预测左心室逆向重构缺失的风险评分：对一级预防中植入式心律转复除颤器植入时机的影响
A risk score to predict the absence of left ventricular reverse remodeling: Implications for the timing of ICD implantation in primary prevention.
作者信息
Pérez-Rodon Jordi, Galve Enrique, Pérez-Bocanegra Carmen, Soriano-Sánchez Teresa, Recio-Iglesias Jesús, Domingo-Baldrich Eva, Alzola-Guevara Mila, Ferreira-González Ignacio, Marsal Josep Ramon, Ribera-Solé Aida, Gutierrez García-Moreno Laura, Cruz-Carlos Luz María, Rivas-Gandara Nuria, Roca-Luque Ivo, Francisco-Pascual Jaume, Evangelista-Masip Artur, Moya-Mitjans Àngel, García-Dorado David
机构信息
Hospital Universitari Vall d'Hebrón, Department of Cardiology, Universitat Autònoma de Barcelona, Vall d'Hebrón Institut de Recerca, CIBER-CV, Barcelona, Spain.
Hospital Universitari Vall d'Hebrón, Department of Cardiology, Universitat Autònoma de Barcelona, Vall d'Hebrón Institut de Recerca, CIBER-CV, Barcelona, Spain.
出版信息
J Cardiol. 2018 May;71(5):505-512. doi: 10.1016/j.jjcc.2017.10.019. Epub 2017 Nov 26.
BACKGROUND
A prophylactic implantable cardioverter defibrillator (ICD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) is only indicated when left ventricular ejection fraction (LVEF) reassessment remains ≤35% after 3-6 months on optimal pharmacological therapy. However, LVEF may not improve during this period and the patient may be exposed to an unnecessary risk of sudden cardiac death. This study aimed to determine the incidence and predictors of the absence of left ventricular reverse remodeling (LVRR) after pharmacological treatment optimization in patients with HFrEF to design a risk score of absence of LVRR.
METHODS
Consecutive outpatients with LVEF ≤35% were included in this observational prospective study. Up-titration of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine was performed in our Heart Failure (HF) Unit. The absence of LVRR was defined as the persistence of an LVEF ≤35% at the 6-month follow-up.
RESULTS
One hundred and twenty patients were included. At the 6-month follow-up, 64%, 76%, 72%, and 7% of patients were at 100% of the target dose of ACE inhibitors/ARBs, beta-blockers, MRAs, and ivabradine, respectively. LVRR was observed in 48% of the patients. Ischemic cardiomyopathy, prolonged HF duration, and larger left ventricular end-diastolic diameter index (LVEDDI) were independent predictors of the absence of LVRR. The risk score based on these predictors showed a c-statistic value of 0.81.
CONCLUSIONS
Pharmacological treatment optimization is associated with LVRR in approximately half of cases, reducing potential ICD indications in parallel. However, ischemic cardiomyopathy, prolonged HF duration, and larger LVEDDI predict the absence of LVRR and favor ICD implantation without delay. The risk score based on the former predictors may help the clinician with the timing of ICD implantation.
背景
对于心力衰竭且左心室射血分数降低（HFrEF）的患者，仅在经过3至6个月的最佳药物治疗后左心室射血分数（LVEF）重新评估仍≤35%时，才考虑植入预防性心脏复律除颤器（ICD）。然而，在此期间LVEF可能不会改善，患者可能会面临不必要的心脏性猝死风险。本研究旨在确定HFrEF患者在优化药物治疗后左心室逆向重构（LVRR）未出现的发生率及预测因素，以设计LVRR未出现的风险评分。
方法
本观察性前瞻性研究纳入了连续的LVEF≤35%的门诊患者。在我们的心力衰竭（HF）单元对血管紧张素转换酶（ACE）抑制剂/血管紧张素II受体阻滞剂（ARB）、β受体阻滞剂、盐皮质激素受体拮抗剂（MRA）和伊伐布雷定进行了剂量上调。LVRR未出现定义为在6个月随访时LVEF持续≤35%。
结果
共纳入120例患者。在6个月随访时，分别有64%、76%、72%和7%的患者达到ACE抑制剂/ARB、β受体阻滞剂、MRA和伊伐布雷定目标剂量的100%。48%的患者观察到LVRR。缺血性心肌病、HF病程延长和较大的左心室舒张末期直径指数（LVEDDI）是LVRR未出现的独立预测因素。基于这些预测因素的风险评分的c统计值为0.81。
结论
在大约一半的病例中，优化药物治疗与LVRR相关，同时减少了潜在的ICD植入指征。然而，缺血性心肌病、HF病程延长和较大的LVEDDI预示LVRR未出现，支持及时植入ICD。基于前几个预测因素的风险评分可能有助于临床医生确定ICD植入的时机。
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