Duncker David, König Thorben, Hohmann Stephan, Bauersachs Johann, Veltmann Christian
Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
J Am Heart Assoc. 2017 Jan 17;6(1):e004512. doi: 10.1161/JAHA.116.004512.
Optimal timing of implantation of an implantable cardioverter/defibrillator (ICD) after newly diagnosed heart failure is unclear given that late reverse remodelling may occur. We aimed to analyze left ventricular ejection fraction (LVEF) after diagnosis of an LVEF ≤35% during optimization of heart failure drug therapy.
One hundred fifty-six patients with newly diagnosed LVEF ≤35% receiving a wearable cardioverter/defibrillator (WCD) were analyzed. WCD was prescribed for 3 months until first re-evaluation. Indications for prolongation of WCD wearing period instead of ICD implantation were: (1) LVEF at 3-month visit 30% to 35%; (2) increase in LVEF of ≥5% compared to the last visit; and (3) nonoptimized heart failure medication. Mean LVEF was 24±7% at diagnosis and 39±11% at last follow-up (mean, 12±10 months). Whereas 88 patients presented a primary preventive ICD indication (LVEF ≤35%) at 3-month follow-up, only 58 showed a persistent primary preventive ICD indication at last follow-up. This delayed improvement in LVEF was related to nonischemic origin of cardiomyopathy, New York Heart Association functional class at baseline, heart rate, better LVEF after 3 months, and higher dosages of mineralocorticoid receptor antagonist. Twelve appropriate WCD shocks for ventricular tachycardia/ventricular fibrillation occurred in 11 patients. Two patients suffered from ventricular tachycardia/ventricular fibrillation beyond 3 months after diagnosis.
A relevant proportion of patients with newly diagnosed heart failure shows recovery of LVEF >35% beyond 3 months after initiation of heart failure therapy. To avoid untimely ICD implantation, prolongation of WCD period should be considered in these patients to prevent sudden cardiac death while allowing left ventricular reverse remodeling during intensified drug therapy.
鉴于可能发生晚期逆向重构，新诊断心力衰竭后植入植入式心脏复律除颤器（ICD）的最佳时机尚不清楚。我们旨在分析在心力衰竭药物治疗优化期间诊断为左心室射血分数（LVEF）≤35%后的左心室射血分数。
分析了156例新诊断为LVEF≤35%并接受可穿戴式心脏复律除颤器（WCD）治疗的患者。WCD使用3个月直至首次重新评估。延长WCD佩戴时间而非植入ICD的指征为：（1）3个月随访时LVEF为30%至35%；（2）与上次随访相比LVEF增加≥5%；（3）心力衰竭药物治疗未优化。诊断时平均LVEF为24±7%，末次随访时为39±11%（平均，12±10个月）。88例患者在3个月随访时出现一级预防ICD指征（LVEF≤35%），而末次随访时只有58例仍有持续的一级预防ICD指征。LVEF的这种延迟改善与心肌病的非缺血性起源、基线时纽约心脏协会功能分级、心率、3个月后较好的LVEF以及更高剂量的盐皮质激素受体拮抗剂有关。11例患者发生了12次针对室性心动过速/心室颤动的适当WCD电击。2例患者在诊断后3个月以上发生室性心动过速/心室颤动。
相当一部分新诊断心力衰竭患者在开始心力衰竭治疗3个月后LVEF恢复至>35%。为避免过早植入ICD，应考虑延长这些患者的WCD使用时间，以预防心脏性猝死，同时在强化药物治疗期间允许左心室逆向重构。
