Sherazi Saadia, Kutyifa Valentina, McNitt Scott, Aktas Mehmet K, Couderc Jean-Philippe, Peterson Benjamin, Bloch Thomsen Poul Erik, Kautzner Joseph, Moss Arthur J, Zareba Wojciech
Cardiology Division, Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, New York.
Cardiology Division, Heart Research Follow-up Program, University of Rochester Medical Center, Rochester, New York.
JACC Clin Electrophysiol. 2015 Mar-Apr;1(1-2):74-80. doi: 10.1016/j.jacep.2015.03.004. Epub 2015 Apr 20.
This study sought to evaluate the prognostic value of heart rate variability (HRV) for death or heart failure in patients with mildly symptomatic heart failure undergoing cardiac resynchronization therapy with a defibrillator (CRT-D).
There are limited data regarding the prognostic value of HRV as a means of identifying high-risk patients treated with CRT-D.
We analyzed the relationship between pre-implant time-domain (SD of all normal-to-normal RR intervals [SDNN], SDs of averaged 5-min normal-to-normal RR intervals, root mean square of successive differences, and mean of the SDs of all normal-to-normal RR intervals for all 5-min segments of the entire recording), and frequency-domain (low-frequency power, very-low-frequency power [VLF], high-frequency power, low-frequency power/low-frequency power ratio) HRV parameters, and the end point of death or heart failure and death alone. Study subjects include 719 patients in normal sinus rhythm enrolled in MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy); outcomes of CRT-D patients with low HRV (lower tertile) were compared with CRT-D patients with preserved HRV (2 upper tertiles) and with patients receiving implantable cardioverter-defibrillators only.
During a mean 3.4 ± 0.9 years of follow-up, 124 patients reached the primary end point of death or heart failure, and 47 died. In multivariate analysis, low SDNN (≤93 ms) was associated with significantly higher risk of death or heart failure (hazard ratio [HR] 1.63 [95% confidence interval (CI): 1.12 to 2.36]; p = 0.010) and mortality (HR 2.10 [95% CI: 1.14 to 3.87]; p = 0.017) compared with higher SDNN (>93 ms). Similarly, low VLF (≤179 ms) was associated with an increased risk of death or heart failure (HR 2.14 [95% CI: 1.46 to 3.13]; p < 0.001) and death alone (HR 2.49 [95% CI: 1.35 to 4.57]; p = 0.003). There was no significant difference in outcome between low HRV patients treated with CRT-D and patients receiving an implantable cardioverter-defibrillator only.
Our findings indicate that autonomic dysfunction (quantified by low SDNN and low VLF) identified patients with no benefit or limited benefit from cardiac resynchronization therapy. Pre-implant HRV analysis might help in optimizing qualifications for this treatment.
本研究旨在评估心率变异性（HRV）对接受心脏再同步化治疗除颤器（CRT-D）的轻度症状性心力衰竭患者死亡或心力衰竭的预后价值。
关于HRV作为识别接受CRT-D治疗的高危患者的一种手段的预后价值的数据有限。
我们分析了植入前时域（所有正常RR间期的标准差[SDNN]、平均5分钟正常RR间期的标准差、连续差值的均方根以及整个记录的所有5分钟段的所有正常RR间期标准差的平均值）和频域（低频功率、极低频功率[VLF]、高频功率、低频功率/高频功率比值）HRV参数与死亡或心力衰竭以及单独死亡终点之间的关系。研究对象包括719例窦性心律正常的患者，这些患者参加了MADIT-CRT（多中心自动除颤器植入试验-心脏再同步治疗）；将HRV较低（三分位数下限）的CRT-D患者的结局与HRV保留（三分位数上限）的CRT-D患者以及仅接受植入式心脏复律除颤器的患者进行比较。
在平均3.4±0.9年的随访期间，124例患者达到了死亡或心力衰竭的主要终点，47例死亡。在多变量分析中，与较高的SDNN（>93 ms）相比，低SDNN（≤93 ms）与死亡或心力衰竭的风险显著更高（风险比[HR] 1.63 [95%置信区间（CI）：1.12至2.36]；p = 0.010）以及死亡率（HR 2.10 [95% CI：1.14至3.87]；p = 0.017）相关。同样，低VLF（≤179 ms）与死亡或心力衰竭的风险增加（HR 2.14 [95% CI：1.46至3.13]；p < 0.001）以及单独死亡（HR 2.49 [95% CI：1.35至4.57]；p = 0.003）相关。接受CRT-D治疗的低HRV患者与仅接受植入式心脏复律除颤器的患者在结局上没有显著差异。
我们的研究结果表明，自主神经功能障碍（通过低SDNN和低VLF量化）可识别出从心脏再同步治疗中无获益或获益有限的患者。植入前HRV分析可能有助于优化该治疗的入选标准。
