Department of Cardiology, Soroka University Medical Center, Beer-Sheva, Israel.
Int J Cardiol. 2013 Jun 20;166(2):421-4. doi: 10.1016/j.ijcard.2011.10.132. Epub 2011 Nov 17.
Current clinical guidelines advocate implantable cardioverter defibrillator (ICD) therapy for the prevention of sudden cardiac death among post myocardial infarction (MI) patients. However, there are scarce data regarding compliance with the guidelines and utilization of this life-saving treatment. We aimed to assess the rate of ICD utilization among post MI patients with left ventricular ejection fraction (LVEF) ≤ 35%.
All patients admitted with a ST-elevation MI at a single tertiary care center from 2005 to 2009, discharged alive with LVEF≤35% and surviving 40 days were included. Patients already implanted with an ICD and whose residence was outside the hospital's area of coverage were excluded. ICD utilization, LVEF re-assessment and mortality were assessed during mean follow up time of 2 years.
Of the 285 subjects, only 26 (9%) received an ICD. There were significant differences in ICD use among different medical health organizations (insurers). Among the 259 subjects not implanted with an ICD, repeat echocardiography study for the re-assessment of LVEF was performed in only 176 (68%). Of those, LVEF remained severely impaired in 47%. After excluding subject whose LVEF improved at follow up, the ICD utilization rate was 14%. In a multi-variable analysis, significant predictors of ICD utilization were age below the median of 61 years, and a repeat echocardiography. Using propensity score and matching of subjects implanted with ICD with those not implanted, ICD implantation was found to be associated with survival benefit.
ICDs are underutilized in post MI patients and compliance with current guidelines is insufficient. Failure to re-assess LVEF is a barrier for this life-saving treatment. Withholding ICD therapy among unselected post MI patients with depressed LVEF is associated with a markedly increased mortality.
评估左心室射血分数（LVEF）≤35%的心肌梗死后患者植入式心律转复除颤器（ICD）的应用率。
入选 2005 年至 2009 年在单一三级医疗中心因 ST 段抬高型心肌梗死住院，存活出院且 LVEF≤35%并生存 40 天的患者。排除已经植入 ICD 且居住在医院覆盖范围之外的患者。平均随访 2 年后评估 ICD 的应用、LVEF 再评估和死亡率。
285 例患者中，仅 26 例（9%）植入 ICD。不同医疗机构（保险公司）之间 ICD 的应用存在显著差异。259 例未植入 ICD 的患者中，仅 176 例（68%）重复进行了超声心动图检查以重新评估 LVEF。其中，47%的患者 LVEF 仍严重受损。排除 LVEF 在随访时改善的患者后，ICD 的应用率为 14%。多变量分析显示，年龄低于中位数 61 岁和重复进行超声心动图检查是 ICD 应用的显著预测因素。应用倾向评分和匹配植入 ICD 的患者与未植入 ICD 的患者后，发现 ICD 植入与生存获益相关。
ICD 在心肌梗死后患者中的应用不足，目前的指南遵循率不足。未能重新评估 LVEF 是这种救命治疗的障碍。在未选择的 LVEF 降低的心肌梗死后患者中，不给予 ICD 治疗与死亡率显著增加相关。
