University of Maryland School of Medicine, Baltimore, Maryland, USA.
Heart Rhythm. 2009 Dec;6(12):1727-34. doi: 10.1016/j.hrthm.2009.08.022. Epub 2009 Aug 22.
Clinical guidelines recommend implantable cardioverter-defibrillators (ICDs) for selected patients with chronic left ventricular dysfunction (LVD) to improve survival, yet ICD treatment rates for eligible patients with LVD or heart failure (HF) in cardiology practices remain poorly studied.
This study sought to determine patient and practice characteristics associated with ICD use in the outpatient setting.
IMPROVE HF (Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting), a prospective cohort study, is designed to characterize management of HF with reduced left ventricular ejection fraction (LVEF < or =35%). Baseline data were collected for 15,381 patients attending 167 outpatient cardiology practices located in the U.S.
By current guidelines, 7,221 patients met eligibility for ICD implantation (+/- cardiac resynchronization therapy [CRT]), of whom 3,659 (50.7%) received either ICD (63.8%) or CRT with defibrillator (36.2%). Individual practice conformity for guideline-recommended ICD use ranged from 0% to 100% (27.3% to 74.6% at the 10th and 90th percentiles, respectively). Adjusted analyses revealed lack of adherence for ICD use most notably with advancing age (odds ratio: 0.87; 95% confidence interval: 0.82 to 0.93 per 10 years), black race (odds ratio: 0.75; 95% confidence interval: 0.60 to 0.94), and lack of insurance (odds ratio: 0.45; 95% confidence interval: 0.26 to 0.78). Characteristics of increased adherence included male sex, ischemic disease, atrial fibrillation, and wider QRS. Practices in the Northeast U.S. were more likely to adhere to guidelines (P <.001), as were those with a dedicated HF clinic (P = .004) and electrophysiologists on staff (P <.001).
Although a number of patient and practice characteristics are associated with guideline-based ICD use, there is significant unexplained variation in the use of ICD therapy for sudden death prophylaxis across cardiology practices.
临床指南建议对患有慢性左心室功能障碍（LVD）的特定患者植入植入式心脏复律除颤器（ICD）以提高生存率，但在心脏病学实践中，对符合 LVD 或心力衰竭（HF）条件的患者进行 ICD 治疗的比率仍研究甚少。
本研究旨在确定与门诊环境下 ICD 使用相关的患者和实践特征。
IMPROVE HF（改善门诊环境下基于证据的心力衰竭治疗的使用）是一项前瞻性队列研究，旨在描述射血分数降低（LVEF<或=35%）的心力衰竭的管理情况。在美国 167 家门诊心脏病学诊所共收集了 15381 名患者的基线数据。
根据现行指南，有 7221 名患者符合 ICD 植入（+/-心脏再同步治疗[CRT]）的条件，其中 3659 名（50.7%）患者接受了 ICD（63.8%）或带除颤器的 CRT（36.2%）。个别实践对指南推荐的 ICD 使用的一致性范围从 0%到 100%（第 10 百分位和第 90 百分位分别为 27.3%到 74.6%）。调整后的分析显示，在 ICD 使用方面，最明显的是随着年龄的增长（比值比：0.87；95%置信区间：每增加 10 岁 0.82 至 0.93）、黑人种族（比值比：0.75；95%置信区间：0.60 至 0.94）和缺乏保险（比值比：0.45；95%置信区间：0.26 至 0.78）。增加依从性的特征包括男性、缺血性疾病、心房颤动和更宽的 QRS。美国东北部的做法更有可能遵守指南（P<0.001），设有专门的心衰诊所（P=0.004）和有心脏电生理学家的做法（P<0.001）也是如此。
尽管许多患者和实践特征与基于指南的 ICD 使用相关，但在心脏病学实践中，使用 ICD 治疗预防猝死的情况存在显著的无法解释的差异。
