心力衰竭患者的心脏再同步治疗伴或不伴除颤器

Cardiac resynchronization therapy with or without defibrillator in patients with heart failure.

机构信息

Division of Cardiology, Department of Medicine, Karolinska Institutet, SE-17176 Stockholm, Sweden.

Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany & German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.

出版信息

Europace. 2022 Jan 4;24(1):48-57. doi: 10.1093/europace/euab233.

AIMS

Randomized data on the efficacy/safety of cardiac resynchronization therapy with vs. without defibrillator (CRT-D,-P) in heart failure with reduced ejection fraction (HFrEF) are scarce. We aimed to evaluate survival associated with use of CRT-D vs. CRT-P in a contemporary cohort with HFrEF.

METHODS AND RESULTS

Patients from Swedish HF Registry treated with CRT-D/CRT-P and fulfilling criteria for primary prevention defibrillator use were included. Logistic regression was used to evaluate predictors of CRT-D non-use. All-cause mortality was compared in CRT-D vs. CRT-P by Cox regression in a 1 : 1 propensity-score-matched cohort. Of 1988 patients with CRT, 1108 (56%) had CRT-D and 880 (44%) CRT-P. Older age, higher ejection fraction (EF), female sex, and the lack of referral to HF nurse-led outpatient clinic were major determinants of CRT-D non-use. After matching, 645 CRT-D patients were compared with 645 with CRT-P. The CRT-D use was associated with lower 1- and 3-year all-cause mortality [hazard ratio (HR):0.76, 95% confidence interval (CI):0.58-0.98; HR: 0.82, 95% CI: 0.68-0.99, respectively]. Results were consistent in all pre-specified subgroups except for CRT-D use being associated with lower 3-year mortality in patients with an EF < 30% but not in those with an EF ≥ 30% (HR: 0.73, 95% CI: 0.59-0.89 and HR: 1.24, 95% CI: 0.83-1.85, respectively; P-interaction = 0.02).

CONCLUSION

In a contemporary HFrEF cohort, CRT-D was associated with lower mortality compared with CRT-P. The CRT-D use was less likely in older patients, females, and in patients not referred to HF nurse-led outpatient clinic. Our findings support the use of CRT-D vs. CRT-P in HFrEF, in particular with severely reduced EF.

目的

心脏再同步治疗（CRT）加除颤器（CRT-D）与 CRT 不加除颤器（CRT-P）在射血分数降低的心力衰竭（HFrEF）中的疗效/安全性的随机数据稀缺。我们旨在评估在具有射血分数降低的心力衰竭的当代队列中，使用 CRT-D 与 CRT-P 与生存率相关联。

方法和结果

纳入了接受 CRT-D/CRT-P 治疗并符合原发性预防除颤器使用标准的瑞典心力衰竭登记处患者。使用逻辑回归评估 CRT-D 未使用的预测因素。在 1:1 倾向评分匹配队列中，通过 Cox 回归比较 CRT-D 与 CRT-P 的全因死亡率。在 1988 例 CRT 患者中，1108 例（56%）接受 CRT-D，880 例（44%）接受 CRT-P。年龄较大、射血分数（EF）较高、女性和未转诊至心力衰竭护士主导的门诊诊所是 CRT-D 未使用的主要决定因素。匹配后，将 645 例 CRT-D 患者与 645 例 CRT-P 患者进行比较。CRT-D 的使用与 1 年和 3 年全因死亡率降低相关[风险比（HR）：0.76，95%置信区间（CI）：0.58-0.98；HR：0.82，95% CI：0.68-0.99]。除 EF<30%的患者中 CRT-D 与 3 年死亡率降低相关，而 EF≥30%的患者中 CRT-D 与 3 年死亡率降低无关（HR：0.73，95% CI：0.59-0.89 和 HR：1.24，95% CI：0.83-1.85，P 交互=0.02）之外，结果在所有预先指定的亚组中均一致。