Pun Patrick H, Sheng Shubin, Sanders Gillian, DeVore Adam D, Friedman Daniel, Fonarow Gregg C, Heidenreich Paul A, Yancy Clyde W, Hernandez Adrian F, Al-Khatib Sana M
Duke Clinical Research Institute, Durham, North Carolina; Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Duke Clinical Research Institute, Durham, North Carolina.
Am J Cardiol. 2017 Mar 15;119(6):886-892. doi: 10.1016/j.amjcard.2016.11.043. Epub 2016 Dec 18.
Implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) reduce mortality in many patients with heart failure (HF), but the current use and effectiveness of ICD/CRT in patients with chronic kidney disease (CKD) are uncertain. We examined associations between kidney function and guideline-recommended prescription of ICD/CRT in the Get With The Guidelines-Heart Failure registry, a performance improvement program for hospitalized patients with HF. We compared differences in ICD and CRT prescription between the following categories of estimated glomerular filtration rate (eGFR; mL/min/1.73 m): ≥60, 59 to 30, <30, and dialysis dependent. From 2008 through 2014, 26,286 patients were eligible for ICD or CRT, and 16,123(61%) had an eGFR <60. De novo ICD and CRT prescription in this group was low at 45% and 30.5%, respectively. Compared to patients with eGFR ≥60, patients with eGFR 30 to 59 were more likely to receive an ICD (adjusted odds ratio [aOR] 1.08, 95% confidence intervals [CI] 1.01 to 1.14), whereas dialysis patients were less likely (aOR 0.61, 95% CI 0.5 to 0.76). Worse kidney function was associated with a decreased likelihood of CRT prescription (aOR 0.97 per 10 ml/min eGFR decrease, p = 0.03). During the study period, the likelihood of both ICD and CRT prescription increased over time among patients with CKD (ICD aOR 1.12, 95% CI 1.07 to 1.18; CRT aOR 1.14, 95% CI 1.06 to 1.23, per year). Prescription of an ICT/CRT was associated with greater 1-year survival in all eGFR groups. In conclusion, there are significant CKD-based differences in prescription of ICD and CRT in HF. However, given the current state of evidence, it is unclear whether improved prescription of ICD and CRT in the CKD population will result in improvement in outcomes.
植入式心脏复律除颤器（ICD）和心脏再同步治疗（CRT）可降低许多心力衰竭（HF）患者的死亡率，但ICD/CRT在慢性肾脏病（CKD）患者中的当前使用情况及有效性尚不确定。我们在“遵循心力衰竭指南”注册研究中研究了肾功能与ICD/CRT指南推荐处方之间的关联，该研究是一项针对住院HF患者的绩效改进计划。我们比较了以下估算肾小球滤过率（eGFR；毫升/分钟/1.73平方米）类别之间ICD和CRT处方的差异：≥60、59至30、<30以及依赖透析。从2008年到2014年，26286例患者符合ICD或CRT治疗条件，其中16123例（61%）eGFR<60。该组中初次ICD和CRT处方率较低，分别为45%和30.5%。与eGFR≥60的患者相比，eGFR为30至59的患者更有可能接受ICD治疗（校正比值比[aOR]为1.08，95%置信区间[CI]为1.01至1.14），而透析患者接受ICD治疗的可能性较小（aOR为0.61，95%CI为0.5至0.76）。肾功能越差，CRT处方的可能性越低（每降低10毫升/分钟eGFR，aOR为0.97，p=0.03）。在研究期间，CKD患者中ICD和CRT处方的可能性均随时间增加（ICD的aOR为1.12，95%CI为1.07至1.18；CRT的aOR为1.14，9年CI为1.06至1.23）。在所有eGFR组中，ICT/CRT处方与1年生存率提高相关。总之，HF患者中ICD和CRT处方存在基于CKD的显著差异。然而，鉴于目前的证据状况，尚不清楚改善CKD人群中ICD和CRT的处方是否会导致预后改善。
