扩张型心肌病伴轻中度左心室收缩功能障碍患者中壁晚期钆增强与心源性猝死的关联

Association Between Midwall Late Gadolinium Enhancement and Sudden Cardiac Death in Patients With Dilated Cardiomyopathy and Mild and Moderate Left Ventricular Systolic Dysfunction.

作者信息

Halliday Brian P, Gulati Ankur, Ali Aamir, Guha Kaushik, Newsome Simon, Arzanauskaite Monika, Vassiliou Vassilios S, Lota Amrit, Izgi Cemil, Tayal Upasana, Khalique Zohya, Stirrat Colin, Auger Dominique, Pareek Nilesh, Ismail Tevfik F, Rosen Stuart D, Vazir Ali, Alpendurada Francisco, Gregson John, Frenneaux Michael P, Cowie Martin R, Cleland John G F, Cook Stuart A, Pennell Dudley J, Prasad Sanjay K

机构信息

From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.).

出版信息

Circulation. 2017 May 30;135(22):2106-2115. doi: 10.1161/CIRCULATIONAHA.116.026910. Epub 2017 Mar 28.

DOI:10.1161/CIRCULATIONAHA.116.026910

PMID:28351901

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5444425/

Abstract

BACKGROUND

Current guidelines only recommend the use of an implantable cardioverter defibrillator in patients with dilated cardiomyopathy for the primary prevention of sudden cardiac death (SCD) in those with a left ventricular ejection fraction (LVEF) <35%. However, registries of out-of-hospital cardiac arrests demonstrate that 70% to 80% of such patients have an LVEF >35%. Patients with an LVEF >35% also have low competing risks of death from nonsudden causes. Therefore, those at high risk of SCD may gain longevity from successful implantable cardioverter defibrillator therapy. We investigated whether late gadolinium enhancement (LGE) cardiovascular magnetic resonance identified patients with dilated cardiomyopathy without severe LV systolic dysfunction at high risk of SCD.

METHODS

We prospectively investigated the association between midwall LGE and the prespecified primary composite outcome of SCD or aborted SCD among consecutive referrals with dilated cardiomyopathy and an LVEF ≥40% to our center between January 2000 and December 2011 who did not have a preexisting indication for implantable cardioverter defibrillator implantation.

RESULTS

Of 399 patients (145 women, median age 50 years, median LVEF 50%, 25.3% with LGE) followed for a median of 4.6 years, 18 of 101 (17.8%) patients with LGE reached the prespecified end point, compared with 7 of 298 (2.3%) without (hazard ratio [HR], 9.2; 95% confidence interval [CI], 3.9-21.8; <0.0001). Nine patients (8.9%) with LGE compared with 6 (2.0%) without (HR, 4.9; 95% CI, 1.8-13.5; =0.002) died suddenly, whereas 10 patients (9.9%) with LGE compared with 1 patient (0.3%) without (HR, 34.8; 95% CI, 4.6-266.6; <0.001) had aborted SCD. After adjustment, LGE predicted the composite end point (HR, 9.3; 95% CI, 3.9-22.3; <0.0001), SCD (HR, 4.8; 95% CI, 1.7-13.8; =0.003), and aborted SCD (HR, 35.9; 95% CI, 4.8-271.4; <0.001). Estimated HRs for the primary end point for patients with an LGE extent of 0% to 2.5%, 2.5% to 5%, and >5% compared with those without LGE were 10.6 (95% CI, 3.9-29.4), 4.9 (95% CI, 1.3-18.9), and 11.8 (95% CI, 4.3-32.3), respectively.

CONCLUSIONS

Midwall LGE identifies a group of patients with dilated cardiomyopathy and an LVEF ≥40% at increased risk of SCD and low risk of nonsudden death who may benefit from implantable cardioverter defibrillator implantation.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00930735.

摘要

背景

目前的指南仅推荐在左心室射血分数（LVEF）<35%的扩张型心肌病患者中使用植入式心脏复律除颤器，用于心脏性猝死（SCD）的一级预防。然而，院外心脏骤停登记显示，70%至80%的此类患者LVEF>35%。LVEF>35%的患者非心脏性猝死的竞争风险也较低。因此，SCD高危患者可能从成功的植入式心脏复律除颤器治疗中延长寿命。我们研究延迟钆增强（LGE）心血管磁共振是否能识别出无严重左心室收缩功能障碍的扩张型心肌病患者中SCD的高危患者。

方法

我们前瞻性研究了2000年1月至2011年12月期间连续转诊至我们中心、LVEF≥40%且无植入式心脏复律除颤器植入既往指征的扩张型心肌病患者中，心肌中层LGE与SCD或SCD未遂这一预先设定的主要复合结局之间的关联。

结果

399例患者（145例女性，中位年龄50岁，中位LVEF 50%，25.3%有LGE）中位随访4.6年，101例有LGE的患者中有18例（17.8%）达到预先设定的终点，而298例无LGE的患者中有7例（2.3%）达到（风险比[HR]，9.2；95%置信区间[CI]，3.9 - 21.8；<0.0001）。有LGE的患者中有9例（8.9%）猝死，无LGE的患者中有6例（2.0%）猝死（HR，4.9；95% CI，1.8 - 13.5；=0.002），而有LGE的患者中有10例（9.9%）发生SCD未遂，无LGE的患者中有1例（0.3%）发生SCD未遂（HR，34.8；95% CI，4.6 - 266.6；<0.001）。调整后，LGE可预测复合终点（HR，9.3；95% CI，3.9 - 22.3；<0.0001）、SCD（HR，4.8；95% CI，1.7 - 13.8；=0.003）和SCD未遂（HR，35.9；95% CI，4.8 - 271.4；<0.001）。LGE范围为0%至2.5%、2.5%至5%和>5%的患者与无LGE的患者相比，主要终点的估计HR分别为10.6（95% CI，3.9 - 29.4）、4.9（95% CI，1.3 - 18.9）和11.8（95% CI，4.3 - 32.3）。