Lyons Kristin J, Podder Mohua, Ezekowitz Justin A
Division of Cardiology, Department of Medicine; Mazankowski Alberta Heart Institute.
Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada.
Heart Rhythm. 2014 Nov;11(11):1983-90. doi: 10.1016/j.hrthm.2014.08.004. Epub 2014 Aug 5.
Implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) are recommended by guidelines for patients with heart failure (HF) meeting specific criteria. Uncertainty exists regarding estimates of device eligibility, related in part to the method of assessing for guideline nonadherence.
The aim of this study was to identify the rates of guideline eligibility and device utilization after accounting for reasons for not receiving an ICD or CRT.
Patients were identified from 2006 to 2011 in a tertiary Heart Function Clinic in Canada. The chart-level data were collected that would indicate guideline eligibility and nonadherence.
A total of 762 patients with HF were included (mean age 66 years; 527 (69%) were males; median left ventricular ejection fraction 33%). Over follow-up, 331 patients (43%) were never guideline eligible whereas 431 (57%) were guideline eligible for a device. Yearly rates for ICD and CRT adherence in "guideline-eligible" patients ranged from 59% to 68% and from 66% to 81%, respectively. "Patient preference" was the most commonly documented reason for guideline nonadherence in eligible patients. After removal of patients with reasons for nonadherence, rates of ICD and CRT adherence in the "truly eligible" patients were found to be higher (70%-81% and 71%-88%, respectively) than those in guideline-eligible patients. Independent predictors of device nonadherence in truly eligible patients were age >75 years, QRS duration <120 ms, left ventricular ejection fraction <30%, and female sex.
Based on chart-level data, utilization rates of device-based therapies in patients with HF appear much higher than those of prior registry-based estimates. Given the importance of patient preferences for lack of device use, future quality-of-care metrics based on guideline adherence should capture detailed chart-level data and patient preferences.
对于符合特定标准的心力衰竭（HF）患者，植入式心脏复律除颤器（ICD）和心脏再同步治疗（CRT）已被指南推荐。在设备适用率的估计方面存在不确定性，部分原因与评估指南不依从性的方法有关。
本研究的目的是在考虑未接受ICD或CRT的原因后，确定指南适用率和设备使用率。
从2006年至2叭1年在加拿大一家三级心脏功能诊所中识别患者。收集了图表级数据，这些数据将表明指南适用性和不依从性。
共纳入762例HF患者（平均年龄66岁；527例（69%）为男性；左心室射血分数中位数为33%）。在随访期间，331例患者（43%）从未符合指南标准，而431例（57%）符合指南设备适用标准。“符合指南标准”的患者中，ICD和CRT的年度依从率分别为59%至68%和66%至81%。“患者偏好”是符合标准的患者中最常记录的指南不依从原因。在排除有不依从原因的患者后，发现“真正符合标准”的患者中ICD和CRT的依从率高于符合指南标准的患者（分别为70%至81%和71%至88%）。真正符合标准的患者中设备不依从的独立预测因素为年龄>75岁、QRS时限<120毫秒、左心室射血分数<30%以及女性。
基于图表级数据，HF患者中基于设备的治疗使用率似乎远高于先前基于登记处的估计值。鉴于患者偏好在未使用设备方面的重要性，未来基于指南依从性的医疗质量指标应获取详细的图表级数据和患者偏好。
