Biton Yitschak, Costa Jason, Zareba Wojciech, Baman Jayson R, Goldenberg Ilan, McNitt Scott, Solomon Scott D, Polonsky Bronislava, Kutyifa Valentina
Cardiology Division, University of Rochester Medical Center, Rochester, New York.
Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Clin Cardiol. 2018 Oct;41(10):1358-1366. doi: 10.1002/clc.23058.
Cardiac resynchronization therapy (CRT) is highly beneficial in patients with heart failure (HF) and left bundle branch block (LBBB); however, up to 30% of patients in this selected group are nonresponders.
We hypothesized that clinical and echocardiographic variables can be used to develop a simple mortality risk stratification score in CRT.
Best-subsets proportional-hazards regression analysis was used to develop a simple clinical risk score for all-cause mortality in 756 patients with LBBB allocated to the CRT with defibrillator (CRT-D) group enrolled in the multicenter automatic defibrillator implantation trial with cardiac resynchronization therapy. The score was used to assess the mortality risk within the CRT-D group and the associations with mortality reduction with CRT-D vs implantable cardioverter defibrillator (ICD) in each risk category.
Four clinical variables comprised the risk score: age ≥ 65, creatinine ≥ 1.4 mg/dL, history of coronary artery bypass graft, and left ventricular ejection fraction (LVEF) < 26%. Every 1 point increase in the score was associated with 2-fold increased mortality within the CRT-D arm (P < 0.001). CRT-D was associated with mortality reduction as compared with ICD only in patients with moderate risk: score 0 (HR = 0.80, P = 0.615), score 1 (HR = 0.54, P = 0.019), score 2 (HR = 0.54, P = 0.016), score 3-4 risk factors (HR = 1.08, P = 0.811); however, the device by score interaction was not significant (P = 0.306). The score was also significantly predictive of left ventricular reverse remodeling (P < 0.001).
Four clinical variables can be used for improved mortality risk stratification in mild HF patients with LBBB implanted with CRT-D.
心脏再同步治疗（CRT）对心力衰竭（HF）合并左束支传导阻滞（LBBB）的患者非常有益；然而，在这个特定群体中，高达30%的患者无反应。
我们假设临床和超声心动图变量可用于制定一个简单的CRT死亡率风险分层评分。
采用最佳子集比例风险回归分析，为756例LBBB患者制定全因死亡率的简单临床风险评分，这些患者被分配到心脏再同步治疗多中心自动除颤器植入试验中的CRT除颤器（CRT-D）组。该评分用于评估CRT-D组内的死亡风险，以及每个风险类别中CRT-D与植入式心律转复除颤器（ICD）降低死亡率的相关性。
四个临床变量构成风险评分：年龄≥65岁、肌酐≥1.4mg/dL、冠状动脉搭桥术史和左心室射血分数（LVEF）<26%。评分每增加1分，CRT-D组内死亡率增加2倍（P<0.001）。仅在中度风险患者中，CRT-D与ICD相比可降低死亡率：评分为0（HR=0.80，P=0.615）、评分为1（HR=0.54，P=0.019）、评分为2（HR=0.54，P=0.016）、有3-4个危险因素（HR=1.08，P=0.811）；然而，器械与评分的交互作用不显著（P=0.306）。该评分对左心室逆向重构也有显著预测作用（P<0.001）。
四个临床变量可用于改善植入CRT-D的轻度HF合并LBBB患者的死亡风险分层。
