Hübinette Clara, Lund Lars H, Gadler Fredrik, Ståhlberg Marcus
Department of Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden Department of Cardiology, Karolinska University Hospital, 171 76 Stockholm, Sweden.
Department of Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden Department of Cardiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
Europace. 2014 Nov;16(11):1580-6. doi: 10.1093/europace/eut416. Epub 2014 Jan 22.
Cardiac resynchronization therapy (CRT) and primary prophylactic implantable cardioverter-defibrillators (ICDs) are underutilized in heart failure (HF). This may originate from an unawareness of device benefits and indications among physicians responsible for HF care and referral. We aimed to describe the awareness of indications for device therapy in a generalized sample of Swedish physicians.
A randomly selected sample of Swedish physicians specializing in cardiology, internal medicine, and family medicine and interns (5% of eligible physicians, n = 519) was invited to fill in a 23-item survey, testing their awareness of indications for device therapy and, as comparison, pharmacological therapy. Acceptable awareness (AA) of CRT indication was predefined as recognizing that a left bundle branch block on ECG warrants further evaluation for CRT. Acceptable awareness of ICD indication was predefined as recognizing that ejection fraction ≤35% alone, without a history of ventricular tachycardia, is sufficient to warrant a primary prophylactic ICD. The response rate was 37% (n = 168). Overall, 32% met AA of CRT indication, and significantly less (15%) met AA of ICD indication. Specialist certification in cardiology was the only significant predictor for AA [odds ratio (95% confidence interval): 37 (10-138)]. However, even among cardiologists, awareness of ICD indications was low (61% with AA). Guideline-recommended indications for pharmacological therapy were conceived significantly better (P = 0.02) than device therapy [median (interquartile range) of correct answers: 50% (33-50) compared with 36% (14-57)].
The study identified an important and substantial awareness gap in the medical community that may explain some of the previously reported low referral rates and utilization of device therapy in HF.
心脏再同步治疗（CRT）和一级预防性植入式心律转复除颤器（ICD）在心力衰竭（HF）中的应用未得到充分利用。这可能源于负责HF治疗和转诊的医生对器械益处和适应症缺乏认识。我们旨在描述瑞典医生总体样本中对器械治疗适应症的认识情况。
随机抽取瑞典专门从事心脏病学、内科和家庭医学的医生以及实习生样本（占符合条件医生的5%，n = 519），邀请他们填写一份包含23个项目的调查问卷，测试他们对器械治疗适应症以及作为对照的药物治疗适应症的认识。CRT适应症的可接受认识（AA）被预先定义为认识到心电图上的左束支传导阻滞需要进一步评估是否适合CRT。ICD适应症的可接受认识被预先定义为认识到单独的射血分数≤35%，且无室性心动过速病史，足以 warrant 进行一级预防性ICD植入。回复率为37%（n = 168）。总体而言，32%的人达到了CRT适应症的AA，而达到ICD适应症AA的人明显较少（15%）。心脏病学专科认证是AA的唯一显著预测因素[比值比（95%置信区间）：37（10 - 138）]。然而，即使在心脏病专家中，对ICD适应症的认识也较低（61%达到AA）。指南推荐的药物治疗适应症的认知明显优于器械治疗（P = 0.02）[正确答案的中位数（四分位间距）：50%（33 - 50），而器械治疗为36%（14 - 57）]。
该研究发现了医学界存在的一个重要且显著的认识差距，这可能解释了先前报道的HF器械治疗转诊率低和使用率低的部分原因。
