Elsokkari Ihab, Parkash Ratika, Tang Anthony, Wells George, Doucette Steve, Yetisir Elizabeth, Gardner Martin, Healey Jeffrey S, Thibault Bernard, Sterns Laurence, Birnie David, Nery Pablo, Sivakumaran Soori, Essebag Vidal, Dorian Paul, Sapp John
Division of Cardiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
Division of Cardiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
JACC Clin Electrophysiol. 2020 Mar;6(3):327-337. doi: 10.1016/j.jacep.2019.11.012. Epub 2020 Jan 29.
This study sought to examine the adverse prognosis associated with ventricular arrhythmia clusters that falls outside the current electrical storm definition.
Electrical storm is most frequently defined as a cluster of ≥3 episodes of ventricular arrhythmia (VA) in a 24-h period. This definition has been associated with adverse cardiovascular outcomes and mortality, but the effect of lesser and greater clustering of arrhythmias has not been described.
Among all patients in the Resynchronization in Ambulatory Heart Failure trial, 14,515 implantable cardioverter-defibrillator-detected events with data available were rigorously adjudicated in blinded fashion. Arrhythmia incidence was examined for clustering, defined as 2 or more VA events occurring within 3 months. The prognostic importance of clustering was analyzed by varying the cluster length and number of events used to define a cluster. Mortality rates of groups with clustered arrhythmias were compared to patients with no arrhythmia or with unclustered arrhythmia.
The trial included 1,764 patients, among whom 465 patients had two or more VA episodes within 3 months, whereas 406 had unclustered arrhythmias. Compared to patients with no arrhythmia, patients experiencing unclustered VA had increased risk of death (hazard ratio [HR]: 1.45; 95% confidence interval [CI]: 1.09 to 1.93; p = 0.011), whereas the risk was even higher in patients with clustered arrhythmia (HR: 2.68; 95% CI: 2.13 to 3.36; p < 0.0001). Mortality risk increased with higher VA burden (number of VAs in a cluster) and shorter cluster length. This was observed in all groups tested, including the cluster with the least VA burden in the longest cluster length tested (2 VA episodes occurring within 3 months) (mortality HR: 2.85; 95% CI: 1.95 to 4.17; p < 0.0001). Although clustered arrhythmias terminated with antitachycardia pacing were associated with increased mortality, clusters terminated with implantable cardioverter-defibrillator shocks were associated with still higher mortality risk.
Significant adverse prognostic association of clustered VAs is observable with even 2 VA events within 3 months and increases with higher cluster density.
本研究旨在探讨当前电风暴定义之外的室性心律失常簇集相关的不良预后。
电风暴最常被定义为24小时内≥3次室性心律失常发作的簇集。这一定义与不良心血管结局和死亡率相关，但心律失常较少和较多簇集的影响尚未得到描述。
在动态心力衰竭再同步化试验的所有患者中，对14515例可植入式心律转复除颤器检测到的、有可用数据的事件进行了盲法严格判定。检查心律失常发生率的簇集情况，定义为3个月内发生2次或更多次室性心律失常事件。通过改变用于定义簇集的簇集长度和事件数量来分析簇集的预后重要性。将心律失常簇集组的死亡率与无心律失常或无簇集性心律失常的患者进行比较。
该试验纳入了1764例患者，其中465例患者在3个月内有两次或更多次室性心律失常发作，而406例有无簇集性心律失常。与无心律失常的患者相比，发生无簇集性室性心律失常的患者死亡风险增加（风险比[HR]：1.45；95%置信区间[CI]：1.09至1.93；p = 0.011），而心律失常簇集的患者风险更高（HR：2.68；95% CI：2.13至3.36；p < 0.0001）。死亡风险随室性心律失常负荷（簇集中室性心律失常的数量）增加和簇集长度缩短而增加。在所有测试组中均观察到这一点，包括在测试的最长簇集长度中室性心律失常负荷最小的簇集（3个月内发生2次室性心律失常事件）（死亡HR：2.85；95% CI：1.95至4.17；p < 0.0001）。虽然通过抗心动过速起搏终止的簇集性心律失常与死亡率增加相关，但通过植入式心律转复除颤器电击终止的簇集与更高的死亡风险相关。
即使在3个月内有2次室性心律失常事件，也可观察到簇集性室性心律失常有显著的不良预后关联，且随着簇集密度增加而增加。
