Bauer Axel, Barthel Petra, Müller Alexander, Ulm Kurt, Huikuri Heikki, Malik Marek, Schmidt Georg
Innere Medizin III, Kardiologie, Eberhard-Karl-Universität Tübingen, Tübingen, Germany.
J Electrocardiol. 2009 Nov-Dec;42(6):597-601. doi: 10.1016/j.jelectrocard.2009.07.013.
In the Improved Stratification of Autonomic Regulation-Risk trial, postinfarction patients with severe autonomic failure (SAF)-defined as abnormal heart rate turbulence in the presence of abnormal deceleration capacity (DC)-were at high risk of subsequent death, even if left ventricular function was not particularly compromised. The aim of this study was to investigate SAF as a risk predictor in independent postinfarction cohorts.
The data of 3 postinfarction trials (ie, St George's Hospital Medical School Postinfarction Survey, Holter substudy of the European Myocardial Infarction Amiodarone Trial with both the placebo and the amiodarone arms, and Multiple Risk Factor Analysis Trial) were reanalyzed in a blinded fashion. The populations included a total of 2534 postinfarction patients. Heart rate turbulence and DC were obtained from 24-hour Holter recordings. Patients with both abnormal heart rate turbulence (slope < or =2.5 ms/R-R and onset > or =0%) and abnormal DC (< or =4.5 milliseconds) were considered suffering from SAF and prospectively classified as high risk. Primary end point was all-cause mortality. During follow-up, 291 of 2534 patients died. In all populations, SAF was a highly significant predictor of death in the subgroups of patients with preserved left ventricular ejection fraction (LVEF; >30%). The mortality risk of these patients was not statistically different from that of patients with impaired LVEF (< or =30%). The combined use of the criteria, LVEF of 30% or less and LVEF of more than 30% as well as SAF lead to a significant increase of sensitivity in all populations, whereas the positive predictive accuracies were preserved.
In postinfarction patients with preserved left ventricular function, SAF identifies a subgroup with increased mortality risk equivalent to patients with LVEF of 30% or less.
在“自主神经调节风险改良分层”试验中，心肌梗死后出现严重自主神经功能衰竭（SAF）（定义为减速能力异常时心率震荡异常）的患者，即便左心室功能未受到特别损害，后续死亡风险依然很高。本研究旨在调查SAF作为独立心肌梗死后队列中的风险预测指标。
对3项心肌梗死后试验（即圣乔治医院医学院心肌梗死后调查、欧洲心肌梗死胺碘酮试验动态心电图子研究的安慰剂组和胺碘酮组，以及多危险因素分析试验）的数据进行了盲法重新分析。研究人群共纳入2534例心肌梗死后患者。通过24小时动态心电图记录获取心率震荡和减速能力数据。心率震荡异常（斜率≤2.5毫秒/R-R且起始≥0%）且减速能力异常（≤4.5毫秒）的患者被视为患有SAF，并前瞻性地归类为高危患者。主要终点为全因死亡率。随访期间，2534例患者中有291例死亡。在所有研究人群中，SAF在左心室射血分数（LVEF）保留（>30%）的患者亚组中是死亡的高度显著预测指标。这些患者的死亡风险与LVEF受损（≤30%）的患者相比无统计学差异。联合使用LVEF≤30%和LVEF>30%以及SAF的标准，可显著提高所有研究人群的敏感性，同时保持阳性预测准确性。
在左心室功能保留的心肌梗死后患者中，SAF可识别出一个死亡风险增加的亚组，其风险与LVEF≤30%的患者相当。
