Köbe Julia, Andresen Dietrich, Maier Sebastian, Stellbrink Christoph, Kleemann Thomas, Gonska Bernd-Dieter, Reif Sebastian, Hochadel Matthias, Senges Jochen, Eckardt Lars
Division of Electrophysiology, University Hospital of Muenster, Germany.
Department of Cardiology, Vivantes Klinikum am Urban, Berlin, Germany.
Int J Cardiol. 2017 Feb 1;228:784-789. doi: 10.1016/j.ijcard.2016.11.212. Epub 2016 Nov 10.
Evidence on cardiac resynchronization therapy (CRT) in older patients is scarce and conflicting. Nevertheless, CRT in the elderly is of major practical relevance as heart failure prevalence increases with age.
The German Device Registry (DEVICE) is a nationwide, prospective registry with a longitudinal follow-up design investigating device implantations in 60 German centres. The present analysis of DEVICE focussed on perioperative complication rates and 1-year outcome of patients ≥75years (n=320) compared to younger patients (n=879) receiving a CRT device.
Comorbidities were more common in older patients (chronic kidney disease (CKD): 27.5% vs. 21.5%, p=0.029; atrial fibrillation (AF): 26.9% vs. 15.6%, p<0.001). Despite higher NYHA classes in the older age group, ejection fractions were comparable (27.2±7.1% ≥75years, 26.2±7.1% <75years, p=0.06). Perioperative complications and mortality rates did not show significant difference between groups. After new device implantation, absolute 1-year mortality was higher in older patients (11.0% ≥75years, 6.4% <75years, p=0.014), with a significantly lower proportion of cardiac deaths in the older group (p=0.05). Patients ≥75years being alive after 1year had lower response rates, with chronic kidney disease (OR 0.46, p<0.05) and smaller QRS complexes (OR 0.31, p<0.01) being particular risk factors for missing improvement of heart failure symptoms. As expected severe heart failure (NYHA IV) was a strong independent predictor of death (HR 1.95, p=0.01), whereas AF as underlying rhythm could be worked out as predictor for mortality especially in the younger patients (HR 2.31, p=0.002).
Patients ≥75years of age receiving a CRT device do not have a higher perioperative mortality and complication rate although comorbidities (CKD and AF) occur more frequently. The absolute 1-year mortality is higher; nevertheless, the proportion of cardiac deaths is even lower in the older patients reflecting a benefit of CRT in this group.
关于老年患者心脏再同步治疗（CRT）的证据稀少且相互矛盾。然而，随着心力衰竭患病率随年龄增长而增加，老年患者的CRT具有重大的实际意义。
德国器械注册研究（DEVICE）是一项全国性的前瞻性注册研究，采用纵向随访设计，调查德国60个中心的器械植入情况。本研究对DEVICE的分析重点关注≥75岁患者（n = 320）与接受CRT器械的年轻患者（n = 879）的围手术期并发症发生率和1年结局。
老年患者的合并症更为常见（慢性肾脏病（CKD）：27.5% 对21.5%，p = 0.029；心房颤动（AF）：26.9% 对15.6%，p < 0.001）。尽管老年组纽约心脏协会（NYHA）分级较高，但射血分数相当（≥75岁为27.2±7.1%，<75岁为26.2±7.1%，p = 0.06）。两组间围手术期并发症和死亡率无显著差异。植入新器械后，老年患者的绝对1年死亡率较高（≥75岁为11.0%，<75岁为6.4%，p = 0.014），老年组心脏性死亡比例显著较低（p = 0.05）。1年后仍存活的≥75岁患者反应率较低，慢性肾脏病（比值比[OR] 0.46，p < 0.05）和较小的QRS波群（OR 0.31，p < 0.01）是心力衰竭症状改善不佳的特别危险因素。正如预期的那样，严重心力衰竭（NYHA IV级）是死亡的强有力独立预测因素（风险比[HR] 1.95，p = 0.01），而房颤作为基础心律可被确定为死亡率的预测因素，尤其是在年轻患者中（HR 2.31，p = 0.002）。
接受CRT器械的≥75岁患者围手术期死亡率和并发症发生率并不更高，尽管合并症（CKD和AF）更频繁发生。绝对1年死亡率较高；然而，老年患者心脏性死亡比例更低，这反映了CRT对该组患者的益处。
