Bhavnani Sanjeev P, Pavuluri Vamsimohan, Coleman Craig I, Guertin Danette, Yarlagadda Ravi K, Clyne Christopher A, Kluger Jeffery
Division of Cardiology, Section of Heart Rhythm Management, and the Evidence Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA.
Pacing Clin Electrophysiol. 2013 Jul;36(7):878-84. doi: 10.1111/pace.12141. Epub 2013 Apr 24.
Several meta-analyses of the implantable cardioverter-defibrillator (ICD) clinical trials have demonstrated that while men derived a mortality reduction with prophylactic ICD implantation, women did not. These trials also observed that women receive less appropriate ICD shock therapy compared to men. We aimed to investigate this "gender-paradox" among a heterogeneous community cohort of patients receiving ICDs.
We identified 1,445 consecutive patients undergoing ICD implantation from 1997 to 2007. The study population consisted of 582 patients, of whom 291 were women who could be propensity matched to 291 men, based on age, ejection fraction, implantation indication (primary or secondary), etiology of cardiomyopathy (ischemic or nonischemic), and the presence of a cardiac resynchronization therapy-defibrillator (CRT-D) device. The impact of gender difference on the probability of death and appropriate ICD shocks for ventricular arrhythmias was calculated using multivariable Cox proportional hazards analyses.
During a mean follow-up of 909 ± 901 days, compared to men, women demonstrated a similar risk of death (25% vs 25%, adjusted hazard ratio [AHR] 1.05 [95% confidence interval (CI) 0.81-1.35], P = 0.74). In contrast, women demonstrated a decreased probability of appropriate ICD-shock therapy (14% vs 19%, AHR 0.80 [95% CI 0.59-0.88], P = 0.03) compared to men, and among cohorts with a nonischemic cardiomyopathy (10% vs 20%, P < 0.001) and CRT-D devices (7% vs 19%, P = 0.01).
Among a community cohort with ICDs, women have a similar mortality compared to men while experiencing less appropriate ICD therapy. These results support the findings of a lower arrhythmic mortality among women.
多项关于植入式心脏复律除颤器（ICD）临床试验的荟萃分析表明，虽然男性通过预防性植入ICD可降低死亡率，但女性却未从中获益。这些试验还观察到，与男性相比，女性接受的ICD电击治疗不太恰当。我们旨在研究接受ICD治疗的异质性社区队列患者中的这种“性别悖论”。
我们确定了1997年至2007年间连续接受ICD植入的1445例患者。研究人群包括582例患者，其中291例女性患者可根据年龄、射血分数、植入指征（一级或二级）、心肌病病因（缺血性或非缺血性）以及是否存在心脏再同步治疗除颤器（CRT-D）装置与291例男性患者进行倾向匹配。使用多变量Cox比例风险分析计算性别差异对死亡概率和因室性心律失常进行恰当ICD电击的影响。
在平均909±901天的随访期间，与男性相比，女性的死亡风险相似（25%对25%，调整后风险比[AHR]为1.05[95%置信区间（CI）0.81 - 1.35]，P = 0.74）。相比之下，与男性相比，女性接受恰当ICD电击治疗的概率降低（14%对19%，AHR为0.80[95%CI 0.59 - 0.88]，P = 0.03），在非缺血性心肌病队列中（10%对20%，P < 0.001）以及CRT-D装置队列中（7%对19%，P = 0.01）也是如此。
在接受ICD治疗的社区队列中，女性与男性死亡率相似，但接受的ICD治疗不太恰当。这些结果支持了女性心律失常死亡率较低的研究发现。
