Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, 34149, Italy.
Eur J Heart Fail. 2014 Mar;16(3):317-24. doi: 10.1002/ejhf.16. Epub 2013 Dec 14.
ACE-inhibitors, β-blockers, implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) improved prognosis of heart failure. We sought to analyse the long-term prognostic impact of evidence-based integrated therapeutic strategies in patients with idiopathic dilated cardiomyopathy (IDCM).
From 1978 to 2007, 853 IDCM patients (45 ± 15 years, 72% males) were enrolled and classified as follows: Group 1, 110 patients (12.8%) enrolled during 1978-1987; Group 2, 376 patients (44.1%) enrolled during 1988-1997; Group 3, 367 patients (43.1%) enrolled during 1998-2007. ACE-inhibitors/angiotensin receptor blockers were administered in 34%, 93%, and 93% (P <0.001), and β-blockers in 11%, 82%, and 86% (P <0.001) in Groups 1, 2, and 3, respectively; ICDs were implanted in 2%, 14%, and 13% (P = 0.005); mean time to device implantation was lower in Group 3. At 8 years, heart transplant (HTx)-free survival rates were 55%, 71%, and 87% in Groups 1, 2, and 3, respectively (P <0.001). Similar progressive improvement was found for pump-failure death (DHF)/HTx, while survival free from sudden death (SD) was significantly improved only in Group 3. Multivariable models considering competing risk indicated early diagnosis (i.e. a baseline less advanced disease stage) and tailored medical therapy (HR 0.44, CI 95% 0.19-0.98) as independent protectors against DHF/HTx. Concerning SD, lower left ventricular ejection fraction emerged as a predictor, while ICD was the only therapy with a protective role (HR 0.08, CI 95% 0.01-0.61). Treatment with digitalis emerged as a predictor of both DHF/HTx and SD.
An effective management and evidence-based integrated therapeutic approach progressively and significantly improved the long-term prognosis of IDCM during the last three decades.
血管紧张素转换酶抑制剂（ACEI）、β受体阻滞剂、植入式心脏复律除颤器（ICD）和心脏再同步治疗（CRT）改善了心力衰竭患者的预后。本研究旨在分析在特发性扩张型心肌病（IDCM）患者中，基于循证的综合治疗策略的长期预后影响。
1978 年至 2007 年间，共纳入 853 例 IDCM 患者（45±15 岁，72%为男性），并分为以下三组：第 1 组，110 例（12.8%）患者于 1978 年至 1987 年期间入组；第 2 组，376 例（44.1%）患者于 1988 年至 1997 年期间入组；第 3 组，367 例（43.1%）患者于 1998 年至 2007 年期间入组。第 1、2、3 组中分别有 34%、93%和 93%（P<0.001）的患者接受了 ACEI/血管紧张素受体阻滞剂治疗，分别有 11%、82%和 86%（P<0.001）的患者接受了β受体阻滞剂治疗；第 2、3 组中分别有 14%和 13%（P=0.005）的患者植入了 ICD；第 3 组的 ICD 植入中位时间更短。8 年时，第 1、2、3 组中免于心脏移植（HTx）的存活率分别为 55%、71%和 87%（P<0.001）。泵衰竭死亡（DHF）/HTx和猝死（SD）的发生率也呈现出相似的改善趋势，但仅在第 3 组中，SD 免于死亡的比例有显著提高。多变量竞争风险模型显示，早期诊断（即基线时疾病分期较轻）和个体化药物治疗（HR 0.44，95%CI 0.19-0.98）是 DHF/HTx 的独立保护因素。对于 SD，左心室射血分数较低是一个预测因素，而 ICD 是唯一具有保护作用的治疗方法（HR 0.08，95%CI 0.01-0.61）。地高辛的使用则是 DHF/HTx 和 SD 的预测因素。
在过去三十年中，有效的管理和基于循证的综合治疗方法显著改善了 IDCM 的长期预后。
