Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
Cardiology Department, Clinique Pasteur, Toulouse, France.
J Am Coll Cardiol. 2017 Apr 4;69(13):1669-1678. doi: 10.1016/j.jacc.2017.01.042.
Patients with nonischemic dilated cardiomyopathy (DCM) may be at lower risk for ventricular arrhythmias compared with those with ischemic cardiomyopathy (ICM). In addition, DCM has been identified as a predictor of positive response to cardiac resynchronization therapy (CRT).
The aim of this study was to investigate the impact of an additional implantable cardioverter-defibrillator over CRT, according to underlying heart disease, in a large study group of primary prevention patients with heart failure.
This was an observational, multicenter, European cohort study of 5,307 consecutive patients with DCM or ICM, no history of sustained ventricular arrhythmias, who underwent CRT implantation with (n = 4,037) or without (n = 1,270) a defibrillator. Propensity-score and cause-of-death analyses were used to compare outcomes.
After a mean follow-up period of 41.4 ± 29.0 months, patients with ICM had better survival when receiving CRT with a defibrillator compared with those who received CRT without a defibrillator (hazard ratio for mortality adjusted on propensity score and all mortality predictors: 0.76; 95% confidence interval [CI]: 0.62 to 0.92; p = 0.005), whereas in patients with DCM, no such difference was observed (hazard ratio: 0.92; 95% CI: 0.73 to 1.16; p = 0.49). Compared with recipients of defibrillators, the excess mortality in patients who did not receive defibrillators was related to sudden cardiac death in 8.0% among those with ICM but in only 0.4% of those with DCM.
Among patients with heart failure with indications for CRT, those with DCM may not benefit from additional primary prevention implantable cardioverter-defibrillator therapy, as opposed to those with ICM.
与缺血性心肌病（ICM）患者相比，非缺血性扩张型心肌病（DCM）患者发生室性心律失常的风险可能较低。此外，DCM 已被确定为心脏再同步治疗（CRT）阳性反应的预测因子。
本研究旨在调查在心力衰竭的大型一级预防患者群体中，根据潜在心脏病，在 CRT 基础上增加植入式心脏复律除颤器（ICD）对患者的影响。
这是一项观察性、多中心、欧洲队列研究，纳入了 5307 例连续的 DCM 或 ICM 患者，这些患者无持续性室性心律失常病史，接受了 CRT 植入治疗（n=4037）或未接受（n=1270）ICD。采用倾向评分和死因分析来比较结果。
在平均 41.4±29.0 个月的随访期间，与接受 CRT 而未接受 ICD 的患者相比，ICM 患者接受 CRT 并联合 ICD 治疗时的存活率更好（死亡率校正后调整倾向评分和所有死亡率预测因素的风险比：0.76；95%置信区间[CI]：0.62 至 0.92；p=0.005），而在 DCM 患者中，未观察到这种差异（风险比：0.92；95% CI：0.73 至 1.16；p=0.49）。与接受 ICD 的患者相比，未接受 ICD 的患者的死亡率增加与 ICM 患者中的心脏性猝死相关（8.0%），但在 DCM 患者中仅为 0.4%。
在有 CRT 适应证的心力衰竭患者中，与 ICM 患者相反，DCM 患者可能不能从 CRT 基础上的 ICD 一级预防治疗中获益。
