Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark.
Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
ESC Heart Fail. 2022 Apr;9(2):1287-1293. doi: 10.1002/ehf2.13810. Epub 2022 Feb 2.
Prophylactic implantable cardioverter-defibrillators (ICD) reduce mortality in patients with ischaemic heart failure (HF), whereas the effect of ICD in patients with non-ischaemic HF is less clear. We aimed to investigate the association between concomitant coronary atherosclerosis and mortality in patients with non-ischaemic HF and the effect of ICD implantation in these patients.
Patients were included from DANISH (Danish Study to Assess the Efficacy of Implantable Cardioverter Defibrillators in Patients with Non-Ischaemic Systolic Heart Failure on Mortality), randomizing patients to ICD or control. Study inclusion criteria for HF were left ventricular ejection fraction ≤ 35% and increased levels (>200 pg/mL) of N-terminal pro-brain natriuretic peptide. Of the 1116 patients from DANISH, 838 (75%) patients had available data from coronary angiogram and were included in this subgroup analysis. We used Cox regression to assess the relationship between coronary atherosclerosis and mortality and the effect of ICD implantation. Of the included patients, 266 (32%) had coronary atherosclerosis. Of these, 216 (81%) had atherosclerosis without significant stenoses, and 50 (19%) had significant stenosis. Patients with atherosclerosis were significantly older {67 [interquartile range (IQR) 61-73] vs. 61 [IQR 54-68] years; P < 0.0001}, and more were men (77% vs. 70%; P = 0.03). During a median follow-up of 64.3 months (IQR 47-82), 174 (21%) of the patients died. The effect of ICD on all-cause mortality was not modified by coronary atherosclerosis [hazard ratio (HR) 0.94; 0.58-1.52; P = 0.79 vs. HR 0.82; 0.56-1.20; P = 0.30], P for interaction = 0.67. In univariable analysis, coronary atherosclerosis was a significant predictor of all-cause mortality [HR, 1.41; 95% confidence interval (CI), 1.04-1.91; P = 0.03]. However, this association disappeared when adjusting for cardiovascular risk factors (age, gender, diabetes, hypertension, smoking, and estimated glomerular filtration rate) (HR 1.05, 0.76-1.45, P = 0.76).
In patients with non-ischaemic systolic heart failure, ICD implantation did not reduce all-cause mortality in patients either with or without concomitant coronary atherosclerosis. The concomitant presence of coronary atherosclerosis was associated with increased mortality. However, this association was explained by other risk factors.
植入式心脏复律除颤器（ICD）可降低缺血性心力衰竭（HF）患者的死亡率，而 ICD 在非缺血性 HF 患者中的作用尚不清楚。我们旨在研究非缺血性 HF 患者同时存在冠状动脉粥样硬化与死亡率之间的关系，以及 ICD 植入对这些患者的影响。
本研究纳入了 DANISH（丹麦评估植入式心脏复律除颤器对非缺血性收缩性心力衰竭患者死亡率影响的研究）中的患者，将患者随机分为 ICD 组或对照组。HF 的研究纳入标准为左心室射血分数≤35%和 N 端脑利钠肽前体水平升高（>200 pg/mL）。在 DANISH 中的 1116 例患者中，有 838 例（75%）患者的冠状动脉造影数据可用，并纳入了本亚组分析。我们使用 Cox 回归评估冠状动脉粥样硬化与死亡率之间的关系以及 ICD 植入的效果。在纳入的患者中，266 例（32%）存在冠状动脉粥样硬化。其中，216 例（81%）存在无明显狭窄的动脉粥样硬化，50 例（19%）存在明显狭窄。存在动脉粥样硬化的患者年龄明显较大{67 [四分位距（IQR）61-73] vs. 61 [IQR 54-68]岁；P<0.0001}，且男性比例更高（77% vs. 70%；P=0.03）。中位随访 64.3 个月（IQR 47-82）期间，有 174 例（21%）患者死亡。ICD 对全因死亡率的影响不受冠状动脉粥样硬化的影响[风险比（HR）0.94；0.58-1.52；P=0.79 与 HR 0.82；0.56-1.20；P=0.30]，交互检验 P 值为 0.67。单变量分析显示，冠状动脉粥样硬化是全因死亡率的一个显著预测因素[HR，1.41；95%置信区间（CI），1.04-1.91；P=0.03]。然而，当调整心血管危险因素（年龄、性别、糖尿病、高血压、吸烟和估计肾小球滤过率）后，这种关联消失（HR 1.05，0.76-1.45，P=0.76）。
在非缺血性收缩性心力衰竭患者中，ICD 植入并未降低同时存在或不存在冠状动脉粥样硬化患者的全因死亡率。同时存在冠状动脉粥样硬化与死亡率增加相关。然而，这种关联可以用其他危险因素来解释。
