心力衰竭患者中药物治疗、起搏与除颤比较（COMPANION）试验中心脏性猝死和恰当电击的预测因素

Predictors of sudden cardiac death and appropriate shock in the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Trial.

作者信息

Saxon Leslie A, Bristow Michael R, Boehmer John, Krueger Steven, Kass David A, De Marco Teresa, Carson Peter, DiCarlo Lorenzo, Feldman Arthur M, Galle Elizabeth, Ecklund Fred

机构信息

Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

出版信息

Circulation. 2006 Dec 19;114(25):2766-72. doi: 10.1161/CIRCULATIONAHA.106.642892. Epub 2006 Dec 11.

DOI:10.1161/CIRCULATIONAHA.106.642892

PMID:17159063

Abstract

BACKGROUND

The factors that determine the risk for sudden death or implantable cardioverter defibrillator therapy in patients receiving cardiac resynchronization therapy (CRT) therapies are largely unknown.

METHODS AND RESULTS

We hypothesized that clinical measures of heart failure severity and the presence of comorbid conditions would predict the risk of malignant arrhythmias in the 1520 patients enrolled in the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Trial. Outcomes in the CRT group after implantable cardioverter defibrillator therapy were also evaluated. The CRT-defibrillator device reduced the risk of sudden death by 56% compared with drug therapy (17 of 595 [2.9%] versus 18 of 308 [5.8%], P<0.02). CRT therapy was not associated with sudden death risk reduction (48 of 617 [7.8%]). Other factors associated with reduced sudden death risk were left ventricular ejection fraction >20% (HR, 0.55 [95% CI, 0.35 to 0.87]; P=0.01), QRS duration >160 ms (HR, 0.63 [95% CI, 0.40 to 0.997]; P=0.05), and female gender (HR, 0.56 [95% CI, 0.34 to 0.94]; P=0.003). The risk for sudden death was increased by advanced New York Heart Association class IV heart failure (HR, 2.62 [95% CI, 1.61 to 4.26]; P<0.011) and renal dysfunction (HR, 1.69 [95% CI, 1.06 to 2.69]; P=0.03). An appropriate shock was experienced in 88 (15%) of the 595 CTR-D patients. In the CRT-defibrillator patients, female gender (HR, 0.54 [95 % CI, 0.31 to 0.94]; P=0.03) and use of neurohormonal antagonists were associated with reduced risk. Class IV heart failure status increased risk. Appropriate implantable cardioverter defibrillator therapy was positively associated with risk of death or all-cause hospitalization (HR, 1.57; P<0.002), pump failure death or hospitalization (HR, 2.35; P<0.001), and sudden death (HR, 2.99; P=0.03), but not total mortality (HR, 1.3; P=0.28).

CONCLUSIONS

In CRT candidates, sudden cardiac death risk is associated with higher New York Heart Association class and renal dysfunction. In CRT-defibrillator recipients, reduction in the risk of an appropriate shock is associated with medical therapy with neurohormonal antagonists, female gender, and New York Heart Association functional class III versus IV clinical status. Shock therapy was associated with worse outcome.

摘要

背景

在接受心脏再同步治疗（CRT）的患者中，决定猝死风险或植入式心脏复律除颤器治疗风险的因素很大程度上尚不清楚。

方法与结果

我们假设心力衰竭严重程度的临床指标和合并症的存在可预测参加心力衰竭医学治疗、起搏和除颤比较（COMPANION）试验的1520例患者发生恶性心律失常的风险。还评估了植入式心脏复律除颤器治疗后CRT组的结局。与药物治疗相比，CRT-除颤器装置使猝死风险降低了56%（595例中的17例[2.9%]对比308例中的18例[5.8%]，P<0.02）。CRT治疗与猝死风险降低无关（617例中的48例[7.8%]）。与猝死风险降低相关的其他因素包括左心室射血分数>20%（HR，0.55[95%CI，0.35至0.87]；P=0.01）、QRS波时限>160毫秒（HR，0.63[95%CI，0.40至0.997]；P=0.05）以及女性（HR，0.56[95%CI，0.34至0.94]；P=0.003）。纽约心脏协会IV级晚期心力衰竭（HR，2.62[95%CI，1.61至4.26]；P<0.011）和肾功能不全（HR，1.69[95%CI，1.06至2.69]；P=0.03）会增加猝死风险。595例CRT-D患者中有88例（15%）经历了恰当电击。在CRT-除颤器患者中，女性（HR，0.54[95%CI，0.31至0.94]；P=0.03）和使用神经激素拮抗剂与风险降低相关。IV级心力衰竭状态会增加风险。恰当的植入式心脏复律除颤器治疗与死亡或全因住院风险呈正相关（HR，1.57；P<0.002）、泵衰竭死亡或住院风险呈正相关（HR，2.35；P<0.001）以及猝死风险呈正相关（HR，2.99；P=0.03），但与总死亡率无关（HR，1.3；P=0.28）。