射血分数减低的非缺血性心力衰竭患者植入型心律转复除颤器恰当治疗危险因素分析

Risk factors analysis for appropriate therapy and all-cause mortality in cardioverter defibrillator implanted patients with reduced ejection fraction and non-ischemic heart failure

目的基于家庭监测所传输的数据和患者的临床资料,探索射血分数减低的非缺血性心力衰竭(心衰)患者植入型心律转复除颤器(ICD)/心脏再同步治疗除颤器(CRT-D)室性心律失常(VA)事件恰当治疗及全因死亡的危险因素。方法本研究回顾性分析了家庭监测功能在心血管植入型电子器械(CIED)的临床应用研究的部分患者数据。从2009年2月到2014年12月植入ICD/CRT-D的79家医院的患者中根据入排标准共纳入234例患者,根据随访期间ICD/CRT-D是否发生恰当治疗的VA事件分为未发生恰当治疗组(93例)和发生过VA恰当治疗组(141例)。患者年龄(58.8±13.4)岁,其中男178例(76.1%,178/234)。主要终点事件为ICD/CRT-D首次发放恰当治疗的VA事件。次要终点为恰当电击(shock)治疗的VA事件或全因死亡事件。通过Cox比例风险模型识别能够预测ICD/CRT-D发放恰当治疗及患者全因死亡的危险因素。结果随访(55.2±21.6)个月,共141例(60.3%,141/234)患者发生过首次恰当治疗的VA事件,103例(44.0%,103/234)患者发生过首次恰当电击治疗的VA事件。共70例(29.9%,70/234)患者发生全因死亡。Cox多因素分析结果显示,左心室舒张末期内径(LVEDD)扩大、有晕厥或晕厥前驱症状是发放首次恰当治疗VA的独立危险因素。男性、有晕厥或晕厥前驱症状、服用胺碘酮是发放首次恰当电击治疗VA的独立危险因素;LVEDD扩大、合并高血压、30 d患者活动度的平均值是全因死亡的独立预测因素;相较于ICD植入患者,CRT-D植入患者首次发放恰当治疗及首次发放恰当电击治疗VA的风险均显著降低。结论在射血分数减低的非缺血性心衰患者中,LVEDD、有晕厥或晕厥前驱症状、植入CRT-D是恰当VA治疗的独立预测因素,LVEDD扩大、合并高血压、低平均患者活动度是全因死亡的独立预测因素。

Objective To investigate risk factors for appropriate therapy of ventricular arrhythmias(VA)and all-cause mortality in implantable cardioverter defibrillator(ICD)or cardiac resynchronization defibrillator(CRT-D)with reduced ejection fraction non-ischemic heart failure.Methods This study retrospectively analyzed data from Study of Home Monitoring System Safety and Efficacy in cardiac implantable electronic device-implanted patients.From February 2009 to December 2014,a total of 234 patients were included with ICD/CRT-D from 79 hospitals according to the inclusion and exclusion criteria.According to whether the ICD/CRT-D had appropriate treatment VA events during the follow-up period,the patients were divided into no appropriate treatment group(n=93)and VA appropriate treatment group(n=141).The average age of the patients was(58.8±13.4)years old.Among them,men accounted for 76.1%(178/234).The primary endpoint was the first appropriate ICD/CRT-D therapy.The secondary endpoint was the first appropriate ICD/CRT-D shock and all-cause mortality.Cox proportional hazard models were used to identify risk factors for appropriate ICD/CRT-D therapy and all-cause mortality.Results During a mean follow-up period of(55.2±21.6)months,141(60.3%,141/234)patients experienced the first appropriate ICD/CRT-D therapy,and,103(44.0%,103/234)patients experienced the first appropriate ICD/CRT-D shock therapy.There were 70(29.9%,70/234)patients died.In multivariate Cox model,left ventricular end-diastolic dimension(LVEDD)and patients with syncope or presyncope symptoms were independent predictive factors of the first appropriate therapy for VA.Male gender,patients with syncope or presyncope symptoms,and those taking amiodarone were independent risk factors of the first appropriate shock for VA.Larger LVEDD,comorbid hypertension,and low mean activity of patients at 30 days were independent predictors of all-cause mortality.Compared patients with ICD,those with CRT-D had significantly lower risks of first appropriate therapy or shock for VA.Conclusion In patients with reduced ejection fraction non-ischemic heart failure,LVEDD and syncope or presyncope symptoms were independent risk factors of appropriate therapy for VA.Larger LVEDD,comorbid hypertension,and low mean patient activity were independent predictors of all-cause mortality.The results of this study can be used to guide the risk stratification of high-risk sudden cardiac death(SCD)in patients with reduced ejection fraction non-ischemic heart failure.