Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA.
Am Heart J. 2012 Sep;164(3):358-64. doi: 10.1016/j.ahj.2012.06.009.
Guidelines recommend that patients with new-onset systolic heart failure (HF) receive a trial of medical therapy before an implantable cardiac defibrillator (ICD). This strategy allows for improvement of left ventricular ejection fraction (LVEF), thereby avoiding an ICD, but exposes patients to risk of potentially preventable sudden cardiac death during the trial of medical therapy.
We reviewed a consecutive series of patients with HF of <6 months duration with a severely depressed LVEF (<30%) evaluated in a HF clinic (N = 224). The ICD implantation was delayed with plans to reassess LVEF approximately 6 months after optimization of β-blockers. Mortality was ascertained by the National Death Index.
Follow-up echocardiograms were performed in 115 of the 224 subjects. Of these, 50 (43%) had mildly depressed or normal LVEF at follow-up ("LVEF recovery") such that an ICD was no longer indicated. In a conservative sensitivity analysis (using the entire study cohort, whether or not a follow-up echocardiogram was obtained, as the denominator), 22% of subjects had LVEF recovery. Mortality at 6, 12, and 18 months in the entire cohort was 2.3%, 4.5%, and 6.8%, respectively. Of 87 patients who tolerated target doses of β-blockers, only 1 (1.1%) died during the first 18 months.
Patients with new-onset systolic HF have both a good chance of LVEF recovery and low 6-month mortality. Achievement of target β-blocker dose identifies a very low-risk population. These data support delaying ICD implantation for a trial of medical therapy.
指南建议新发收缩性心力衰竭（HF）患者在植入式心脏复律除颤器（ICD）之前尝试药物治疗。这一策略可提高左心室射血分数（LVEF），从而避免植入 ICD，但会使患者在药物治疗试验期间面临潜在可预防的心脏性猝死风险。
我们回顾了在 HF 诊所评估的 224 例病程<6 个月且 LVEF 严重降低（<30%）的 HF 患者的连续系列。计划在优化β受体阻滞剂后大约 6 个月重新评估 LVEF，从而延迟 ICD 植入。通过国家死亡指数确定死亡率。
224 例患者中有 115 例进行了随访超声心动图检查。其中，50 例（43%）在随访时 LVEF 轻度降低或恢复正常（“LVEF 恢复”），因此不再需要 ICD。在保守的敏感性分析中（使用整个研究队列，无论是否进行了随访超声心动图，作为分母），22%的患者发生 LVEF 恢复。整个队列的 6、12 和 18 个月死亡率分别为 2.3%、4.5%和 6.8%。在 87 例耐受β受体阻滞剂目标剂量的患者中，仅 1 例（1.1%）在头 18 个月内死亡。
新发收缩性 HF 患者有很大机会恢复 LVEF，且 6 个月死亡率较低。达到目标β受体阻滞剂剂量可确定风险极低的人群。这些数据支持延迟 ICD 植入以进行药物治疗试验。
