伴有原发性预防植入式心脏除颤器患者的竞争风险：全球电异质性与临床结局研究。
Competing risks in patients with primary prevention implantable cardioverter-defibrillators: Global Electrical Heterogeneity and Clinical Outcomes study.
机构信息
Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Department of Medicine, Cardiovascular Division, Oregon Health & Science University, Portland, Oregon.
出版信息
Heart Rhythm. 2021 Jun;18(6):977-986. doi: 10.1016/j.hrthm.2021.03.006. Epub 2021 Mar 6.
BACKGROUND
Global electrical heterogeneity (GEH) is associated with sudden cardiac death in the general population. Its utility in patients with systolic heart failure who are candidates for primary prevention (PP) implantable cardioverter-defibrillators (ICDs) is unclear.
OBJECTIVE
The purpose of this study was to investigate whether GEH is associated with sustained ventricular tachycardia/ventricular fibrillation leading to appropriate ICD therapies in patients with heart failure and PP ICDs.
METHODS
We conducted a multicenter retrospective cohort study. GEH was measured by spatial ventricular gradient (SVG) direction (azimuth and elevation) and magnitude, QRS-T angle, and sum absolute QRST integral on preimplant 12-lead electrocardiograms. Survival analysis using cause-specific hazard functions compared the strength of associations with 2 competing outcomes: sustained ventricular tachycardia/ventricular fibrillation leading to appropriate ICD therapies and all-cause death without appropriate ICD therapies.
RESULTS
We analyzed 2668 patients (mean age 63 ± 12 years; 624 (23%) female; 78% white; 43% nonischemic cardiomyopathy; left ventricular ejection fraction 28% ± 11% from 6 academic medical centers). After adjustment for demographic, clinical, device, and traditional electrocardiographic characteristics, SVG elevation (hazard ratio [HR] per 1SD 1.14; 95% confidence interval [CI] 1.04-1.25; P = .004), SVG azimuth (HR per 1SD 1.12; 95% CI 1.01-1.24; P = .039), SVG magnitude (HR per 1SD 0.75; 95% CI 0.66-0.85; P < .0001), and QRS-T angle (HR per 1SD 1.21; 95% CI 1.08-1.36; P = .001) were associated with appropriate ICD therapies. Sum absolute QRST integral had different associations in infarct-related cardiomyopathy (HR 1.29; 95% CI 1.04-1.60) and nonischemic cardiomyopathy (HR 0.78; 95% CI 0.62-0.96) (P = .022).
CONCLUSION
In patients with PP ICDs, GEH is independently associated with appropriate ICD therapies. The SVG vector points in distinctly different directions in patients with 2 competing outcomes.
背景
全球电异质性（GEH）与普通人群中的心脏性猝死有关。其在接受原发性预防（PP）植入式心脏复律除颤器（ICD）治疗的收缩性心力衰竭患者中的应用尚不清楚。
目的
本研究旨在探讨 GEH 是否与导致心力衰竭和 PP ICD 患者适当 ICD 治疗的持续性室性心动过速/心室颤动有关。
方法
我们进行了一项多中心回顾性队列研究。通过空间心室梯度（SVG）方向（方位和仰角）和幅度、QRS-T 角和 12 导联心电图的总和绝对值 QRST 积分来测量 GEH。使用特定病因的危险函数进行生存分析，比较了与 2 种竞争结果的关联强度：导致适当 ICD 治疗的持续性室性心动过速/心室颤动和无适当 ICD 治疗的全因死亡。
结果
我们分析了 2668 名患者（平均年龄 63 ± 12 岁；624 名（23%）女性；78%为白人；43%为非缺血性心肌病；左心室射血分数为 28% ± 11%，来自 6 所学术医疗中心）。在校正人口统计学、临床、设备和传统心电图特征后，SVG 抬高（每 1SD 增加 1.14；95%置信区间 [CI] 1.04-1.25；P =.004）、SVG 方位（每 1SD 增加 1.12；95%CI 1.01-1.24；P =.039）、SVG 幅度（每 1SD 增加 0.75；95%CI 0.66-0.85；P <.0001）和 QRS-T 角（每 1SD 增加 1.21；95%CI 1.08-1.36；P =.001）与适当 ICD 治疗有关。总和绝对值 QRST 积分在梗死相关心肌病（HR 1.29；95%CI 1.04-1.60）和非缺血性心肌病（HR 0.78；95%CI 0.62-0.96）（P =.022）中的关联不同。
结论
在接受 PP ICD 治疗的患者中，GEH 与适当的 ICD 治疗独立相关。SVG 向量在两种竞争结果患者中指向明显不同的方向。
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