Barra Sérgio, Providência Rui, Tang Anthony, Heck Patrick, Virdee Munmohan, Agarwal Sharad
Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, UK (B., P.H., M.V., S.A.).
Barts Heart Centre, Barts Health NHS Trust, London, UK (R.P.).
J Am Heart Assoc. 2015 Nov 6;4(11):e002539. doi: 10.1161/JAHA.115.002539.
It remains to be determined whether patients receiving cardiac resynchronization therapy (CRT) benefit from the addition of an implantable cardioverter-defibrillator (ICD).
We performed a literature search looking for studies of patients implanted with CRTs. Comparisons were performed between patients receiving CRT-defibrillator (CRT-D) versus CRT-pacemaker (CRT-P). The primary outcome was all-cause mortality. Data were pooled using a random-effects model. The relative risk (RR) and hazard ratio (HR, when available) were used as measurements of treatment effect. Nineteen entries were entitled for inclusion, comprising 12 378 patients (7030 receiving CRT-D and 5348 receiving CRT-P) and 29 799 patient-years of follow-up. Those receiving CRT-D were younger, were more often males, had lower NYHA class, lower prevalence of atrial fibrillation, higher prevalence of ischemic heart disease, and were more often on beta-blockers. Ten studies showed significantly lower mortality rates with the CRT-D device, while the remaining 9 were neutral. The pooled data of studies revealed that CRT-D patients had significantly lower mortality rates compared with CRT-P patients (mortality rates: CRT-D 16.6% versus CRT-P 27.1%; RR=0.69, 95% CI 0.62-0.76; P<0.00001). The number needed to treat to prevent one death was 10. The observed I(2) values showed moderate heterogeneity among studies (I(2)=48%). The benefit of CRT-D was more pronounced in ischemic cardiomyopathy (HR=0.70, 95% CI 0.59-0.83, P<0.001, I(2)=0%), but a trend for benefit, albeit of lower magnitude, could also be seen in non-ischemic dilated cardiomyopathy (HR=0.79, 95% CI 0.61-1.02, P=0.07, I(2)=36%).
The addition of the ICD associates with a reduction in the risk of all-cause mortality in CRT patients. This seems to be more pronounced in patients with ischemic cardiomyopathy.
接受心脏再同步治疗（CRT）的患者是否能从植入式心脏复律除颤器（ICD）的添加中获益仍有待确定。
我们进行了文献检索，以寻找有关植入CRT患者的研究。对接受CRT除颤器（CRT-D）与CRT起搏器（CRT-P）的患者进行了比较。主要结局是全因死亡率。使用随机效应模型汇总数据。相对风险（RR）和风险比（HR，如可用）用作治疗效果的测量指标。有19篇文献符合纳入标准，包括12378例患者（7030例接受CRT-D，5348例接受CRT-P）以及29799患者年的随访。接受CRT-D的患者更年轻，男性更多，纽约心脏协会（NYHA）分级更低，房颤患病率更低，缺血性心脏病患病率更高，且更常使用β受体阻滞剂。10项研究显示CRT-D装置的死亡率显著更低，而其余9项研究结果呈中性。研究的汇总数据显示，与CRT-P患者相比，CRT-D患者的死亡率显著更低（死亡率：CRT-D为16.6%，CRT-P为27.1%；RR=0.69，95%CI 0.62 - 0.76；P<0.00001）。预防一例死亡所需治疗的患者数为10。观察到的I²值显示研究间存在中度异质性（I²=48%）。CRT-D在缺血性心肌病中的获益更为显著（HR=0.70，95%CI 0.59 - 0.83，P<0.001，I²=0%），但在非缺血性扩张型心肌病中也可见到获益趋势，尽管获益程度较低（HR=0.79，95%CI 0.61 - 1.02，P=0.07，I²=36%）。
在CRT患者中添加ICD可降低全因死亡风险。这在缺血性心肌病患者中似乎更为显著。
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