Hospital das Clínicas and Faculdade de Medicina, Universidade Federal de Minas Gerais, Minas Gerais, Brazil.
Arrhythmia & Electrophysiology Service, Hospital San Vicente de Paul, Medellin, Colombia.
Int J Cardiol. 2018 Sep 15;267:88-93. doi: 10.1016/j.ijcard.2018.05.091. Epub 2018 May 29.
In patients with Chagas cardiomyopathy (ChCM), sudden cardiac death (SCD) is the leading cause of mortality. Implantable cardioverter-defibrillator (ICD) is a well-established therapy for secondary prevention in patients with structural heart disease, but there are conflicting opinions regarding its efficacy and safety in patients with ChCM. The aim of this meta-analysis was to assess the efficacy of the ICD for secondary prevention in patients with ChCM, comparing mortality as the primary outcome of patients treated with ICD with those treated with amiodarone.
We systematically searched five databases for studies assessing mortality outcomes in patients with ChCM and sustained ventricular tachycardia (VT) treated with ICD implantation or with amiodarone. The results of studies were pooled using random-effects modeling.
There was no randomized clinical trial comparing efficacy of ICD versus medical treatment in patients with ChCM. Six observational studies were included, totalizing 115 patients in amiodarone group and 483 patients in ICD group. The mortality outcome in the ICD population was 9.7 per 100 patient-years of follow-up (95%CI 5.7-13.7) and 9.6 per 100 patient-years in the amiodarone group (95%CI 6.7-12.4) (p = 0.95). Meta-regression did not show any association with LV ejection fraction (p = 0.32), age (p = 0.44), beta-blocker (p = 0.33) or angiotensin-converting enzyme inhibitors (p = 0.096) usage.
The best available evidence derived from small observational studies suggests that ICD therapy in secondary prevention of sudden death (VT or resuscitated SCD) is not associated with lower rate of all-cause mortality in patients with ChCM. Randomized controlled trials are needed to answer this question.
在患有恰加斯心肌病（Chagas cardiomyopathy，ChCM）的患者中，心源性猝死（sudden cardiac death，SCD）是主要的死亡原因。植入式心脏复律除颤器（implantable cardioverter-defibrillator，ICD）是结构性心脏病患者二级预防的成熟疗法，但对于 ChCM 患者，其疗效和安全性存在争议。本荟萃分析旨在评估 ICD 用于 ChCM 患者二级预防的疗效，以 SCD 作为主要终点，比较 ICD 治疗组与胺碘酮治疗组患者的死亡率。
我们系统地在五个数据库中检索了评估 ChCM 合并持续性室性心动过速（sustained ventricular tachycardia，VT）患者接受 ICD 植入或胺碘酮治疗的死亡率结局的研究。使用随机效应模型对研究结果进行汇总。
没有比较 ICD 与 ChCM 患者药物治疗疗效的随机临床试验。纳入了六项观察性研究，胺碘酮组共 115 例患者，ICD 组共 483 例患者。ICD 组的死亡率为每 100 例患者-年 9.7 例（95%置信区间 5.7-13.7），胺碘酮组为每 100 例患者-年 9.6 例（95%置信区间 6.7-12.4）（p=0.95）。元回归未显示与左心室射血分数（left ventricular ejection fraction，LVEF）（p=0.32）、年龄（p=0.44）、β受体阻滞剂（beta-blocker，βB）（p=0.33）或血管紧张素转换酶抑制剂（angiotensin-converting enzyme inhibitors，ACEI）（p=0.096）的使用相关。
源自小样本观察性研究的最佳现有证据表明，在 ChCM 患者中，ICD 治疗二级预防心源性猝死（VT 或复苏性 SCD）与全因死亡率降低无关。需要随机对照试验来回答这个问题。
