Elliott P M, Gimeno Blanes J R, Mahon N G, Poloniecki J D, McKenna W J
Department of Cardiological Sciences, St George's Hospital Medical School, London, UK.
Lancet. 2001 Feb 10;357(9254):420-4. doi: 10.1016/S0140-6736(00)04005-8.
A previous study suggested that severe left-ventricular hypertrophy (maximum wall thickness > or = 30 mm) in patients with hypertrophic cardiomyopathy is associated with a risk of sudden cardiac death sufficient to warrant consideration for implantation of a cardioverter defibrillator (ICD). However, the prognostic significance of left-ventricular hypertrophy in relation to other clinical risk factors is poorly characterised.
We studied 630 patients consecutively referred to one hospital in London, UK (mean age 37 years [SD 16]; 382 male; mean follow-up 59 months). Patients underwent two-dimensional and doppler echocardiography, upright exercise testing, and Holter monitoring.
39 patients died suddenly or had an appropriate ICD discharge; nine died from progressive heart failure; 11 from other cardiovascular causes and 23 from non-cardiac causes. There was a trend towards higher probability of sudden death or ICD discharge with increasing wall thickness (p=0.029, relative risk per 5 mm increment 1.31 [95% CI 1.03-1.66]). Of the 39 patients who died suddenly or had an ICD discharge, ten had a wall thickness of 30 mm or more. Patients with wall thickness of 30 mm or more had higher probability of sudden death or ICD discharge than patients with wall thickness less than 30 mm (p=0.049, 2.07 [1.00-4.25]. When considered together, the number of additional risk factors (one to three) was a better predictor of risk of sudden death or ICD discharge than wall thickness (p=0.0001, relative risk per additional factor 2.00 [1.43-2.79] vs p=0.058, 1.26 per 5 mm increment [0.99-1.60]). There was no relation between the pattern of hypertrophy and survival.
The risk of sudden death associated with a wall thickness of 30 mm or more in patients without other risk factors is insufficient to justify aggressive prophylactic therapy. Most sudden deaths occurred in patients with wall thickness less than 30 mm, so the presence of mild hypertrophy cannot be used to reassure patients that they are at low risk.
先前的一项研究表明，肥厚型心肌病患者严重的左心室肥厚（最大壁厚≥30mm）与足以考虑植入心脏复律除颤器（ICD）的心脏性猝死风险相关。然而，左心室肥厚相对于其他临床危险因素的预后意义尚未得到充分描述。
我们连续研究了630例转诊至英国伦敦一家医院的患者（平均年龄37岁[标准差16]；男性382例；平均随访59个月）。患者接受了二维和多普勒超声心动图、直立运动试验和动态心电图监测。
39例患者发生心脏性猝死或ICD恰当放电；9例死于进行性心力衰竭；11例死于其他心血管原因，23例死于非心脏原因。随着壁厚增加，心脏性猝死或ICD放电的可能性有升高趋势（p = 0.029，每增加5mm的相对风险为1.31[95%可信区间1.03 - 1.66]）。在39例发生心脏性猝死或ICD放电的患者中，10例壁厚≥30mm。壁厚≥30mm的患者心脏性猝死或ICD放电的可能性高于壁厚＜30mm的患者（p = 0.049，2.07[1.00 - 4.25]）。综合考虑时，额外危险因素的数量（1至3个）比壁厚更能预测心脏性猝死或ICD放电的风险（p = 0.0001，每个额外因素的相对风险为2.00[1.43 - 2.79]，而每增加5mm的相对风险为p = 0.058，1.26[0.99 - 1.60]）。肥厚模式与生存率之间无关联。
在无其他危险因素的患者中，壁厚≥30mm相关的心脏性猝死风险不足以证明积极的预防性治疗是合理的。大多数心脏性猝死发生在壁厚＜30mm的患者中，因此轻度肥厚的存在不能让患者放心其处于低风险状态。
