Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Massachusetts General Hospital, Harvard Medical School, Boston.
JAMA Cardiol. 2018 Jul 1;3(7):591-600. doi: 10.1001/jamacardio.2018.1049.
The majority of sudden and/or arrhythmic deaths (SAD) in patients with coronary heart disease occur in those without severe systolic dysfunction, for whom strategies for sudden death prevention are lacking.
To provide contemporary estimates of SAD vs other competing causes of death in patients with coronary heart disease without severe systolic dysfunction to search for high-risk subgroups that might be targeted in future trials of SAD prevention.
DESIGN, SETTING, AND PARTICIPANTS: This prospective observational cohort study included 135 clinical sites in the United States and Canada. A total of 5761 participants with coronary heart disease who did not qualify for primary prevention implantable cardioverter defibrillator therapy based on left ventricular ejection fraction (LVEF) of more than 35% or New York Heart Association (NYHA) heart failure class (LVEF >30%, NYHA I).
Clinical risk factors measured at baseline including age, LVEF, and NYHA heart failure class.
Primary outcome of SAD, which is a composite of SAD and resuscitated ventricular fibrillation arrest.
The mean (SD) age of the cohort was 64 (11) years. During a median of 3.9 years, the cumulative incidence of SAD and non-SAD was 2.1% and 7.7%, respectively. Sudden and/or arrhythmic death was the most common mode of cardiovascular death accounting for 114 of 202 cardiac deaths (56%), although noncardiac death was the primary mode of death in this population. The 4-year cumulative incidence of SAD was lowest in those with an LVEF of more than 60% (1.0%) and highest among those with LVEF of 30% to 40% (4.9%) and class III/IV heart failure (5.1%); however, the cumulative incidence of non-SAD was similarly elevated in these latter high-risk subgroups. Patients with a moderately reduced LVEF (40%-49%) were more likely to die of SAD, whereas those with class II heart failure and advancing age were more likely to die of non-SAD. The proportion of deaths due to SAD varied widely, from 14% (18 of 131 deaths) in patients with NYHA II to 49% (37 of 76 deaths) in those younger than 60 years.
In a contemporary population of patients with coronary heart disease without severe systolic dysfunction, SAD accounts for a significant proportion of overall mortality. Moderately reduced LVEF, age, and NYHA class distinguished SAD and non-SAD, whereas other markers were equally associated with both modes of death. Absolute and proportional risk of SAD varied significantly across clinical subgroups, and both will need to be maximized in future risk stratification efforts.
大多数患有冠心病的突发和/或心律失常性死亡（SAD）发生在没有严重收缩功能障碍的患者中，这些患者缺乏预防猝死的策略。
提供无严重收缩功能障碍的冠心病患者 SAD 与其他死亡竞争原因的当代估计值，以寻找可能成为未来 SAD 预防试验目标的高危亚组。
设计、地点和参与者：这是一项在美国和加拿大的 135 个临床地点进行的前瞻性观察队列研究。共有 5761 名患有冠心病的患者参加了研究，他们不符合基于左心室射血分数（LVEF）大于 35%或纽约心脏协会（NYHA）心力衰竭分级（LVEF>30%，NYHA I）的原发性预防植入式心脏复律除颤器治疗的标准。
基线时测量的临床危险因素包括年龄、LVEF 和 NYHA 心力衰竭分级。
SAD 的主要结局，是 SAD 和复苏性室颤骤停的复合结局。
队列的平均（标准差）年龄为 64±11 岁。在中位数为 3.9 年的随访期间，SAD 和非-SAD 的累积发生率分别为 2.1%和 7.7%。SAD 是心血管死亡的最常见模式，占 202 例心脏死亡中的 114 例（56%），尽管在这一人群中，非心脏性死亡是主要的死亡模式。LVEF 大于 60%的患者 4 年累积 SAD 发生率最低（1.0%），LVEF 为 30%至 40%和 III/IV 级心力衰竭的患者最高（4.9%和 5.1%）；然而，这些高风险亚组的非 SAD 累积发生率也同样升高。LVEF 中度降低（40%-49%）的患者更有可能死于 SAD，而 II 级心力衰竭和年龄较大的患者更有可能死于非 SAD。SAD 导致的死亡比例差异很大，从 NYHA II 的 14%（131 例死亡中的 18 例）到 60 岁以下患者的 49%（76 例死亡中的 37 例）。
在无严重收缩功能障碍的冠心病当代患者人群中，SAD 占总死亡率的很大比例。中度降低的 LVEF、年龄和 NYHA 分级区分了 SAD 和非 SAD，而其他标志物与这两种死亡模式同样相关。SAD 的绝对和相对风险在临床亚组之间有显著差异，在未来的风险分层工作中都需要将其最大化。
