亚洲心力衰竭患者植入式心脏复律除颤器的适应证与实际应用之间的差异
Disparity Between Indications for and Utilization of Implantable Cardioverter Defibrillators in Asian Patients With Heart Failure.
作者信息
Chia Yvonne May Fen, Teng Tiew-Hwa Katherine, Tan Eugene S J, Tay Wan Ting, Richards A Mark, Chin Calvin Woon Loong, Shimizu Wataru, Park Sang Weon, Hung Chung-Lieh, Ling Lieng H, Ngarmukos Tachapong, Omar Razali, Siswanto Bambang B, Narasimhan Calambur, Reyes Eugene B, Yu Cheuk-Man, Anand Inder, MacDonald Michael R, Yap Jonathan, Zhang Shu, Finkelstein Eric A, Lam Carolyn S P
机构信息
From the Department of Medicine, Duke-NUS Medical School, Singapore (Y.M.F.C., C.W.L.C., E.A.F., C.S.P.L.); Department of Cardiology, National Heart Centre Singapore (T.-H.K.T., W.T.T., C.W.L.C., J.Y., C.S.P.L.); School of Population Health, The University of Western Australia, Perth (T.-H.K.T.); Department of Cardiology, National University Heart Centre Singapore (E.S.J.T., A.M.R., L.H.L.); Cardiovascular Research Institute, National University of Singapore (A.M.R., L.H.L., C.S.P.L.); Christchurch Heart Institute, University of Otago, New Zealand (A.M.R.); Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan (W.S.); Department of Cardiology, Sejong General Hospital, Bucheon, Korea (S.W.P.); Department of Cardiology, Mackay Memorial Hospital, Taipei, Taiwan (C.-L.H.); Department of Cardiovascular Disease, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.N.); National Heart Institute, Institut Jantung Negara, Kuala Lumpur, Malaysia (R.O.); Department of Cardiology, National Cardiovascular Center Universitas Indonesia, Jakarta (B.B.S.); Department of Cardiology, CARE Hospital, Hyderabad, Telangana, India (C.N.); Department of Cardiology, Manila Doctors Hospital, Philippines (E.B.R.); Department of Cardiology, Prince of Wales Hospital, The Chinese University of Hong Kong, The People's Republic of China (C.-M.Y.); Department of Cardiology, Hong Kong Baptist Hospital, The People's Republic of China (C.-M.Y.); Department of Cardiology, VA Medical Center, University of Minnesota, MN (I.A.); Department of Cardiology, Changi General Hospital, Singapore (M.R.M.); and Department of Cardiology, Fuwai Hospital, Beijing, China (S.Z.).
出版信息
Circ Cardiovasc Qual Outcomes. 2017 Nov;10(11). doi: 10.1161/CIRCOUTCOMES.116.003651.
BACKGROUND
Implantable cardioverter defibrillators (ICDs) are lifesaving devices for patients with heart failure (HF) and reduced ejection fraction. However, utilization and determinants of ICD insertion in Asia are poorly defined. We determined the utilization, associations of ICD uptake, patient-perceived barriers to device therapy and, impact of ICDs on mortality in Asian patients with HF.
METHODS AND RESULTS
Using the prospective ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) registry, 5276 patients with symptomatic HF and reduced ejection fraction (HFrEF) from 11 Asian regions and across 3 income regions (high: Hong Kong, Japan, Korea, Singapore, and Taiwan; middle: China, Malaysia, and Thailand; and low: India, Indonesia, and Philippines) were studied. ICD utilization, clinical characteristics, as well as device perception and knowledge, were assessed at baseline among ICD-eligible patients (EF ≤35% and New York Heart Association Class II-III). Patients were followed for the primary outcome of all-cause mortality. Among 3240 ICD-eligible patients (mean age 58.9±12.9 years, 79.1% men), 389 (12%) were ICD recipients. Utilization varied across Asia (from 1.5% in Indonesia to 52.5% in Japan) with a trend toward greater uptake in regions with government reimbursement for ICDs and lower out-of-pocket healthcare expenditure. ICD (versus non-ICD) recipients were more likely to be older (63±11 versus 58±13 year; <0.001), have tertiary (versus ≤primary) education (34.9% versus 18.1%; <0.001) and be residing in a high (versus low) income region (64.5% versus 36.5%; <0.001). Among 2000 ICD nonrecipients surveyed, 55% were either unaware of the benefits of, or needed more information on, device therapy. ICD implantation reduced risks of all-cause mortality (hazard ratio, 0.71; 95% confidence interval, 0.52-0.97) and sudden cardiac deaths (hazard ratio, 0.33; 95% confidence interval, 0.14-0.79) over a median follow-up of 417 days.
CONCLUSIONS
ICDs reduce mortality risk, yet utilization in Asia is low; with disparity across geographic regions and socioeconomic status. Better patient education and targeted healthcare reforms in extending ICD reimbursement may improve access.
CLINICAL TRIAL REGISTRATION
URL: https://clinicaltrials.gov/ct2/show/NCT01633398. Unique identifier: NCT01633398.
背景
植入式心脏复律除颤器（ICD）是用于心力衰竭（HF）且射血分数降低患者的挽救生命的设备。然而，亚洲地区ICD植入的利用率及决定因素尚不明确。我们确定了亚洲HF患者中ICD的利用率、植入ICD的相关因素、患者感知到的设备治疗障碍以及ICD对死亡率的影响。
方法与结果
利用前瞻性亚洲心力衰竭（亚洲心力衰竭患者心源性猝死）注册研究，对来自11个亚洲地区、跨越3个收入区域（高收入：中国香港、日本、韩国、新加坡和台湾；中等收入：中国、马来西亚和泰国；低收入：印度、印度尼西亚和菲律宾）的5276例有症状HF且射血分数降低（HFrEF）的患者进行了研究。在符合ICD植入条件的患者（射血分数≤35%且纽约心脏协会心功能分级为II - III级）基线时评估ICD利用率、临床特征以及对设备的认知和了解情况。对患者进行全因死亡率这一主要结局的随访。在3240例符合ICD植入条件的患者（平均年龄58.9±12.9岁，79.1%为男性）中，389例（12%）接受了ICD植入。亚洲各地的利用率有所不同（从印度尼西亚的1.5%到日本的52.5%），在有政府为ICD提供报销且自付医疗费用较低的地区，ICD植入率有升高趋势。接受ICD植入（与未接受ICD植入相比）的患者更可能年龄较大（63±11岁对58±13岁；<0.001）、接受过高等教育（与小学及以下教育程度相比）（34.9%对18.1%；<0.001）且居住在高收入（与低收入）地区（64.5%对36.5%；<0.001）。在接受调查的2000例未接受ICD植入的患者中，55%要么不了解设备治疗的益处，要么需要更多关于设备治疗的信息。在中位随访417天期间，ICD植入降低了全因死亡率（风险比，0.71；95%置信区间，0.52 - 0.97）和心源性猝死风险（风险比，0.33；95%置信区间，0.14 - 0.79）。
结论
ICD可降低死亡风险，但在亚洲的利用率较低；不同地理区域和社会经济状况存在差异。更好的患者教育以及在扩大ICD报销方面有针对性的医疗改革可能会改善可及性。
临床试验注册
网址：https://clinicaltrials.gov/ct2/show/NCT01633398。唯一标识符：NCT01633398。
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