Zeitler Emily P, Friedman Daniel J, Daubert James P, Al-Khatib Sana M, Solomon Scott D, Biton Yitschak, McNitt Scott, Zareba Wojciech, Moss Arthur J, Kutyifa Valentina
Cardiology Division, Duke University Hospital and Duke Clinical Research Institute, Durham, North Carolina.
Cardiology Division, Brigham and Women's Hospital, Boston, Massachusetts.
J Am Coll Cardiol. 2017 May 16;69(19):2369-2379. doi: 10.1016/j.jacc.2017.03.531.
Data regarding cardiac resynchronization therapy (CRT) in patients with multiple comorbidities are limited.
This study evaluated the association of multiple comorbidities with the benefits of CRT over implantable cardioverter-defibrillator (ICD) alone.
We examined 1,214 MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy) study patients with left bundle branch block (LBBB) and 0, 1, 2, or ≥3 comorbidities, including renal dysfunction, hypertension (HTN), diabetes, coronary artery disease, history of atrial arrhythmias, history of ventricular arrhythmias, current smoking, and cerebrovascular accident. In an adjusted analysis, we analyzed risk of heart failure (HF) events or death by comorbidity group in all patients and in patients with CRT with defibrillator (CRT-D) versus ICD. Then we examined percent change in left ventricular (LV) end-diastolic volume, LV end-systolic volume, LV ejection fraction, left atrial volume, and LV dyssynchrony at 1-year in CRT-D patients by comorbidity group.
There was an inverse relationship between comorbidity burden and improvements in LV end-systolic volume, LV end-diastolic volume, left ventricular ejection fraction, left atrial volume, and LV dyssynchrony. In an adjusted model, there was an increasing risk of death or nonfatal HF events with increasing comorbidity burden regardless of treatment group (p < 0.001). During a mean follow-up of 4.65 years, there was no interaction with respect to comorbidity burden and the benefit of CRT-D versus ICD only for death or nonfatal HF events (interaction p = 0.943). In the groups with greatest comorbidity burden (2 and ≥3), the absolute risk reduction associated with CRT-D over ICD alone appeared greater than that seen for groups with less comorbidity burden (0 and 1).
During long-term follow-up of MADIT-CRT study patients with LBBB randomized to CRT-D, there were differences in HF or death risk and in the degree of reverse remodeling among comorbidity groups. However, the burden of comorbidity does not appear to compromise the clinical benefits of CRT-D compared with ICD alone.
关于合并多种疾病患者的心脏再同步治疗（CRT）的数据有限。
本研究评估了多种合并症与CRT相对于单独植入式心脏复律除颤器（ICD）的获益之间的关联。
我们检查了1214例参加多中心自动除颤器植入试验（MADIT-CRT）且患有左束支传导阻滞（LBBB）的患者，这些患者合并0、1、2或≥3种疾病，包括肾功能不全、高血压（HTN）、糖尿病、冠状动脉疾病、房性心律失常病史、室性心律失常病史、当前吸烟情况和脑血管意外。在一项校正分析中，我们分析了所有患者以及接受带除颤器的CRT（CRT-D）与ICD治疗的患者中，按合并症分组的心力衰竭（HF）事件或死亡风险。然后，我们按合并症分组检查了CRT-D患者在1年时左心室（LV）舒张末期容积、LV收缩末期容积、LV射血分数、左心房容积和LV不同步性的百分比变化。
合并症负担与LV收缩末期容积、LV舒张末期容积、左心室射血分数、左心房容积和LV不同步性的改善之间呈负相关。在一个校正模型中，无论治疗组如何，随着合并症负担增加，死亡或非致命性HF事件的风险都会增加（p < 0.001）。在平均4.65年的随访期间，仅就死亡或非致命性HF事件而言，合并症负担与CRT-D相对于ICD的获益之间没有交互作用（交互作用p = 0.943）。在合并症负担最重的组（2种及≥3种）中，与单独使用ICD相比，CRT-D带来的绝对风险降低似乎大于合并症负担较轻的组（0种和1种）。
在对随机分配接受CRT-D治疗的MADIT-CRT研究中患有LBBB的患者进行长期随访期间，合并症组之间在HF或死亡风险以及逆向重构程度方面存在差异。然而，与单独使用ICD相比，合并症负担似乎并未损害CRT-D的临床获益。
