Rickard John, Bassiouny Mohammed, Tedford Ryan J, Baranowski Bryan, Spragg David, Cantillon Daniel, Varma Niraj, Wilkoff Bruce L, Tang W H Wilson
Division of Electrophysiology, Department of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland.
Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Am J Cardiol. 2015 Jan 1;115(1):82-5. doi: 10.1016/j.amjcard.2014.09.052. Epub 2014 Oct 15.
Patients with ambulatory New York Heart Association (NYHA) class IV heart failure were significantly underrepresented in clinical trials of cardiac resynchronization therapy (CRT). The natural long-term trajectory of survival free of left ventricular assist device (LVAD) or heart transplant in patients with ambulatory class IV symptoms who underwent CRT has not been established. We extracted clinical data on 723 consecutive patients with NYHA class III or ambulatory class IV heart failure, left ventricular ejection fraction ≤35%, and a QRS duration ≥120 ms who underwent CRT from September 30, 2003, to August 6, 2007. Chart notes immediately before CRT were reviewed to confirm NYHA class status before CRT. Kaplan-Meier curves and a multivariate Cox proportional hazards model were constructed to determine long-term survival free of heart transplant and LVAD based on NYHA class status. Of the 723 patients, 52 had ambulatory class IV symptoms. Over a mean follow-up of 5.0 ± 2.5 years controlling for many possible confounders, ambulatory NYHA class IV status was independently associated with poor long-term outcomes. The 1-, 2-, 3-, 4-, and 5-year survival free of LVAD or heart transplant for class III versus ambulatory class IV patients was 92.0%, 84.0%, 75.0%, 68.1%, and 63.2% versus 75.0%, 61.5%, 52.0%, 45%, and 40.4%, respectively. Although patients with ambulatory class IV heart failure receiving CRT have inferior long-term outcomes compared with those with class III symptoms, survival in class IV patients continues to parallel class III patients over an extended follow-up. At 5 years, survival free of LVAD or heart transplant in ambulatory class IV patients receiving CRT is 40%.
纽约心脏协会（NYHA）心功能IV级的门诊心力衰竭患者在心脏再同步治疗（CRT）的临床试验中代表性明显不足。对于接受CRT治疗的有门诊IV级症状的患者，未使用左心室辅助装置（LVAD）或未进行心脏移植的自然长期生存轨迹尚未明确。我们提取了2003年9月30日至2007年8月6日期间连续接受CRT治疗的723例NYHA III级或门诊IV级心力衰竭、左心室射血分数≤35%且QRS时限≥120毫秒的患者的临床数据。回顾CRT治疗前的病历记录以确认CRT治疗前的NYHA分级状态。构建Kaplan-Meier曲线和多变量Cox比例风险模型，以根据NYHA分级状态确定未进行心脏移植和未使用LVAD的长期生存率。在这723例患者中，52例有门诊IV级症状。在平均5.0±2.5年的随访期间，控制了许多可能的混杂因素后，门诊NYHA IV级状态与不良的长期预后独立相关。III级与门诊IV级患者未使用LVAD或未进行心脏移植的1年、2年、3年、4年和5年生存率分别为92.0%、84.0%、75.0%、68.1%和63.2%，而IV级患者分别为75.0%、61.5%、52.0%、45%和40.4%。尽管接受CRT治疗的门诊IV级心力衰竭患者的长期预后比III级症状患者差，但在延长的随访期内，IV级患者的生存率仍与III级患者相当。在5年时，接受CRT治疗的门诊IV级患者未使用LVAD或未进行心脏移植的生存率为40%。
