Bakos Z, Chatterjee N C, Reitan C, Singh J P, Borgquist R
Department of Clinical Sciences, Arrhythmia section, Lund University, Skane University Hospital, Lund, Sweden.
Division of Cardiology, Massachusetts General Hospital, Boston, USA.
BMC Cardiovasc Disord. 2018 Apr 24;18(1):70. doi: 10.1186/s12872-018-0802-8.
Cardiac resynchronization therapy (CRT) is an established therapy for appropriately selected patients with heart failure. Response to CRT has been heterogeneously defined using both clinical and echocardiographic measures, with poor correlation between the two.
The study cohort was comprised of 202 CRT-treated patients and CRT response was defined at 6 months post-implant. Echocardiographic response (E+) was defined as a reduction in LVESV ≥ 15%, clinical response as an improvement of ≥ 1 NYHA class (C+), and biomarker response as a ≥ 25% reduction in NT-proBNP(B+). The association of response measures (E+, B+, C+; response score range 0-3) and clinical endpoints at 3 years was assessed in landmarked Cox models.
Echo and clinical responders demonstrated greater declines in NT-proBNP than non-responders (median [E+/B+]: -52%, [E+]: -27%, [C+]: -39% and [E-/C-]: -13%; p = 0.01 for trend). Biomarker (HR 0.43 [95% CI: 0.22-0.86], p = 0.02) and clinical (HR 0.40 [0.23-0.70] p = 0.001) response were associated with a significantly reduced risk of the primary endpoint. When integrating each response measure into a composite score, each 1 point increase was associated with a 31% decreased risk for a composite endpoint of mortality, LVAD, transplant and HF hospitalization (HR 0.69 [95% CI: 0.50-0.96], p = 0.03), and a 52% decreased risk of all-cause mortality (HR 0.48 [95% CI: 0.26-0.89], p = 0.02).
Serial changes in NT-proBNP are associated with clinical outcomes following CRT implant. Integration of biomarker, clinical, and echocardiographic response may discriminate CRT responders versus non-responders in a clinically meaningful way, and with higher accuracy.
The cohort was combined from study NCT01949246 and the study based on local review board approval 2011/550 in Lund, Sweden.
心脏再同步治疗（CRT）是针对经适当选择的心力衰竭患者的一种既定疗法。使用临床和超声心动图测量方法对CRT反应的定义存在异质性，两者之间的相关性较差。
研究队列由202例接受CRT治疗的患者组成，CRT反应定义为植入后6个月时的反应。超声心动图反应（E+）定义为左室舒张末期容积（LVESV）降低≥15%，临床反应定义为纽约心脏协会（NYHA）心功能分级改善≥1级（C+），生物标志物反应定义为N末端脑钠肽前体（NT-proBNP）降低≥25%（B+）。在有标志性的Cox模型中评估反应测量指标（E+、B+、C+；反应评分范围0 - 3）与3年时临床终点的关联。
超声心动图和临床反应者的NT-proBNP下降幅度大于无反应者（中位数[E+/B+]：-52%，[E+]：-27%，[C+]：-39%，[E-/C-]：-13%；趋势p = 0.01）。生物标志物（风险比[HR] 0.43 [95%置信区间：0.22 - 0.86]，p = 0.02）和临床（HR 0.40 [0.23 - 0.70]，p = 0.001）反应与主要终点风险显著降低相关。当将每个反应测量指标整合为一个综合评分时，综合评分每增加1分，死亡、左心室辅助装置（LVAD）植入、心脏移植和心力衰竭住院的综合终点风险降低31%（HR 0.69 [95%置信区间：0.50 - 0.96]，p = 0.03），全因死亡率风险降低52%（HR 0.48 [95%置信区间：0.26 - 0.89]，p = 0.02）。
CRT植入后NT-proBNP的系列变化与临床结局相关。整合生物标志物、临床和超声心动图反应可能以具有临床意义且准确性更高的方式区分CRT反应者和无反应者。
该队列由研究NCT01949246以及基于瑞典隆德当地伦理审查委员会批准号2011/550的研究合并而成。
