肾功能中度受损的心力衰竭患者室性心律失常事件的竞争风险分析

Competing risk analysis of ventricular arrhythmia events in heart failure patients with moderately compromised renal dysfunction.

作者信息

Goldenberg Ido, Younis Arwa, Aktas Mehmet K, McNitt Scott, Zareba Wojciech, Kutyifa Valentina

机构信息

Department of Medicine, Clinical Cardiovascular Research Center, Cardiology Division, University of Rochester School of Medicine and Dentistry, 265 Crittenden Blvd., PO Box 653, Rochester, NY 14642, USA.

出版信息

Europace. 2020 Sep 1;22(9):1384-1390. doi: 10.1093/europace/euaa146.

DOI:10.1093/europace/euaa146

PMID:32875313

Abstract

AIMS

Patients with impaired renal function were shown to have an attenuated benefit from implantable cardioverter-defibrillator. However, there are limited data on the competing risk of ventricular arrhythmia events and death by renal function in patients without severe disease. Therefore, we aimed to assess the competing risk of ventricular arrhythmia events and death by renal function.

METHODS AND RESULTS

We analysed 1782 patients (99%) enrolled in Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) with glomerular filtration rate (GFR) data available. Cumulative incidence function curves were used to display the rate of ventricular tachycardia (VT), ventricular fibrillation (VF), and the competing risk of death without experiencing VT/VF. Multivariable Fine and Gray regression models and recurrent event analysis were performed. There were 355 (20%) patients with GFR < 52 and 1427 with GFR ≥ 52 (lowest quintile). The incidence of non-fatal VT/VF at 4 years was higher in patients with high GFR (26%) as compared to low GFR (16%), whereas rates of death without non-fatal VT/VF were 5% and 20% (P < 0.001). In Fine and Gray models, the low GFR group was 35% less likely to experience VT/VF compared to the high GFR [95% confidence interval (CI) 0.48-0.88, P = 0.005]. In contrast,death without experiencing VT/VF was 3.5-fold higher in the low GFR group (95% CI 2.38-5.12, P-value < 0.001). Recurrent event analysis consistently showed a lower risk of recurrent VT/VF, recurrent anti-tachycardia pacing only, and shock in the low GFR group.

CONCLUSIONS

We show, in a competing risk model, a lower risk of VT/VF events and a higher risk of mortality without an arrhythmic event in patients with moderate renal dysfunction in MADIT-CRT. These findings can be used for improved selection of patients for defibrillator therapy among CRT candidates.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT00180271.

摘要

目的

肾功能受损的患者从植入式心脏复律除颤器中获益减弱。然而，关于无严重疾病患者中心律失常事件和死亡的竞争风险与肾功能之间的数据有限。因此，我们旨在评估心律失常事件和死亡的竞争风险与肾功能的关系。

方法与结果

我们分析了1782例（99%）参与多中心自动除颤器植入试验-心脏再同步治疗（MADIT-CRT）且有肾小球滤过率（GFR）数据的患者。累积发病率函数曲线用于显示室性心动过速（VT）、室颤（VF）的发生率以及未发生VT/VF时的死亡竞争风险。进行了多变量Fine和Gray回归模型以及复发事件分析。有355例（20%）患者GFR＜52，1427例患者GFR≥52（最低五分位数）。4年时，高GFR患者非致命性VT/VF的发生率（26%）高于低GFR患者（16%），而未发生非致命性VT/VF时的死亡率分别为5%和20%（P＜0.001）。在Fine和Gray模型中，低GFR组发生VT/VF的可能性比高GFR组低35%[95%置信区间（CI）0.48 - 0.88，P = 0.005]。相反，未发生VT/VF时低GFR组的死亡率高3.5倍（95% CI 2.38 - 5.12，P值＜0.001）。复发事件分析一致显示低GFR组复发VT/VF、仅复发抗心动过速起搏以及电击的风险较低。