Swindle Jason, Burroughs Thomas E, Schnitzler Mark A, Hauptman Paul J
Center for Outcomes Research, Saint Louis University School of Medicine, St Louis, MO 63110, USA.
Am Heart J. 2008 Aug;156(2):322-8. doi: 10.1016/j.ahj.2008.04.003. Epub 2008 Jun 2.
The use of implantable cardiac devices in the management of heart failure has increased, but patient selection and inhospital outcomes in clinical practice have not been critically explored. Therefore, we evaluated the inhospital mortality and costs associated with patients with heart failure who received an implantable cardioverter defibrillator, cardiac resynchronization device, or device lead.
We analyzed admissions with International Classification of Diseases, Ninth Revision, procedure codes for implantation/revision of cardioverter defibrillator or cardiac resynchronization device and a primary or secondary diagnosis code for heart failure in a prospective hospital database from 2004 to 2005. Odds ratios were calculated to quantify risk for mortality. Average accumulated costs over time were calculated before and after day of first device implant procedure.
Among 27,907 hospitalizations, inhospital mortality varied based on day of device implantation and use of intravenous inotropic therapy. Mortality was 0.3% for patients who did not require inotropic drugs versus 3.3%, 6.6%, and 15.2% for patients who required initiation of drug before, on the day of, or after device implantation, respectively. Logistic regression demonstrated that the most potent risk for inhospital mortality was the use of inotropic drugs. Similar trends were observed for any vasoactive therapy. There was a marked increase in costs associated with these admissions.
Implantation of cardiac devices during a hospitalization for heart failure may be associated with significant inhospital mortality if patients require intravenous vasoactive therapy. Risk stratification methodology that incorporates ongoing/anticipated need for these drugs will likely improve clinical decision making.
植入式心脏设备在心力衰竭治疗中的应用有所增加，但临床实践中的患者选择和住院结局尚未得到深入探讨。因此，我们评估了接受植入式心脏复律除颤器、心脏再同步化设备或设备导线的心力衰竭患者的住院死亡率和费用。
我们在一个前瞻性医院数据库中分析了2004年至2005年的住院病例，这些病例具有国际疾病分类第九版中关于心脏复律除颤器或心脏再同步化设备植入/修订的程序编码以及心力衰竭的主要或次要诊断编码。计算比值比以量化死亡风险。在首次设备植入手术日之前和之后计算随时间累积的平均费用。
在27907例住院病例中，住院死亡率因设备植入日期和静脉内使用正性肌力药物而异。不需要正性肌力药物的患者死亡率为0.3%，而在设备植入前、植入当天或植入后开始使用药物的患者死亡率分别为3.3%、6.6%和15.2%。逻辑回归表明，住院死亡率的最主要风险因素是使用正性肌力药物。对于任何血管活性治疗也观察到类似趋势。这些住院病例的费用显著增加。
如果心力衰竭患者住院期间需要静脉血管活性治疗，植入心脏设备可能与显著的住院死亡率相关。纳入对这些药物持续/预期需求的风险分层方法可能会改善临床决策。
