细化世界卫生组织定义：预测 POST SCD 研究中疑似心源性猝死患者尸检定义的心律失常性猝死。
Refining the World Health Organization Definition: Predicting Autopsy-Defined Sudden Arrhythmic Deaths Among Presumed Sudden Cardiac Deaths in the POST SCD Study.
机构信息
Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine (Z.H.T., J.E.O., A.B., J.P.), University of California.
Department of Medicine (J.W.S.), University of California.
出版信息
Circ Arrhythm Electrophysiol. 2019 Jul;12(7):e007171. doi: 10.1161/CIRCEP.119.007171. Epub 2019 Jun 28.
BACKGROUND
Conventional definitions of sudden cardiac death (SCD) presume cardiac cause. We studied the World Health Organization-defined SCDs autopsied in the POST SCD study (Postmortem Systematic Investigation of SCD) to determine whether premortem characteristics could identify autopsy-defined sudden arrhythmic death (SAD) among presumed SCDs.
METHODS
Between January 2, 2011, and January 4, 2016, we prospectively identified all 615 World Health Organization-defined SCDs (144 witnessed) 18 to 90 years in San Francisco County for medical record review and autopsy via medical examiner surveillance. Autopsy-defined SADs had no extracardiac or acute heart failure cause of death. We used 2 nested sets of premortem predictors-an emergency medical system set and a comprehensive set adding medical record data-to develop Least Absolute Selection and Shrinkage Operator models of SAD among witnessed and unwitnessed cohorts.
RESULTS
Of 615 presumed SCDs, 348 (57%) were autopsy-defined SAD. For witnessed cases, the emergency medical system model (area under the receiver operator curve 0.75 [0.67-0.82]) included presenting rhythm of ventricular tachycardia/fibrillation and pulseless electrical activity, while the comprehensive (area under the receiver operator curve 0.78 [0.70-0.84]) added depression. If only ventricular tachycardia/fibrillation witnessed cases (n=48) were classified as SAD, sensitivity was 0.46 (0.36-0.57), and specificity was 0.90 (0.79-0.97). For unwitnessed cases, the emergency medical system model (area under the receiver operator curve 0.68 [0.64-0.73]) included black race, male sex, age, and time since last seen normal, while the comprehensive (area under the receiver operator curve 0.75 [0.71-0.79]) added use of β-blockers, antidepressants, QT-prolonging drugs, opiates, illicit drugs, and dyslipidemia. If only unwitnessed cases <1 hour (n=59) were classified as SAD, sensitivity was 0.18 (0.13-0.22) and specificity was 0.95 (0.90-0.97).
CONCLUSIONS
Our models identify premortem characteristics that can better specify autopsy-defined SAD among presumed SCDs and suggest the World Health Organization definition can be improved by restricting witnessed SCDs to ventricular tachycardia/fibrillation or nonpulseless electrical activity rhythms and unwitnessed cases to <1 hour since last normal, at the cost of sensitivity.
背景
传统的心脏性猝死 (SCD) 定义假定为心脏原因。我们研究了在 POST SCD 研究（死后系统性 SCD 调查）中进行尸检的世界卫生组织定义的 SCD，以确定在假定的 SCD 中，是否可以通过生前特征来识别尸检定义的心律失常性 SAD（SAD）。
方法
2011 年 1 月 2 日至 2016 年 1 月 4 日，我们前瞻性地确定了旧金山县所有 615 例世界卫生组织定义的 SCD（144 例有目击者），通过法医监测进行医疗记录审查和尸检。尸检定义的 SAD 无心脏外或急性心力衰竭死亡原因。我们使用了 2 组嵌套的生前预测因素-急诊医疗系统组和添加医疗记录数据的综合组-为有目击者和无目击者队列开发 SAD 的最小绝对选择和收缩运算符模型。
结果
在 615 例假定的 SCD 中，348 例（57%）为尸检定义的 SAD。对于有目击者的病例，急诊医疗系统模型（接受者操作特征曲线下面积 0.75 [0.67-0.82]）包括室性心动过速/颤动和无脉电活动的表现节律，而综合模型（接受者操作特征曲线下面积 0.78 [0.70-0.84]）增加了抑郁。如果只将室性心动过速/颤动有目击者的病例（n=48）分类为 SAD，则敏感性为 0.46（0.36-0.57），特异性为 0.90（0.79-0.97）。对于无目击者的病例，急诊医疗系统模型（接受者操作特征曲线下面积 0.68 [0.64-0.73]）包括黑种人、男性、年龄和最后一次正常观察到的时间，而综合模型（接受者操作特征曲线下面积 0.75 [0.71-0.79]）增加了β受体阻滞剂、抗抑郁药、QT 延长药物、阿片类药物、非法药物和血脂异常的使用。如果仅将无目击者的<1 小时病例（n=59）分类为 SAD，则敏感性为 0.18（0.13-0.22），特异性为 0.95（0.90-0.97）。
结论
我们的模型确定了可以更好地确定尸检定义的 SAD 的生前特征，并表明可以通过将有目击者的 SCD 限制为室性心动过速/颤动或无脉电活动节律以及将无目击者的 SCD 限制为<1 小时来改善世界卫生组织的定义。最后一次正常，以牺牲敏感性为代价。
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