McGill University Health Center, Montréal, Québec, Canada; Cardiology Department, Luigi Sacco Hospital, Milan, Italy.
McGill University Health Center, Montréal, Québec, Canada.
Can J Cardiol. 2015 Mar;31(3):270-7. doi: 10.1016/j.cjca.2014.11.023. Epub 2014 Nov 26.
It is unknown whether implantable cardioverter-defibrillator (ICD) discharges actively contribute to a worse prognosis independent of the underlying arrhythmia. There is considerable variability in the reported risk of mortality after appropriate and inappropriate ICD shocks. The aim of our systematic review was to provide a reliable effect size of the association between ICD shock and mortality for both types of therapies.
On the basis of a systematic literature search, 10 studies were considered eligible for inclusion in the analysis, and data on the hazard ratio (HR) of mortality after ICD shock were extracted from each study.
On pooled analysis, a substantial difference was detected in the risk for subsequent mortality between appropriate and inappropriate shocks. Among patients receiving an appropriate ICD shock, the HR for cardiac death was 2.95 (95% confidence interval [CI], 2.12-4.11; P < 0.001) compared with an HR of 1.71 (95% CI, 1.45-2.02) for those receiving an inappropriate shock. Clinical variables like ejection fraction, New York Heart Association class, and length of follow-up did not affect the HRs in our meta-regression models.
Our analysis showed a significant association between appropriate and inappropriate ICD shocks and mortality, with a stronger association for appropriate shocks. Previous trials of ICD therapy reduction programming have shown a significant reduction of inappropriate shocks. The management of appropriate shocks is more challenging and may be optimized by the assessment and treatment of the underlying ventricular arrhythmias. The role of therapies aimed at modifying the arrhythmic substrate and the potential impact on ICD shocks and mortality requires further investigation.
目前尚不清楚植入式心脏复律除颤器（ICD）放电是否会独立于潜在心律失常而对预后产生不利影响。适当和不适当的 ICD 电击后死亡率的报告风险存在相当大的差异。我们系统评价的目的是为 ICD 电击与死亡率之间的关联提供一个可靠的效应大小，适用于这两种治疗类型。
根据系统文献检索，有 10 项研究被认为符合纳入分析的标准，并从每项研究中提取关于 ICD 电击后死亡率的危险比（HR）的数据。
汇总分析显示，适当和不适当电击之间的死亡率风险存在显著差异。在接受适当 ICD 电击的患者中，心脏性死亡的 HR 为 2.95（95%置信区间 [CI]，2.12-4.11；P<0.001），而接受不适当电击的患者的 HR 为 1.71（95% CI，1.45-2.02）。在我们的荟萃回归模型中，临床变量如射血分数、纽约心脏协会（NYHA）心功能分级和随访时间的长短均未影响 HR。
我们的分析表明，适当和不适当的 ICD 电击与死亡率之间存在显著关联，适当电击的关联更强。以前的 ICD 治疗减少编程试验已经表明，不适当的电击显著减少。适当电击的管理更具挑战性，通过评估和治疗潜在的室性心律失常可能会得到优化。旨在改变心律失常基质的治疗方法的作用以及对 ICD 电击和死亡率的潜在影响需要进一步研究。
