Denver Health Medical Center, Denver, CO
University of Colorado Denver Anschutz Medical Campus, Aurora, CO.
J Am Heart Assoc. 2017 Nov 9;6(11):e006937. doi: 10.1161/JAHA.117.006937.
In US clinical practice, many patients who undergo placement of an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death receive dual-chamber devices. The superiority of dual-chamber over single-chamber devices in reducing the risk of inappropriate ICD shocks in clinical practice has not been established. The objective of this study was to compare risk of adverse outcomes, including inappropriate shocks, between single- and dual-chamber ICDs for primary prevention.
We identified patients receiving a single- or dual-chamber ICD for primary prevention who did not have an indication for pacing from 15 hospitals within 7 integrated health delivery systems in the Longitudinal Study of Implantable Cardioverter-Defibrillators from 2006 to 2009. The primary outcome was time to first inappropriate shock. ICD shocks were adjudicated for appropriateness. Other outcomes included all-cause hospitalization, heart failure hospitalization, and death. Patient, clinician, and hospital-level factors were accounted for using propensity score weighting methods. Among 1042 patients without pacing indications, 54.0% (n=563) received a single-chamber device and 46.0% (n=479) received a dual-chamber device. In a propensity-weighted analysis, device type was not significantly associated with inappropriate shock (hazard ratio, 0.91; 95% confidence interval, 0.59-1.38 [=0.65]), all-cause hospitalization (hazard ratio, 1.03; 95% confidence interval, 0.87-1.21 [=0.76]), heart failure hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.72-1.21 [=0.59]), or death (hazard ratio, 1.19; 95% confidence interval, 0.93-1.53 [=0.17]).
Among patients who received an ICD for primary prevention without indications for pacing, dual-chamber devices were not associated with lower risk of inappropriate shock or differences in hospitalization or death compared with single-chamber devices. This study does not justify the use of dual-chamber devices to minimize inappropriate shocks.
在美国临床实践中，许多因预防心源性猝死而植入植入式心律转复除颤器（ICD）的患者会接受双腔设备。在临床实践中，双腔设备降低不适当 ICD 电击风险的优势尚未得到证实。本研究的目的是比较单腔和双腔 ICD 在预防原发性疾病中的不良结局（包括不适当电击）风险。
我们从 2006 年至 2009 年期间在 7 个综合医疗服务系统的 15 家医院中，确定了因预防原发性疾病而未因起搏指征接受单腔或双腔 ICD 的患者。主要结局是首次发生不适当电击的时间。对 ICD 电击进行了适宜性判定。其他结局包括全因住院、心力衰竭住院和死亡。使用倾向评分加权方法考虑了患者、临床医生和医院层面的因素。在 1042 名无起搏指征的患者中，54.0%（n=563）接受了单腔装置，46.0%（n=479）接受了双腔装置。在倾向评分加权分析中，装置类型与不适当电击（风险比，0.91；95%置信区间，0.59-1.38[=0.65]）、全因住院（风险比，1.03；95%置信区间，0.87-1.21[=0.76]）、心力衰竭住院（风险比，0.93；95%置信区间，0.72-1.21[=0.59]）或死亡（风险比，1.19；95%置信区间，0.93-1.53[=0.17]）均无显著相关性。
在因预防原发性疾病而植入 ICD 且无起搏指征的患者中，与单腔装置相比，双腔装置并未降低不适当电击风险或在住院或死亡方面存在差异。本研究不能证明使用双腔装置以最小化不适当电击的合理性。
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