QRS 时限和形态对轻度心力衰竭心脏再同步治疗结局的影响：来自同步化逆转左心室收缩功能障碍重构（REVERSE）研究的结果。
Effect of QRS duration and morphology on cardiac resynchronization therapy outcomes in mild heart failure: results from the Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) study.
机构信息
Division of Cardiology, Medical University of South Carolina, 25 Courtenay Dr, ART 7031, Charleston, SC 29425-5920, USA.
出版信息
Circulation. 2012 Aug 14;126(7):822-9. doi: 10.1161/CIRCULATIONAHA.112.097709. Epub 2012 Jul 10.
BACKGROUND
Cardiac resynchronization therapy (CRT) decreases mortality, improves functional status, and induces reverse left ventricular remodeling in selected populations with heart failure. We aimed to assess the impact of baseline QRS duration and morphology and the change in QRS duration with pacing on CRT outcomes in mild heart failure.
METHODS AND RESULTS
Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) was a multicenter randomized trial of CRT among 610 patients with mild heart failure. Baseline and CRT-paced QRS durations and baseline QRS morphology were evaluated by blinded core laboratories. The mean baseline QRS duration was 151±23 milliseconds, and 60.5% of subjects had left bundle-branch block (LBBB). Patients with LBBB experienced a 25.3-mL/m(2) mean reduction in left ventricular end-systolic volume index (P<0.0001), whereas non-LBBB patients had smaller decreases (6.7 mL/m(2); P=0.18). Baseline QRS duration was also a strong predictor of change in left ventricular end-systolic volume index with monotonic increases as QRS duration prolonged. Similarly, the clinical composite score improved with CRT for LBBB subjects (odds ratio, 0.530; P=0.0034) but not for non-LBBB subjects (odds ratio, 0.724; P=0.21). The association between clinical composite score and QRS duration was highly significant (odds ratio, 0.831 for each 10-millisecond increase in QRS duration; P<0.0001), with improved response at longer QRS durations. The change in QRS duration with CRT pacing was not an independent predictor of any outcomes after correction for baseline variables.
CONCLUSION
REVERSE demonstrated that LBBB and QRS prolongation are markers of reverse remodeling and clinical benefit with CRT in mild heart failure.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00271154.
背景
心脏再同步治疗（CRT）可降低死亡率，改善功能状态，并在心力衰竭的特定人群中诱导左心室逆向重构。我们旨在评估基线 QRS 持续时间和形态以及起搏时 QRS 持续时间的变化对轻度心力衰竭患者 CRT 结局的影响。
方法和结果
同步逆转收缩性左心室功能障碍的重构（REVERSE）是一项多中心、随机 CRT 试验，共纳入 610 例轻度心力衰竭患者。通过盲法核心实验室评估基线和 CRT 起搏时的 QRS 持续时间和基线 QRS 形态。平均基线 QRS 持续时间为 151±23 毫秒，60.5%的患者存在左束支传导阻滞（LBBB）。LBBB 患者的左心室收缩末期容积指数平均减少 25.3mL/m²（P<0.0001），而非 LBBB 患者的减少量较小（6.7 mL/m²；P=0.18）。基线 QRS 持续时间也是左心室收缩末期容积指数变化的强有力预测因子，随着 QRS 持续时间的延长呈单调增加。同样，CRT 可改善 LBBB 患者的临床综合评分（优势比，0.530；P=0.0034），但对非 LBBB 患者无改善（优势比，0.724；P=0.21）。临床综合评分与 QRS 持续时间之间的关联具有高度显著性（每增加 10 毫秒 QRS 持续时间，优势比为 0.831；P<0.0001），随着 QRS 持续时间的延长，反应得到改善。在对基线变量进行校正后，CRT 起搏时 QRS 持续时间的变化不是任何结局的独立预测因子。
结论
REVERSE 表明 LBBB 和 QRS 延长是轻度心力衰竭患者 CRT 逆向重构和临床获益的标志物。
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