Department of Electrocardiology, Institute of Cardiology, The John Paul II Hospital in Cracow, Jagiellonian University, School of Medicine, Cracow, Poland.
Kardiol Pol. 2012;70(11):1099-110.
Proper selection of patients at high risk for sudden cardiac death (SCD) and increasing use of implantable cardioverter-defibrillators (ICD) may contribute to improved survival among patients at the highest SCD risk.
To assess patient survival rate after implantation of an ICD without resynchronisation capability in our own patient population. Using uni- and multivariate analysis, we attempted to identify factors associated with significant worsening of patient survival rate.
From the population of patients who underwent ICD implantation for primary or secondary prevention of SCD in 2008-2010, we selected 376 patients with coronary artery disease or dilated cardiomyopathy (56 females, 320 males). Mean age was 66.1 ± 11.2 (range 22-89) years. ICD implantation protocols and in-hospital and outpatient records were reviewed retrospectively. We analysed the following clinical and procedural variables: age, gender, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class, mean heart rate (HR), QRS width, number of antiarrhythmic ICD interventions, type of SCD prevention, ICD type, performing defibrillation threshold testing (DFT) to establish defibrillation safety margin at ICD implantation, ventricular lead location, history of cardiovascular disease and arrhythmia, medications used (amiodarone, sotalol, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, loop diuretics, aldosterone antagonists). Date and cause of death were established by contacting patient family and/or the hospital to which the patient was admitted shortly before death or the general practitioner caring for the patient (verification of death certificates).
During the mean follow-up period of 447 ± 313 days, 46 patients died of known causes. Causes of death included sudden death in 16 patients, heart failure in 20 patients, and other causes in 10 patients (respiratory failure - 1, bleeding diathesis - 2, lung cancer - 3, colorectal cancer - 1, traffic accident - 1, and stroke - 2 patients). A comparison between primary and secondary prevention patients was performed. Mean QRS width <118 ms, resting HR < 78 bpm and LVEF >30% were significant cutoff values for improved survival as determined using the ROC curves. HR >78 bpm was observed in all SCD patients. In Kaplan-Meier univariate analysis including 27 parameters potentially influencing survival, 10 significant parameters were identified (type of prevention, presence of cardiomyopathy, ventricular tachycardia, HR, QRS width, LVEF, NYHA class, performing DFT, and statin and diuretic treatment). In Cox multivariate analysis, risk of death was increased with mean LVEV <30% (3-fold increase in risk), no DFT (2-fold increase in risk), NYHA class III or IV (3-fold increase in risk), and no statin use (2-fold increase in risk). Mean HR <78 bpm and QRS width <118 ms were independently related to an increased survival.
Death rate was higher in patients with LVEF <30%, NYHA class III or IV, no DFT performed and no statin treatment. In these patients, indications for cardiac resynchronisation therapy should be considered. HR <78 bpm and QRS width <118 ms are independent protective factors. HR >78 bpm was observed in all SCD patients. Sicker ICD patients live for a shorter time. The presence of atrial fibrillation, number of antiarrhythmic ICD interventions, ICD type and revascularisation approach did not affect survival/mortality.
在高危人群中选择合适的患者，并增加植入式心脏复律除颤器（ICD）的使用，可能有助于提高最高 SCD 风险患者的生存率。
评估在我们自己的患者群体中，无再同步功能的 ICD 植入后的患者生存率。通过单变量和多变量分析，我们试图确定与患者生存率显著恶化相关的因素。
从 2008 年至 2010 年因 SCD 的一级或二级预防而接受 ICD 植入的患者人群中，我们选择了 376 名患有冠状动脉疾病或扩张型心肌病的患者（女性 56 名，男性 320 名）。平均年龄为 66.1 ± 11.2（范围 22-89）岁。回顾性审查 ICD 植入方案以及住院和门诊记录。我们分析了以下临床和程序变量：年龄、性别、左心室射血分数（LVEF）、纽约心脏协会（NYHA）功能分级、平均心率（HR）、QRS 宽度、抗心律失常 ICD 干预次数、SCD 预防类型、ICD 类型、进行除颤阈值测试（DFT）以在 ICD 植入时建立除颤安全裕度、心室导联位置、心血管疾病和心律失常史、使用的药物（胺碘酮、索他洛尔、β受体阻滞剂、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂、他汀类药物、噻嗪类利尿剂、醛固酮拮抗剂）。通过联系患者家属和/或患者在死亡前不久入院的医院或照顾患者的全科医生（验证死亡证明）来确定死亡日期和原因。
在平均 447 ± 313 天的随访期间，46 名患者死于已知原因。死亡原因包括 16 例猝死、20 例心力衰竭和 10 例其他原因（呼吸衰竭-1 例、出血倾向-2 例、肺癌-3 例、结直肠癌-1 例、交通事故-1 例和中风-2 例）。对一级和二级预防患者进行了比较。使用 ROC 曲线确定，平均 QRS 宽度<118 ms、静息 HR<78 bpm 和 LVEF>30%是改善生存的显著截值。所有 SCD 患者的 HR>78 bpm。在包括 27 个可能影响生存的潜在参数的 Kaplan-Meier 单变量分析中，确定了 10 个有意义的参数（预防类型、存在心肌病、室性心动过速、HR、QRS 宽度、LVEF、NYHA 分级、进行 DFT 以及他汀类药物和利尿剂治疗）。在 Cox 多变量分析中，平均 LVEV<30%（风险增加 3 倍）、未进行 DFT（风险增加 2 倍）、NYHA 分级 III 或 IV（风险增加 3 倍）和未使用他汀类药物（风险增加 2 倍）与死亡风险增加相关。平均 HR<78 bpm 和 QRS 宽度<118 ms 与生存率增加独立相关。
LVEF<30%、NYHA 分级 III 或 IV、未进行 DFT 和未使用他汀类药物的患者死亡率更高。在这些患者中，应考虑心脏再同步治疗的适应证。HR<78 bpm 和 QRS 宽度<118 ms 是独立的保护因素。所有 SCD 患者的 HR>78 bpm。病情较重的 ICD 患者的存活时间较短。房颤的存在、抗心律失常 ICD 干预次数、ICD 类型和血运重建方法并不影响生存率/死亡率。
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