De Luca Giacomo, Bosello Silvia Laura, Gabrielli Francesca Augusta, Berardi Giorgia, Parisi Federico, Rucco Manuela, Canestrari Giovanni, Loperfido Francesco, Galiuto Leonarda, Crea Filippo, Ferraccioli Gianfranco
Institute of Rheumatology and Affine Sciences - Department of Rheumatology, Catholic University of the Sacred Heart, Rome, Italy.
Division of Heart Failure and Cardiac Rehabilitation, Complesso Integrato Columbus, Rome, Italy.
PLoS One. 2016 Apr 21;11(4):e0153012. doi: 10.1371/journal.pone.0153012. eCollection 2016.
Arrhythmias are frequent in Systemic Sclerosis (SSc) and portend a bad prognosis, accounting alone for 6% of total deaths. Many of these patients die suddenly, thus prevention and intensified risk-stratification represent unmet medical needs. The major goal of this study was the definition of ECG indexes of poor prognosis.
We performed a prospective cohort study to define the role of 24h-ECG-Holter as an additional risk-stratification technique in the identification of SSc-patients at high risk of life-threatening arrhythmias and sudden cardiac death (SCD). One-hundred SSc-patients with symptoms and/or signs suggestive of cardiac involvement underwent 24h-ECG-Holter. The primary end-point was a composite of SCD or need for implantable cardioverter defibrillator (ICD).
Fifty-six patients (56%) had 24h-ECG-Holter abnormalities and 24(24%) presented frequent ventricular ectopic beats (VEBs). The number of VEBs correlated with high-sensitive cardiac troponin T (hs-cTnT) levels and inversely correlated with left-ventricular ejection fraction (LV-EF) on echocardiography. During a mean follow-up of 23.1±16.0 months, 5 patients died suddenly and two required ICD-implantation. The 7 patients who met the composite end-point had a higher number of VEBs, higher levels of hs-cTnT and NT-proBNP and lower LV-EF (p = 0.001 for all correlations). All these 7 patients had frequent VEBs, while LV-EF was not reduced in all and its range was wide. At ROC curve, VEBs>1190/24h showed 100% of sensitivity and 83% of specificity to predict the primary end-point (AUROC = 0.92,p<0.0001). Patients with VEBS>1190/24h had lower LV-EF and higher hs-cTnT levels and, at multivariate analysis, the presence of increased hs-cTnT and of right bundle branch block on ECG emerged as independent predictors of VEBs>1190/24h. None of demographic or disease-related characteristics emerged as predictors of poor outcome.
VEBS>1190/24h identify patients at high risk of life-threatening arrhythmic complications. Thus, 24h-ECG-Holter should be considered a useful additional risk-stratification test to select SSc-patients at high-risk of SCD, in whom an ICD-implantation could represent a potential life-saving intervention.
心律失常在系统性硬化症（SSc）中很常见，且预后不良，仅占总死亡人数的6%。这些患者中有许多人突然死亡，因此预防和强化风险分层是尚未满足的医疗需求。本研究的主要目标是确定预后不良的心电图指标。
我们进行了一项前瞻性队列研究，以确定24小时动态心电图（ECG-Holter）作为一种额外的风险分层技术在识别有危及生命的心律失常和心源性猝死（SCD）高风险的SSc患者中的作用。100例有提示心脏受累症状和/或体征的SSc患者接受了24小时ECG-Holter检查。主要终点是SCD或需要植入式心律转复除颤器（ICD）的综合指标。
56例患者（56%）有24小时ECG-Holter异常，24例（24%）出现频发室性早搏（VEB）。VEB的数量与高敏心肌肌钙蛋白T（hs-cTnT）水平相关，与超声心动图上的左心室射血分数（LV-EF）呈负相关。在平均23.1±16.0个月的随访期间，5例患者突然死亡，2例需要植入ICD。达到综合终点的7例患者有更多的VEB、更高的hs-cTnT和NT-proBNP水平以及更低的LV-EF（所有相关性的p = 0.001）。所有这7例患者都有频发VEB，而并非所有患者的LV-EF都降低，其范围较宽。在ROC曲线分析中，VEB>1190/24小时对预测主要终点的敏感性为100%，特异性为83%（曲线下面积 = 0.92，p<0.0001）。VEB>1190/24小时的患者LV-EF较低且hs-cTnT水平较高，在多变量分析中，hs-cTnT升高和心电图上右束支传导阻滞的存在是VEB>1190/24小时的独立预测因素。没有人口统计学或疾病相关特征可作为不良预后的预测因素。
VEB>1190/24小时可识别有危及生命的心律失常并发症高风险的患者。因此，24小时ECG-Holter应被视为一种有用的额外风险分层检查，以筛选有SCD高风险的SSc患者，对于这些患者，植入ICD可能是一种潜在的挽救生命的干预措施。
