Bauer Axel
Medizinische Klinik und Poliklinik I, Munich University Clinic, Munich, Germany; German Center for Cardiovascular Research (DZHK), Germany.
Int J Cardiol. 2017 Jun 15;237:19-21. doi: 10.1016/j.ijcard.2017.03.087. Epub 2017 Mar 18.
Despite major advances in medical therapies late mortality after myocardial infarction (MI) is still high. A substantial proportion of post-MI patients die from sudden cardiac death. Prophylactic implantable-cardioverter defibrillator (ICD) therapy has been established for post-MI patients with reduced left ventricular ejection fraction (LVEF ≤35%). However, most patients who die after MI have an LVEF >35%. For this large group of patients, no specific prophylactic strategies exist. There is strong evidence that measures of cardiac autonomic dysfunction after MI provide important prognostic information in post-MI patients with preserved LVEF. Combinations of autonomic markers can identify high-risk patients after MI with LVEF >35% whose prognosis is equally worse than that of patients with LVEF ≤35%. The ongoing REFINE-ICD (NCT00673842) and SMART-MI trials (NCT02594488) test different preventive strategies in high-risk post-MI patients with cardiac autonomic dysfunction and LVEF 36-50%. While REFINE-ICD follows the traditional concept of ICD-implantation, SMART-MI uses implantable cardiac monitors with remote monitoring capabilities to sensitively detect asymptomatic, but prognostically relevant arrhythmias that could trigger specific diagnostic and therapeutic interventions.
尽管医学治疗取得了重大进展，但心肌梗死（MI）后的晚期死亡率仍然很高。相当一部分心肌梗死后患者死于心源性猝死。对于左心室射血分数降低（LVEF≤35%）的心肌梗死后患者，预防性植入式心脏复律除颤器（ICD）治疗已得到确立。然而，大多数心肌梗死后死亡的患者LVEF>35%。对于这一庞大的患者群体，不存在特定的预防策略。有强有力的证据表明，心肌梗死后心脏自主神经功能障碍的指标可为左心室射血分数保留的心肌梗死后患者提供重要的预后信息。自主神经标志物的组合可以识别心肌梗死后LVEF>35%的高危患者，其预后与LVEF≤35%的患者同样糟糕。正在进行的REFINE-ICD试验（NCT00673842）和SMART-MI试验（NCT02594488）在伴有心脏自主神经功能障碍且LVEF为36%-50%的心肌梗死后高危患者中测试不同的预防策略。虽然REFINE-ICD遵循ICD植入的传统概念，但SMART-MI使用具有远程监测功能的植入式心脏监测器，以灵敏地检测可能触发特定诊断和治疗干预的无症状但与预后相关的心律失常。
