非缺血性收缩性心力衰竭患者一级预防植入型心律转复除颤器的年龄和结局。
Age and Outcomes of Primary Prevention Implantable Cardioverter-Defibrillators in Patients With Nonischemic Systolic Heart Failure.
机构信息
From Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark (M.B.E., F.G., R.V., C.H., J.H.S., D.E.H., S.P., L.K., J.J.T.); Department of Cardiology, Aarhus University Hospital, Denmark (J.C.N., H.E.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark (J.H., N.E.B.); Department of Cardiology, Odense University Hospital, Denmark (L.V., A.B.); Department of Health, Science and Technology (E.K., A.M.T., C.T.-P.) and Clinical Institute (N.E.B.), Aalborg University, Denmark; Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Denmark (E.K., A.M.T., C.T.-P.); Analysis Group Inc, Boston, MA (J.S.); Department of Cardiology, Zealand University Hospital, Roskilde, Denmark (L.L.O.); Frederiksberg Heart Clinic, Denmark (P.H.); Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark (F.H.S.); Department of Cardiology, Odense University Hospital, Svendborg, Denmark (K.E.); and Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark (J.J.T.).
出版信息
Circulation. 2017 Nov 7;136(19):1772-1780. doi: 10.1161/CIRCULATIONAHA.117.028829. Epub 2017 Sep 6.
BACKGROUND
The DANISH study (Danish Study to Assess the Efficacy of ICDs [Implantable Cardioverter Defibrillators] in Patients With Non-Ischemic Systolic Heart Failure on Mortality) did not demonstrate an overall effect on all-cause mortality with ICD implantation. However, the prespecified subgroup analysis suggested a possible age-dependent association between ICD implantation and mortality with survival benefit seen only in the youngest patients. The nature of this relationship between age and outcome of a primary prevention ICD in patients with nonischemic systolic heart failure warrants further investigation.
METHODS
All 1116 patients from the DANISH study were included in this prespecified subgroup analysis. We assessed the relationship between ICD implantation and mortality by age, and an optimal age cutoff was estimated nonparametrically with selection impact curves. Modes of death were divided into sudden cardiac death and nonsudden death and compared between patients younger and older than this age cutoff with the use of χ analysis.
RESULTS
Median age of the study population was 63 years (range, 21-84 years). There was a linearly decreasing relationship between ICD and mortality with age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.003-1.06; =0.03). An optimal age cutoff for ICD implantation was present at ≤70 years. There was an association between reduced all-cause mortality and ICD in patients ≤70 years of age (HR, 0.70; 95% CI, 0.51-0.96; =0.03) but not in patients >70 years of age (HR, 1.05; 95% CI, 0.68-1.62; =0.84). For patients ≤70 years old, the sudden cardiac death rate was 1.8 (95% CI, 1.3-2.5) and nonsudden death rate was 2.7 (95% CI, 2.1-3.5) events per 100 patient-years, whereas for patients >70 years old, the sudden cardiac death rate was 1.6 (95% CI, 0.8-3.2) and nonsudden death rate was 5.4 (95% CI, 3.7-7.8) events per 100 patient-years. This difference in modes of death between the 2 age groups was statistically significant (=0.01).
CONCLUSIONS
In patients with systolic heart failure not caused by ischemic heart disease, the association between the ICD and survival decreased linearly with increasing age. In this study population, an age cutoff for ICD implantation at ≤70 years yielded the highest survival for the population as a whole.
CLINICAL TRIAL REGISTRATION
URL: https://www.clinicaltrials.gov. Unique identifier: NCT00542945.
背景
丹麦研究（丹麦评估 ICD 对非缺血性收缩性心力衰竭患者死亡率影响的研究）并未显示 ICD 植入对全因死亡率有总体影响。然而，预设的亚组分析表明，ICD 植入与死亡率之间可能存在年龄依赖性关联，只有最年轻的患者才能看到生存获益。在非缺血性收缩性心力衰竭患者中，初级预防 ICD 的年龄与结局之间的这种关系性质需要进一步研究。
方法
本预设亚组分析纳入了丹麦研究中的所有 1116 名患者。我们通过年龄评估 ICD 植入与死亡率之间的关系，并使用选择影响曲线非参数估计最佳年龄截止值。将死亡模式分为心源性猝死和非心源性猝死，并使用 χ 检验比较年龄截止值以下和以上患者之间的死亡模式。
结果
研究人群的中位年龄为 63 岁（范围，21-84 岁）。ICD 与年龄之间存在线性降低的关系（风险比[HR]，1.03；95%置信区间[CI]，1.003-1.06；=0.03）。ICD 植入的最佳年龄截止值为≤70 岁。在≤70 岁的患者中，ICD 与全因死亡率降低相关（HR，0.70；95%CI，0.51-0.96；=0.03），但在>70 岁的患者中则无相关性（HR，1.05；95%CI，0.68-1.62；=0.84）。对于≤70 岁的患者，心源性猝死率为 1.8（95%CI，1.3-2.5），非心源性猝死率为 2.7（95%CI，2.1-3.5）/100 患者年，而对于>70 岁的患者，心源性猝死率为 1.6（95%CI，0.8-3.2），非心源性猝死率为 5.4（95%CI，3.7-7.8）/100 患者年。这两个年龄组之间的死亡模式差异具有统计学意义（=0.01）。
结论
在非缺血性收缩性心力衰竭患者中，ICD 与生存之间的关联随年龄的增加呈线性下降。在本研究人群中，ICD 植入的年龄截止值为≤70 岁，可使整个人群的生存率达到最高。
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