Guttmann Oliver P, Pavlou Menelaos, O'Mahony Constantinos, Monserrat Lorenzo, Anastasakis Aristides, Rapezzi Claudio, Biagini Elena, Gimeno Juan Ramon, Limongelli Giuseppe, Garcia-Pavia Pablo, McKenna William J, Omar Rumana Z, Elliott Perry M
University College London Institute for Cardiovascular Science and Barts Heart Centre, St. Bartholomew's Hospital, London, UK.
Department of Statistical Science, University College London, London, UK.
Heart. 2017 May;103(9):672-678. doi: 10.1136/heartjnl-2016-309672. Epub 2016 Oct 28.
Atrial fibrillation (AF) is associated with increased morbidity and mortality in patients with hypertrophic cardiomyopathy (HCM). The primary aim of this study (HCM Risk-AF) was to determine the predictors of AF in a large multicentre cohort of patients with HCM. Exploratory analyses were performed to investigate the association between AF and survival and the efficacy of antiarrhythmic therapy in maintaining sinus rhythm (SR).
A retrospective, longitudinal cohort of patients recruited between 1986 and 2008 in seven centres was used to develop multivariable Cox regression models fitted with preselected predictors. HCM was defined as unexplained hypertrophy (maximum left ventricular wall thickness of ≥15 mm or in accordance with published criteria for the diagnosis of familial disease). 28% of patients (n=1171) had coexistent hypertension. The primary end point was paroxysmal, permanent or persistent AF detected on ECG, Holter monitoring or implantable device interrogation.
Of the 4248 patients with HCM without pre-existing AF, 740 (17.4%) reached the primary end point. Multivariable Cox regression revealed an association between AF and female sex, age, left atrial diameter, New York Heart Association (NYHA) class, hypertension and vascular disease. The proportion of patients with cardiovascular death at 10 years was 4.9% in the SR group and 10.9% in the AF group (difference in proportions=5.9%; 95% CI (4.1% to 7.8%)). The proportion of patients with non-cardiovascular death at 10 years was 3.2% in the SR group and 5.9% in the AF group (difference in proportions=2.8%; 95% CI (0.1% to 4.2%)). An intention-to-treat propensity score analysis demonstrated that β-blockers, calcium channel antagonists and disopyramide initially maintained SR during follow-up, but their protective effect diminished with time. Amiodarone therapy did not prevent AF during follow-up.
This study shows that patients with HCM who are at risk of AF development can be identified using readily available clinical parameters. The development of AF is associated with a poor prognosis but there was no evidence that antiarrhythmic therapy prevents AF in the long term.
心房颤动（AF）与肥厚型心肌病（HCM）患者的发病率和死亡率增加相关。本研究（HCM Risk-AF）的主要目的是确定一大群HCM患者中AF的预测因素。进行探索性分析以研究AF与生存之间的关联以及抗心律失常治疗维持窦性心律（SR）的疗效。
使用1986年至2008年期间在七个中心招募的患者的回顾性纵向队列来建立拟合预选预测因素的多变量Cox回归模型。HCM被定义为无法解释的肥厚（最大左心室壁厚度≥15 mm或符合已发表的家族性疾病诊断标准）。28%的患者（n = 1171）合并高血压。主要终点是通过心电图、动态心电图监测或植入式设备询问检测到的阵发性、永久性或持续性AF。
在4248例无既往AF的HCM患者中，740例（17.4%）达到主要终点。多变量Cox回归显示AF与女性、年龄、左心房直径、纽约心脏协会（NYHA）分级、高血压和血管疾病之间存在关联。SR组10年心血管死亡患者比例为4.9%，AF组为10.9%（比例差异 = 5.9%；95%CI（4.1%至7.8%））。SR组10年非心血管死亡患者比例为3.2%，AF组为5.9%（比例差异 = 2.8%；95%CI（0.1%至4.2%））。意向性治疗倾向评分分析表明，β受体阻滞剂、钙通道拮抗剂和丙吡胺在随访期间最初维持SR，但它们的保护作用随时间减弱。胺碘酮治疗在随访期间未能预防AF。
本研究表明，使用易于获得临床参数可以识别有发生AF风险的HCM患者。AF的发生与预后不良相关，但没有证据表明抗心律失常治疗能长期预防AF。
