Engstrom Nathan, Dobson Geoffrey P, Ng Kevin, Letson Hayley L
College of Medicine & Dentistry, Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia.
Cardiac Investigations, The Townsville University Hospital, Douglas, QLD, Australia.
Front Cardiovasc Med. 2020 Oct 27;7:577248. doi: 10.3389/fcvm.2020.577248. eCollection 2020.
Despite major advances in treating patients with severe heart failure, deciding who should receive an implantable cardiac defibrillator (ICD) remains challenging. To study the risk factors and mortality in patients after receiving an ICD (January 2008-December 2015) in a regional hospital in Australia. Eighty-two primary prevention patients received an ICD for ischemic cardiomyopathy (ICM, = 41) and non-ischemic cardiomyopathy (NICM, = 40) with 4.8-yrs follow-up. One patient had mixed ICM/NICM indications. Ventricular arrhythmias were assessed using intracardiac electrograms. Statistical analysis compared the total population and ICM and NICM groups using Kaplan-Meier for survival, Cox regression for mortality predictors, and binary logistic regression for predictors of ventricular arrhythmias ( < 0.05). Major risk factors were hypercholesterolemia (70.7%), hypertension (47.6%), and obesity (41.5%). Severe obstructive sleep apnea (OSA) was found exclusively in NICM patients (23.7%, = 0.001). Mortality was 30.5% after 4.8-yrs. The majority of patients (n=67) had no sustained ventricular arrhythmias yet 28% received therapy ( = 23), 18.51% were appropriate ( = 15), and 13.9% inappropriate ( = 11). Patients receiving ≥2 incidences of inappropriate shocks were 18-times more likely to die ( = 0.013). Three sudden cardiac deaths (SCD) (3.7%) were prevented by the ICD. Patients implanted with an ICD in Townsville had 30.5% all-cause mortality after 4.8-yrs. Only 28% of patients received ICD therapy and 13.9% were inappropriate. OSA may have contributed to the fourfold increase in inappropriate therapy in NICM patients. Our study raises important efficacy, ethical and healthcare cost questions about who should receive an ICD, and possible regional and urban center disparities.
尽管在治疗严重心力衰竭患者方面取得了重大进展，但决定谁应该接受植入式心脏除颤器（ICD）仍然具有挑战性。为了研究澳大利亚一家地区医院中接受ICD治疗的患者（2008年1月至2015年12月）的危险因素和死亡率。82例一级预防患者因缺血性心肌病（ICM，n = 41）和非缺血性心肌病（NICM，n = 40）接受了ICD治疗，并进行了4.8年的随访。1例患者有ICM/NICM混合适应症。使用心内电图评估室性心律失常。统计分析采用Kaplan-Meier法比较总人群以及ICM和NICM组的生存率，采用Cox回归分析死亡率预测因素，采用二元逻辑回归分析室性心律失常预测因素（P < 0.05）。主要危险因素为高胆固醇血症（70.7%）、高血压（47.6%）和肥胖（41.5%）。严重阻塞性睡眠呼吸暂停（OSA）仅在NICM患者中发现（23.7%，P = 0.001）。4.8年后死亡率为30.5%。大多数患者（n = 67）没有持续性室性心律失常，但28%的患者接受了治疗（n = 23），其中18.51%为恰当治疗（n = 15），13.9%为不恰当治疗（n = 11）。接受≥2次不恰当电击的患者死亡可能性高18倍（P = 0.013）。ICD预防了3例心源性猝死（SCD）（3.7%）。在汤斯维尔植入ICD的患者4.8年后全因死亡率为30.5%。只有28%的患者接受了ICD治疗，13.9%的治疗不恰当。OSA可能导致了NICM患者不恰当治疗增加四倍。我们的研究提出了关于谁应该接受ICD治疗的重要疗效、伦理和医疗成本问题，以及可能存在的地区和城市中心差异。
