植入式心脏复律除颤器的获益是否因心力衰竭患者猝死的预计比例风险而异？
Does the Implantable Cardioverter-Defibrillator Benefit Vary With the Estimated Proportional Risk of Sudden Death in Heart Failure Patients?
机构信息
University of Washington, Seattle, WA.
Duke Clinical Research Institute, Duke University, Durham, NC.
出版信息
JACC Clin Electrophysiol. 2017 Mar;3(3):291-298. doi: 10.1016/j.jacep.2016.09.006.
BACKGROUND
Prediction of which heart failure patients are most likely to die of sudden death vs. non-sudden death is an important factor in determining who will benefit the most from an ICD.
OBJECTIVE
We developed the Seattle Proportional Risk Model (SPRM) to estimate the proportion of total mortality due to sudden death. We prospectively validated the model in HF-ACTION and tested whether the ICD benefit varied with the SPRM.
METHODS
Among 2331 patients enrolled, 1947 patients were retained for analysis over a median follow-up of 2.5 years. The SPRM was calculated using age, gender, diabetes, BMI, SBP, EF, NYHA, sodium, creatinine, and digoxin use.
RESULTS
ICD use (ICD or CRT-D) was present prior to death in 1204 patients (62%). SPRM was predictive of sudden death vs. non-sudden death in those without an ICD (P=0.002). The hazard ratio representing ICD versus no ICD was 0.63 for all-cause mortality (P=0.0002). The ICD benefit varied with the SPRM for all-cause mortality (P=0.001), with a greater benefit in those with a higher conditional probability of sudden death.
CONCLUSIONS
In an ambulatory NYHA II-IV HF population and EF ≤35%, the SPRM was predictive of the proportional risk of sudden vs. non-sudden death. ICDs were associated with a decreased risk of all-cause mortality by 37% and the ICD benefit varied with the SPRM. The SPRM may have utility in risk stratifying patients for a primary prevention ICD.
背景
预测心力衰竭患者中哪些更可能死于心源性猝死（sudden death）而非非心源性猝死（non-sudden death），是确定哪些患者将从植入式心脏复律除颤器（ICD）中获益最大的重要因素。
目的
我们开发了西雅图比例风险模型（Seattle Proportional Risk Model，SPRM）来估计心源性猝死导致的总死亡率比例。我们前瞻性地在 HF-ACTION 中验证了该模型，并检验了 ICD 的获益是否与 SPRM 相关。
方法
在纳入的 2331 例患者中，1947 例患者在中位随访 2.5 年后被保留用于分析。SPRM 通过年龄、性别、糖尿病、BMI、SBP、EF、NYHA、钠、肌酐和地高辛使用来计算。
结果
在 1204 例（62%）死亡前，患者中使用了 ICD（ICD 或 CRT-D）。在没有 ICD 的患者中，SPRM 预测了心源性猝死与非心源性猝死（P=0.002）。代表 ICD 与无 ICD 的全因死亡率的危险比为 0.63（P=0.0002）。ICD 的获益因 SPRM 而异（P=0.001），在突然死亡的条件概率较高的患者中获益更大。
结论
在有症状的 NYHA II-IV 级 HF 患者中，EF≤35%，SPRM 可预测心源性猝死与非心源性猝死的比例风险。ICD 与全因死亡率降低 37%相关，且获益与 SPRM 相关。SPRM 可能有助于对原发性预防 ICD 的患者进行风险分层。
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