Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
Cardiac Electrophysiology Section, University of California, San Francisco, Section of Cardiology, San Francisco Veterans Administration Medical Center, San Francisco, California; Division of Cardiology, Department of Medicine, University of California, San Francisco, Section of Cardiology, San Francisco Veterans Administration Medical Center, San Francisco, California.
Am J Cardiol. 2014 Jun 15;113(12):2052-6. doi: 10.1016/j.amjcard.2014.03.049. Epub 2014 Apr 1.
Cardiac resynchronization therapy (CRT) reduces morbidity and mortality among selected patients with left ventricular systolic dysfunction and severe heart failure symptoms despite guideline-directed medical therapy (GDMT). Contemporaneous guidelines provided clear recommendations regarding selection of patients for CRT, including that all patients should first receive GDMT with β blockers and renin-angiotensin axis antagonists. Prevalence of GDMT among real-world patients receiving CRT defibrillators (CRT-D) has not been well studied. We identified 45,392 patients in the National Cardiovascular Data Registry Implantable Cardioverter-Defibrillator Registry who underwent first CRT-D implantation for primary prevention of sudden death from January 2006 to June 2008. We calculated the proportion of patients with contemporaneous class I guideline indications for CRT-D, the proportion receiving GDMT for heart failure, and the proportion receiving GDMT who had class I guideline indications for CRT-D. Among patients without contraindications, 87% were prescribed β blockers, 78% an angiotensin-converting enzyme inhibitor or an angiotensin II receptor inhibitor, and 70% both a β blocker and an angiotensin-converting enzyme or angiotensin II receptor inhibitor at discharge. Finally, 50% of patients met class I guideline indications and were prescribed GDMT at discharge; 9% neither met class I indications nor were prescribed GDMT at discharge. The major limitation of this study is the lack of dosage information in the Implantable Cardioverter-Defibrillator Registry and lack of prescribing information at times other than discharge. In conclusion, many patients receiving CRT-D are not receiving GDMT at discharge. Ensuring that all patients receiving CRT-D are also receiving GDMT appears to be a quality improvement target.
心脏再同步治疗（CRT）可降低左心室收缩功能障碍和严重心力衰竭症状患者的发病率和死亡率，尽管有指南指导的药物治疗（GDMT）。同时代的指南明确建议选择 CRT 的患者，包括所有患者都应首先接受 GDMT 联合β受体阻滞剂和肾素-血管紧张素轴拮抗剂。在接受 CRT 除颤器（CRT-D）的真实世界患者中，GDMT 的流行程度尚未得到很好的研究。我们从 2006 年 1 月至 2008 年 6 月，在国家心血管数据注册中心植入式心脏复律除颤器登记处中确定了 45392 名因预防猝死而首次接受 CRT-D 植入的患者。我们计算了具有同时代 CRT-D 类 I 指南适应证的患者比例、心力衰竭接受 GDMT 的患者比例以及接受 GDMT 且具有 CRT-D 类 I 指南适应证的患者比例。在无禁忌症的患者中，87%的患者处方了β受体阻滞剂，78%的患者处方了血管紧张素转换酶抑制剂或血管紧张素 II 受体抑制剂，70%的患者同时处方了β受体阻滞剂和血管紧张素转换酶抑制剂或血管紧张素 II 受体抑制剂。最后，50%的患者符合类 I 指南适应证并在出院时开具了 GDMT；9%的患者既不符合类 I 适应证也未开具 GDMT。本研究的主要局限性是植入式心脏复律除颤器登记处缺乏剂量信息，并且在出院以外的时间缺乏处方信息。总之，许多接受 CRT-D 的患者在出院时未接受 GDMT。确保所有接受 CRT-D 的患者同时也接受 GDMT 似乎是一个质量改进目标。
