Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Pacing Clin Electrophysiol. 2021 Feb;44(2):225-234. doi: 10.1111/pace.14150. Epub 2021 Jan 5.
Current guidelines did not provide recommendations on indications of an additional implantable cardioverter-defibrillator (ICD) to patients receiving cardiac resynchronization therapy (CRT), and it still remains controversial due to lack of evidence from randomized controlled trials.
PubMed, Embase, and Cochrane CENTRAL from the inception to May 2020 were systematically screened for studies reporting on the comparison of cardiac resynchronization therapy with defibrillator (CRT-D) and cardiac resynchronization therapy with pacemaker (CRT-P), focusing on the adjusted hazard ratio (aHR) of all-cause mortality. We pooled the effects using a random-effect model.
Twenty-one studies encompassing 69,919 patients were included in this meta-analysis. With no restriction to characteristics of including population, CRT-D was associated with a lower all-cause mortality compared with CRT-P significantly (aHR: 0.80, 95% confidence interval [CI]: 0.74-0.87, I = 36.8%, p < .001). This mortality benefit was also observed in patients with ischemic cardiomyopathy (aHR: 0.74, 95% CI: 0.64-0.86, I = 0%, p < .001). However, there is no significant difference in patients with nonischemic cardiomyopathy (NICM) (aHR: 0.91, 95% CI: 0.82-1.01, I = 0%, p = .087), older age (age ≥75 years, aHR: 0.96, 95% CI: 0.83-1.12, I = 0%, p = .610). Subgroup analysis was performed and indicated the survival benefit of CRT-D for primary prevention compared with CRT-P (aHR: 0.87, 95% CI: 0.79-0.95, I = 0%, p = .003).
After adjusted the differences in clinical characteristics, additional ICD therapy was associated with a reduced all-cause mortality in patients receiving CRT. However, our work suggested that additional ICD may not be applied to elderly (≥75 years) or patients with NICM.
目前的指南并未为接受心脏再同步治疗（CRT）的患者提供关于植入式心脏复律除颤器（ICD）附加指征的建议，由于缺乏随机对照试验的证据，这仍然存在争议。
系统检索了从建立到 2020 年 5 月的 PubMed、Embase 和 Cochrane CENTRAL 数据库，以寻找比较心脏再同步治疗除颤器（CRT-D）和心脏再同步治疗起搏器（CRT-P）的研究报告，重点是全因死亡率的调整后的危险比（aHR）。我们使用随机效应模型汇总效应。
这项荟萃分析共纳入了 21 项研究，共纳入了 69919 名患者。在不限制纳入人群特征的情况下，与 CRT-P 相比，CRT-D 显著降低了全因死亡率（aHR：0.80，95%置信区间[CI]：0.74-0.87，I = 36.8%，p < 0.001）。在缺血性心肌病患者中也观察到了这种死亡率获益（aHR：0.74，95%CI：0.64-0.86，I = 0%，p < 0.001）。然而，在非缺血性心肌病（NICM）患者中（aHR：0.91，95%CI：0.82-1.01，I = 0%，p = 0.087），这一差异无统计学意义。在年龄较大（年龄≥75 岁）的患者中（aHR：0.96，95%CI：0.83-1.12，I = 0%，p = 0.610），差异也无统计学意义。进行了亚组分析，结果表明 CRT-D 用于一级预防与 CRT-P 相比具有生存获益（aHR：0.87，95%CI：0.79-0.95，I = 0%，p = 0.003）。
在调整了临床特征差异后，接受 CRT 的患者接受附加 ICD 治疗与降低全因死亡率相关。然而，我们的研究结果表明，附加 ICD 可能不适用于老年人（≥75 岁）或 NICM 患者。
