiodarone (336 patients)or placebo (338 patients). The primary end point was overallmortality, and the median follow-up was 45 months (range, 0to 54).
Results There was no significant difference in overall mortalitybetween the two treatment groups (P = 0.6). The two-year actuarialsurvival rate was 69.4 percent (95 percent confidence interval,64.2 to 74.6) for the patients in the amiodarone group and 70.8percent (95 percent confidence interval, 65.7 to 75.9) for thosein the placebo group. At two years, the rate of sudden deathwas 15 percent in the amiodarone group and 19 percent in theplacebo group (P = 0.43). There was a trend toward a reductionin overall mortality among the patients with nonischemic cardiomyopathywho received amiodarone (P = 0.07). Amiodarone was significantlymore effective in suppressing ventricular arrhythmias and increasedthe left ventricular ejection fraction by 42 percent at twoyears.
Conclusions Although amiodarone was effective in suppressingventricular arrhythmias and improving ventricular function,it did not reduce the incidence of sudden death or prolong survivalamong patients with heart failure, except for a trend towardreduced mortality among those with nonischemic cardiomyopathy.
Most patients with heart failure are treated with a combinationof drugs that usually includes cardiac glycosides, diuretics,and afterload-reducing agents.1,2 Such regimens provide symptomaticrelief,2 but their effects on survival have been variable oruncertain. For example, the effects of diuretics or digoxinon overall mortality among patients with heart failure remainto be determined.3 In a subgroup of patients, beta-blockingdrugs may improve survival, although their use in these patientsis still controversial and unclear.4 On the other hand, afterload-reducingagents, such as hydralazine, nitrates, and especially angiotensin-converting-enzymeinhibitors,5 have been found to prolong survival.
Patients with congestive heart failure and ventricular arrhythmiasare at particularly high risk for fatal cardiovascular events.6,7,8,9Among patients with frequent and complex ventricular arrhythmiason Holter monitoring, the annual mortality rate is about 15percent, and half the deaths are sudden, presumably caused bycardiac arrhythmias.6,7,8,9 Attempts have been made to suppressventricular arrhythmias with antiarrhythmic agents, in the expectationof prolonging survival.10,11,12 The Cardiac Arrhythmia SuppressionTrials showed that the suppression of arrhythmias with encainideor flecainide increased mortality among patients with myocardialinfarction.13,14
The results of several small studies suggest that amiodaronemay be beneficial in the treatment of patients with recent infarction.15,16Amiodarone is a powerful antiarrhythmic agent that markedlysuppresses complex premature ventricular contractions and unsustainedventricular tachycardia, with little depressant effect on hemodynamicfunction.17 The drug does not have important proarrhythmic effects.18,19We therefore tested the hypothesis that amiodarone can prolongsurvival among patients with heart failure and asymptomaticbut frequent and complex ventricular arrhythmias.
Methods
The design of the trial has been described elsewhere.19 Patientswere screened at 24 centers, listed in the Appendix. The protocolwas approved by an institutional review board at each center,and all patients gave informed consent. The conduct of the studywas monitored by an external data and safety monitoring boardand by the Human Rights Committee of the Hines Veterans AffairsCooperative Studies Program Coordinating Center.
Patients with a documented history of congestive heart failure,whether ischemic or nonischemic in origin, and at least 10 ventricularpremature beats per hour, unaccompanied by symptoms, were eligiblefor the study. All patients had shortness of breath on exertionor paroxysmal nocturnal dyspnea, an echocardiogram showing aleft ventricular internal diameter of at least 55 mm or a cardiothoracicratio higher than 0.50, and a left ventricular ejection fractionof 40 percent or less. All patients received vasodilator therapy.Digoxin and diuretics were administered as deemed appropriateby the treating physicians.
Women of childbearing age were excluded from the study. Othercriteria for exclusion were myocardial infarction within thethree months before enrollment, symptomatic ventricular arrhythmia,a history of aborted sudden cardiac arrest or sustained ventriculartachycardia, uncontrolled thyroid disease, the need for antiarrhythmictherapy, electrocardiographic changes in the QRS interval (greater/equal180 msec) or QTc interval (greater/equal 500 msec), a seriousdisease other than heart disease that was likely to be fatalwithin three years, and symptomatic hypotension or systolicblood pressure under 90 mm Hg.
Before randomization, the patients were stratified accordingto the cause of their heart disease (ischemic or nonischemic),the ejection fraction (<30 percent or 30 to 40 percent),and the participating hospital at which the patient was receivingcare. Ischemic heart disease was documented on the basis ofcoronary angiographic studies, electrocardiographic changesindicative of myocardial infarction, and chest pain typicalof angina with concomitant electrocardiographic changes or reversibledefects on radioisotope perfusion scans. Each patient was randomlyassigned to receive amiodarone (800 mg once a day for 14 days,then 400 mg once a day for 50 weeks, and then 300 mg once aday until the end of the study) or placebo throughout the trial.Clinic visits were made after 2 weeks and then monthly untilthe end of the study (maximal follow-up, 4.5 years). At eachvisit, a complete history was taken and a physical examinationperformed, with documentation of side effects and use of concomitantdrugs.
A 24-hour continuous electrocardiogram was obtained at baseline; at 2 weeks; at months 1, 3, 6, 9, and 12; and then every6 months. Chest films (with the cardiothoracic ratio calculated),blood gas values, and pulmonary-function values were determinedannually. The left ventricular ejection fraction was determinedby radionuclide ventriculography at base line and at months6, 12, and 24. Echocardiograms were obtained at base line andat months 12 and 24. Deaths and aborted cardiac arrests werereviewed in a blinded manner by a committee and classified assudden or nonsudden deaths from cardiac causes or deaths fromother causes. In patients with sustained ventricular tachycardia(greater/equal 30 seconds), symptomatic unsustained ventriculartachycardia, or intolerable side effects, the study drug waswithdrawn, but the patients were followed and included in thestatistical analyses.
Patients were recruited for the study over a period of 3.5 years,and all patients were followed for 1 additional year after theenrollment period. Compliance was ensured by means of frequentclinic visits, telephone calls, and pill counts.
The study end points were overall mortality and sudden deathfrom cardiac causes. Other factors examined included the effectsof amiodarone on the left ventricular ejection fraction andon the suppression of ventricular arrhythmias.
Statistical Analysis
All patients were followed until the completion of the studyand were included in the statistical analysis according to theintention-to-treat principle. Continuous and categorical datawere compared at base line by the t-test and chi-square test,respectively. Differences in survival were analyzed with theKaplan-Meier method. Data on surviving patients were censoredat the date of the last follow-up visit. For the analysis ofsudden deaths, data on deaths from other causes were censoredon the date of the death. A two-sided alpha level less thanor equal to 0.05 was considered to indicate statistical significance.
Results
Characteristics of the Patients
During the 3.5-year period of enrollment, 1303 patients werescreened, and 674 (52 percent) were randomly assigned to oneof two treatment groups. A total of 336 patients were assignedto the amiodarone group, and 338 to the placebo group. The base-linecharacteristics of the randomized patients are shown in Table 1.The mean age of the entire group was 66 years. The medianperiod of follow-up was 45 months (range, 0 to 54).
Table 1. Base-Line Characteristics of 674 Patients with Congestive Heart Failure Who Were Randomly Assigned to Receive Amiodarone or Placebo.
Overall Mortality and Sudden Death
Amiodarone had no significant effect on survival. There were274 deaths during the study: 131 (39 percent) in the amiodaronegroup and 143 (42 percent) in the placebo group. The overallactuarial survival at two years was 69.4 percent (95 percentconfidence interval, 64.2 to 74.6 percent) in the amiodaronegroup and 70.8 percent (95 percent confidence interval, 65.7to 75.9 percent) in the placebo group (P = 0.6) (Figure 1).
Figure 1. Kaplan-Meier Estimates of Overall Mortality and Sudden Death from Cardiac Causes. Amiodarone had no significant effect, as compared with placebo, on either overall mortality or the incidence of sudden death. The numbers below the figures are the numbers of patients at risk.
Sixty-four of the deaths in the amiodarone group (49 percent)and 75 of those in the placebo group (52 percent) were classifiedas sudden. The death was ascribed to pump failure in 34 patientsin the amiodarone group (26 percent) and in 40 patients in theplacebo group (28 percent); 22 patients in the amiodarone group(17 percent) and 23 in the placebo group (16 percent) died fromnoncardiac causes. The cause of death could not be ascertainedin 11 patients in the amiodarone group and in 5 in the placebogroup. As compared with placebo, amiodarone had no significanteffect on sudden death; at two years, the rate of sudden deathwas 15 percent in the amiodarone group and 19 percent in theplacebo group (P = 0.43) (Figure 1).
Influence of Cause of Heart Failure on Outcome
Coronary artery disease was diagnosed in 242 of the patientsassigned to amiodarone (72 percent) and in 239 of those assignedto placebo (71 percent). Survival curves, according to the causeof heart disease, are shown in Figure 2. As compared with placebo,amiodarone had no significant effect on overall mortality amongpatients with ischemic heart disease (Figure 2), but there wasa trend in favor of amiodarone over placebo among those withnonischemic heart disease (P = 0.07) (Figure 2).
Figure 2. Kaplan-Meier Estimates of Overall Mortality, According to the Presence or Absence of Ischemic Cardiomyopathy. Among the patients with ischemic cardiomyopathy, amiodarone had no significant effect on mortality, as compared with placebo; among those with heart failure of nonischemic origin, there was a trend toward a reduction in overall mortality induced by amiodarone. The numbers below the figures are the numbers of patients at risk.
Suppression of Ventricular Arrhythmias
At base line the mean (±SD) heart rate was similar inthe two treatment groups (Table 1). After two weeks of treatment,the heart rate was significantly lower in the group assignedto amiodarone (70 ±12 beats per minute, as compared with79 ±13 in the placebo group; P<0.001). This differencepersisted throughout the study.
At randomization, the mean frequency of premature ventricularcontractions in the amiodarone group was 254 ±370 perhour, with 77 percent of the patients having one or more episodesof ventricular tachycardia. In the placebo group, the mean frequencyof premature ventricular contractions was 279 ±387 perhour, with 85 percent of the patients having episodes of ventriculartachycardia. Two weeks after randomization, the average frequencyof premature ventricular contractions was 266 ±412 perhour in the placebo group, and it did not change significantlythereafter. In contrast, in the amiodarone group, the frequencyof premature ventricular contractions fell to 66 ±156per hour (P<0.001) at two weeks and to 44 ±145 perhour (P<0.001) at three months. In the placebo group, 76percent of the patients continued to have episodes of ventriculartachycardia two weeks after randomization. In the amiodaronegroup, only 33 percent of the patients had episodes of ventriculartachycardia at two weeks, as compared with 77 percent at baseline (P<0.001), and the frequency of episodes of ventriculartachycardia remained lower in that group than in the placebogroup throughout the study. Symptomatic ventricular tachycardiadeveloped in 18 patients in the amiodarone group and in 20 inthe placebo group (P not significant).
Survival did not differ significantly between the 159 patientsin whom ventricular arrhythmias (premature ventricular contractions)were suppressed by 80 percent or more after two weeks of amiodaronetherapy and the 71 patients in whom such suppression was notachieved (P = 0.93) (Figure 3). Similarly, with respect to mortality,there was no significant difference between the group of 111patients in whom episodes of ventricular tachycardia were eliminatedby amiodarone at two weeks and the group of 65 patients in whomsuch episodes continued to occur (P = 0.36). Moreover, in thesubgroup of patients with ventricular tachycardia at base line,amiodarone, as compared with placebo, had no effect on mortality.
Figure 3. Kaplan-Meier Estimates of Overall Mortality, According to the Effect of Amiodarone on Premature Ventricular Contractions. The comparison is between the patients in whom premature ventricular contractions were suppressed by 80 percent or more and the patients in whom this level of suppression was not achieved. For the purpose of the analysis, runs of ventricular tachycardia are included. There was no significant difference between the group with suppressed contractions and the group with unsuppressed contractions. A similar analysis revealed no significant difference in overall mortality between the group in which runs of ventricular tachycardia were present after two weeks of therapy and the group in which such runs were absent. The numbers below the figure are the numbers of patients at risk.
Effect of Amiodarone on Left Ventricular Ejection Fraction
At randomization, the mean ejection fraction was 24.9 ±8.3percent in the amiodarone group and 25.7 ±8.2 percentin the placebo group. The patients in the amiodarone group hada significant improvement in the ejection fraction at six months(33.7 ±11.0 percent, as compared with 29.2 ±10.7in the placebo group; P<0.001). At 12 and 24 months, themean ejection fractions in the amiodarone group were 33.4 ±11.9and 35.4 ±11.5 percent, respectively. These values weresignificantly higher than those in the placebo group (29.7 ±11.0and 29.8 ±12.2 at 12 and 24 months, respectively; P<0.001).
The overall mortality did not differ significantly between thetwo treatment groups according to the level of the left ventricularejection fraction (<30 percent or 30 to 40 percent). In bothtreatment groups, however, patients with a left ventricularejection fraction under 30 percent had lower survival ratesthan those with a left ventricular ejection fraction of 30 to40 percent (P<0.001).
Side Effects
The frequency of adverse effects during the study is shown inTable 2. Abnormalities in thyroid function were observed infour patients in the amiodarone group (1.2 percent) and in twopatients in the placebo group (0.6 percent). Elevated hepatic-enzymelevels (at least twice the normal values) were seen in fourpatients in the amiodarone group (1.2 percent) and in two inthe placebo group (0.6 percent). Severe pulmonary fibrosis occurredin four patients in the amiodarone group (1.2 percent) and inthree patients in the placebo group (0.9 percent). There wereno episodes of torsade de pointes in either group.
The study medication was discontinued in 90 patients in theamiodarone group (27 percent) and in 78 patients in the placebogroup (23 percent) because of intolerable side effects, as definedby the protocol or as decided by the physician or the patient;the difference between the two groups was not statisticallysignificant (P = 0.1). An additional 46 patients in the amiodaronegroup and 32 in the placebo group withdrew from the study orwere lost to follow-up.
Discussion
Our study shows that amiodarone, as compared with placebo, hadno effect on overall mortality or sudden death, despite significantsuppression of ventricular arrhythmias and a significant increasein the left ventricular ejection fraction. However, we observeda trend toward a lower mortality rate among patients with nonischemiccardiomyopathy who received amiodarone. There was no relationbetween the degree of impairment in the left ventricular ejectionfraction (<30 percent or 30 to 40 percent) at base line andthe effect of amiodarone on overall mortality.
Amiodarone is known to be effective in controlling life-threateningarrhythmias.20,21,22 There is also evidence that the drug maybe effective in reducing cardiac-related and overall mortalityin survivors of myocardial infarction.15,16 Our findings inpatients with heart failure were therefore unexpected. In previous,smaller studies, the results have been variable. For example,in retrospective studies, Cleland et al.12 and Chatterjee10reported improved survival in patients with heart failure treatedwith amiodarone, whereas a small, prospective, randomized trialreported by Nicklas et al.23 found no benefit. A recent study24from Argentina (Grupo de Estudio de la Sobrevida en la InsuficienciaCardiaca en Argentina, or GESICA) reported a 28 percent reductionin overall mortality in the amiodarone group as compared witha control group (P = 0.024). The rates of sudden death and deathdue to progressive heart failure were reduced by 27 and 23 percent,respectively (P = 0.16). The fact that the GESICA trial wasnot blind probably does not explain the discrepancy betweenthese results and ours. The most striking difference betweenthe two studies is that the proportion of patients with coronaryartery disease in the GESICA trial was smaller (39 percent)than in our study (70 percent). This difference is important,since in our study there was a trend toward a reduction in mortalityamong the patients with nonischemic cardiomyopathy (P = 0.07).
In our study, amiodarone increased the left ventricular ejectionfraction by 42 percent at two years, confirming the resultsof previous studies.17 These data are consistent with the observationthat amiodarone may improve the capacity for exercise in patientswith heart failure.25 The observed improvement in systolic functionmay be related to the drug's property of lengthening the periodof repolarization.26 Increases in left ventricular ejectionfraction induced by cardioactive drugs are often not positivelycorrelated with a reduction in mortality.27,28 Indeed, certaininotropic agents, such as beta-agonists and phosphodiesteraseinhibitors, may even decrease survival,27 although they increaseventricular function. In the second Vasodilator-Heart FailureTrial, a combination of hydralazine and isosorbide dinitrateresulted in a significantly greater improvement in the leftventricular ejection fraction but a higher mortality rate thantreatment with enalapril.5 Thus, there appears to be no systematicrelation between changes in the left ventricular ejection fractioninduced by amiodarone or other cardioactive drugs and theireffect on survival.
Our data on amiodarone indicate a similar disparity betweenthe suppression of arrhythmia and sudden death or overall mortality,a phenomenon that was evident in the Cardiac Arrhythmia SuppressionTrials.13,14,21 No difference in overall mortality was foundbetween the group of patients in whom ventricular arrhythmiaswere suppressed (those with 80 percent or greater suppressionof premature ventricular contractions) and those in whom arrhythmiaswere not suppressed.
Because our study was conducted at various Veterans Affairsmedical centers, most of the patients were men. The effect ofantiarrhythmic therapy on mortality among women with congestiveheart failure and arrhythmia is unknown.
A number of conclusions can be drawn from this double-blind,placebo-controlled study of amiodarone in patients with mild-to-moderateheart failure. The drug was well tolerated and effective insuppressing arrhythmias and improving ventricular function,but it did not reduce the frequency of sudden death or prolongsurvival. Its effects were not significantly influenced by thelevel of the left ventricular ejection fraction or the degreeof suppression of premature ventricular contractions on Holtermonitoring. However, there was a trend toward reduced overallmortality among patients with nonischemic cardiomyopathy, whichmerits further study.
Supported by the Department of Veterans Affairs CooperativeStudies Program of the Medical Research Service (Washington,D.C.), by Sanofi Winthrop Recherche (Paris), and by Wyeth-AyerstLaboratories (Philadelphia).
We are indebted to Patricia Jones for her assistance in thepreparation of the manuscript.
* The institutions and investigators participating in the SurvivalTrial of Antiarrhythmic Therapy in Congestive Heart Failureare listed in the Appendix.
Source Information
From the Department of Cardiology, Veterans Affairs Medical Center, Washington, D.C. (S.N.S., R.D.F., D.L.); Veterans Affairs Cooperative Studies Coordinating Center, Hines, Ill., and Loyola University Medical Center, Maywood, Ill. (S.G.F.); the Department of Cardiology, Wadsworth Veterans Affairs Medical Center, Los Angeles (B.N.S.); the Department of Cardiology, Veterans Affairs Medical Center, Kansas City, Mo. (H.D.L.); the Department of Cardiology, Veterans Affairs Medical Center, Fresno, Calif. (P.C.D.); the Department of Cardiology, Veterans Affairs Medical Center, San Francisco (B.M.M.); and the Cooperative Studies Program, Veterans Affairs Medical Center, Albuquerque, N.M. (C.C.).
Address reprint requests to Dr. Singh at the Division of Cardiology, Veterans Affairs Medical Center 1E301, 50 Irving St., NW, Washington, DC 20422.
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Appendix
The following Veterans Affairs medical centers and investigatorsparticipated in the Survival Trial of Antiarrhythmic Therapyin Congestive Heart Failure: Bronx, N.Y. -- P. Scweitzer andP. Patascil; Chicago, West Side -- J. Cumming and T. Redmond;Dallas -- P. Grayburn and S. Dougherty; Fresno, Calif. -- P.C.Deedwania and R. Kanefield; Jackson, Miss. -- T.N. Srivastavaand T. King; Kansas City, Mo. -- D. Lewis and R. Corbett; LomaLinda, Calif. -- D.R. Ferry and K. Okubo; Long Beach, Calif.-- R. Wesley and S. Saniga; Louisville, Ky. -- A. Joseph andN. Zettwoch; Madison, Wis. -- P. Kosolcharoen and K. Cox; Miami-- C.S. Chakko and J. Johnson; Newington, Conn. -- M.J. Radfordand D. Roth; North Chicago -- R. Singh and A. Skillman; OklahomaCity -- R. Lazzara and T. Deaton; Pittsburgh -- M. Amidi andJ. Pulman; Providence, R.I. -- S. Sharma and E. Coccio; Richmond,Va. -- K.A. Ellenbogen and E. Early; Salem, Va. -- D. Russelland M. Judd; Salt Lake City -- R. Klein and L. Morrison; SanFrancisco -- B. Massie and E. Derr; Sepulveda, Calif. -- V.N.Udhoji and P. Pekale; Syracuse, N.Y. -- R. Warner and P. Lilja;Washington, D.C. -- R. Hall and D. Lazzeri; West Haven, Conn.-- I. Cohen and L. Canestri.
Cochairmen's office, Washington, D.C. -- S.N. Singh and R.D.Fletcher; Cooperative Studies Program Central Research Pharmacy,Albuquerque, N.M. -- M. Sather (chief) and C.L. Colling (studypharmacist); Central Holter Monitor Laboratory, Washington,D.C. -- R.D. Fletcher; nurse coordinator, Washington, D.C. --D. Lazzeri; Hines Cooperative Studies Program Coordinating Center-- W.G. Henderson (chief), S. Gross Fisher (biostatistician),L. Weber (study programmer), and D. Cavello and M. Biondic (studycoordinators).
Data and Safety Monitoring Board -- J.T. Bigger (chairman),J. Anderson, D. Echt, M. Packer, J. Morganroth, and G. Williams;Executive Committee -- S. Singh, R. Fletcher, S. Gross Fisher,P. Deedwania, D. Lewis, B. Massie, B.N. Singh, and C. Colling;Mortality Committee -- B.N. Singh (chairman), D. Lewis, S. Singh,and S. Gross Fisher; Department of Veterans Affairs CentralOffice -- D. Deykin (chief of Cooperative Studies Program),J. Gold (administrative officer), and P. Huang (staff assistant).
Amiodarone in Congestive Heart Failure
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