Koplan Bruce A, Epstein Laurence M, Albert Christine M, Stevenson William G
Cardiac Arrhythmia Service/Division of Cardiology, Brigham and Women's Hospital, Boston, MA 02115, USA.
Am Heart J. 2006 Oct;152(4):714-9. doi: 10.1016/j.ahj.2006.06.008.
Although clinical trials have expanded implantable defibrillator (ICD) indications, octogenarians have been poorly represented in these studies. Overall, survival in this subgroup is ill-defined.
Consecutive patients > or = 80 years of age at ICD implant between July 1995 and September 2003 were retrospectively analyzed. Kaplan-Meier survival analysis was performed, and mortality predictors were identified. Consecutive nonelderly patients aged 60 to 70 years (60-70 group) who received ICDs over the same period were analyzed as a reference. Mortality predictors in the > or = 80 group were compared to the 60-to-70 group.
A total of 348 patients (age, > or = 80 years [n = 107]; age, 60-70 years [n = 241]) were included. Mean follow-up time for the entire cohort was 3.3 +/- 2.2 years. Other than the estimated glomerular filtration rate (eGFR) (58 +/- 22 vs 66 +/- 22 mL/min) in the > or = 80 group versus the 60-to-70 group, no other differences in baseline characteristics were observed. Median survival was 4.2 years after implant in the > or = 80 group versus 7 years in the 60-to-70 group (P < .01). Mortality predictors in the > or = 80 group included ejection fraction (EF) < or = 30% (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.3-4.0) and eGFR < 60 mL/min (HR, 2.2; 95% CI, 1.3-3.7). In the 60-to-70 group, EF < or = 30% (HR, 2.7; 95% CI, 1.6-4.5), eGFR < 60 mL/min (HR, 3.4; 95% CI, 2.2-5.3), diabetes (HR, 1.8; 95% CI, 1.9-2.9), and QRS width > 120 ms (HR, 2.1; 95% CI, 1.4-3.3) predicted mortality. QRS > 120 ms and diabetes were not predictors in octogenarians (HR, 1.1 and 1.5, respectively; 95% CI, 0.7-1.9 and 0.8-2.7, respectively). Analysis of octogenarians subgrouped by EF < or = 30% and eGFR < 60 mL/min identified patients whose median survival was 6.1 years (neither predictor present; n = 28), 4.7 years (either predictor present; n = 46), and 19 months (both predictors present; n = 33) (P < .01 between groups). Survival analysis in the > or = 80-year-old cohort grouped by eGFR quartile identified groups with median survival of 5.6, 4.7, 3.5 years, and 18 months, respectively, in the highest to the lowest eGFR quartile (> 75, 61-75, 41-60, and < 41 mL/min).
Median survival in octogenarian ICD recipients is greater than 4 years. In addition to baseline EF, eGFR is a strong predictor of mortality in elderly ICD candidates. These easily identifiable clinical variables may assist clinical decision making and help to provide appropriate post-ICD implant survival expectations in this elderly patient group.
尽管临床试验扩大了植入式心脏除颤器（ICD）的适应症，但在这些研究中，80岁及以上的老年人代表性不足。总体而言，该亚组的生存率尚不明确。
对1995年7月至2003年9月期间接受ICD植入时年龄≥80岁的连续患者进行回顾性分析。进行了Kaplan-Meier生存分析，并确定了死亡预测因素。将同期接受ICD植入的60至70岁连续非老年患者（60-70组）作为对照进行分析。将≥80岁组的死亡预测因素与60至70岁组进行比较。
共纳入348例患者（年龄≥80岁[n = 107]；年龄60-70岁[n = 241]）。整个队列的平均随访时间为3.3±2.2年。除了≥80岁组与60至70岁组的估计肾小球滤过率（eGFR）（58±22 vs 66±22 mL/min）外，未观察到基线特征的其他差异。≥80岁组植入后的中位生存期为4.2年，而60至70岁组为7年（P <.01）。≥80岁组的死亡预测因素包括射血分数（EF）≤30%（风险比[HR]，2.2；95%置信区间[CI]，1.3 - 4.0）和eGFR < 60 mL/min（HR，2.2；95% CI，1.3 - 3.7）。在60至70岁组中，EF≤30%（HR，2.7；95% CI，1.6 - 4.5）、eGFR < 60 mL/min（HR，3.4；95% CI，2.2 - 5.3）、糖尿病（HR，1.8；95% CI，1.9 - 2.9）和QRS宽度> 120 ms（HR，2.1；95% CI，1.4 - 3.3）可预测死亡。QRS > 120 ms和糖尿病在80岁及以上老年人中不是预测因素（HR分别为1.1和1.5；95% CI分别为0.7 - 1.9和0.8 - 2.7）。对按EF≤30%和eGFR < 60 mL/min分组的80岁及以上老年人亚组分析发现，中位生存期分别为6.1年（无预测因素；n = 28）、4.7年（有一个预测因素；n = 46）和19个月（有两个预测因素；n = 33）的患者组（组间P <.01）。对≥80岁队列按eGFR四分位数分组的生存分析发现，eGFR四分位数从高到低（> 75、61 - 75、41 - 60和< 41 mL/min）的组中位生存期分别为5.6年、4.7年、3.5年和18个月。
80岁及以上ICD接受者的中位生存期大于4年。除了基线EF外，eGFR是老年ICD候选者死亡的有力预测因素。这些易于识别的临床变量可能有助于临床决策，并有助于为该老年患者组提供ICD植入后适当的生存预期。
