Setoguchi Soko, Nohria Anju, Rassen Jeremy A, Stevenson Lynne Warner, Schneeweiss Sebastian
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02130, USA.
CMAJ. 2009 Mar 17;180(6):611-6. doi: 10.1503/cmaj.080769.
Implantable defibrillators are recommended for the prevention of sudden cardiac death in patients with heart failure. However, criteria to identify those who would benefit most from this therapy are lacking. We assessed the maximum potential benefit of preventing sudden death in patients with repeated hospital admissions because of heart failure.
Using a cohort assembled from an administrative database, we identified 14,374 patients admitted to hospital for the first time because of heart failure between Jan. 1, 2000, and Dec. 31, 2004. We followed subsequent admissions related to heart failure as well as mortality and causes of death to Mar. 31, 2006. We regarded all out-of-hospital cardiac deaths as sudden deaths. We calculated the maximum potential benefit of preventing sudden death by subtracting the observed survival after each hospital admission from the hypothetical survival whereby all out-of-hospital cardiac deaths were assumed to be preventable.
The mean age of the cohort was 77 years, 45% were women, 11% had cerebrovascular disease, and 21% had chronic kidney disease. Out-of-hospital cardiac deaths constituted 13.7% (1226/8967) of all deaths during 32,055 person-years of follow-up. The median survival declined with each subsequent hospital admission related to heart failure. The hypothetical prevention of all out-of-hospital deaths prolonged life by 0.63 (95% confidence interval [CI] 0.49 to 0.77) years after the first hospital admission. This potential benefit dropped to 0.28 (95% CI 0.10 to 0.46) years after 3 hospital admissions related to heart failure. Among patients less than 65 years old, and older patients without kidney disease, dementia or cancer, more than 50% survived longer than 2 years until they had 2 or 3 hospital admissions related to heart failure.
The use of implantable defibrillators to prevent sudden death would provide limited benefit among older patients with comorbidities and among patients with multiple hospital admissions related to heart failure.
对于心力衰竭患者，推荐使用植入式除颤器预防心脏性猝死。然而，目前尚缺乏用以识别能从该治疗中获益最大人群的标准。我们评估了因心力衰竭反复住院的患者预防猝死的最大潜在获益。
利用从管理数据库中汇集的队列，我们识别出2000年1月1日至2004年12月31日期间首次因心力衰竭住院的14374例患者。我们追踪了随后与心力衰竭相关的住院情况以及至2006年3月31日的死亡率和死亡原因。我们将所有院外心脏性死亡视为猝死。通过从假设所有院外心脏性死亡均可预防的生存情况中减去每次住院后的实际生存情况，计算预防猝死的最大潜在获益。
该队列的平均年龄为77岁，45%为女性，11%患有脑血管疾病，21%患有慢性肾脏病。在32055人年的随访期间，院外心脏性死亡占所有死亡的13.7%（1226/8967）。随着随后每次与心力衰竭相关的住院，中位生存期缩短。假设预防所有院外死亡，首次住院后可延长寿命0.63年（95%置信区间[CI]0.49至0.77）。在因心力衰竭住院3次后，这一潜在获益降至0.28年（95%CI0.10至0.46）。在年龄小于65岁以及无肾脏疾病、痴呆或癌症的老年患者中，超过50%的患者在出现2次或3次与心力衰竭相关的住院之前存活超过2年。
对于患有合并症的老年患者以及因心力衰竭多次住院的患者，使用植入式除颤器预防猝死的获益有限。
