Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel.
Faculty of Medicine, Hebrew University, Jerusalem, Israel.
Am J Cardiol. 2024 Jan 15;211:17-28. doi: 10.1016/j.amjcard.2023.10.044. Epub 2023 Oct 23.
The current guidelines advocate prophylactic implantable cardioverter-defibrillator (ICD) for all patients with symptomatic heart failure (HF) with low left ventricular ejection fraction. Because many patients will never use their device, a score delineating subgroups with differential ICD benefit is crucial. We aimed to evaluate the MADIT-II-based Risk Stratification Score (MRSS) feasibility to delineate the ICD survival benefit in a nationwide registry of patients with HF with prophylactic ICDs. Accordingly, all Israeli patients with HF with prophylactic ICD/cardiac resynchronization therapy defibrillators were categorized into MRSS-based risk subgroups. The study end points included overall mortality, sustained ventricular arrhythmia (VA), and a competing risk of VA (potential preventable arrhythmic death, where ICD could benefit survival) versus nonarrhythmic death. Potential ICD survival benefit was estimated by the area between these cumulative incidence curves. In 2,177 patients with HF implanted prophylactic device, 189 patients (8.7%) had VA and 316 (14.5%) died during a median follow-up of 2.9 years. The MRSS risk subgroups were significantly associated with overall mortality (p <0.001) and weakly with VA (p = 0.3). The competing risk analysis of VA versus nonarrhythmic death revealed a significantly shorter duration (p <0.001) and smaller magnitude of ICD survival benefit with increased risk subgroups, yielding an estimated 76, 60, 38, and 0 life days gained from prophylactic ICD implant during a 5-year follow-up for the MRSS low-, intermediate-, high-, and very high-risk subgroups, respectively (p for trend <0.05). In conclusion, MRSS use in a nationwide registry of patients with ischemic and nonischemic cardiomyopathy, revealed subgroups with differing ICD survival benefit, suggesting it could help evaluate prophylactic ICD survival benefit.
目前的指南主张对所有有症状的左心室射血分数低的心力衰竭（HF）患者预防性植入式心脏转复除颤器（ICD）。由于许多患者永远不会使用他们的设备，因此区分具有不同 ICD 获益的亚组的评分至关重要。我们旨在评估基于 MADIT-II 的风险分层评分（MRSS）在具有预防性 ICD 的 HF 患者的全国性登记处中区分 ICD 生存获益的可行性。因此，所有以色列具有预防性 ICD/心脏再同步治疗除颤器的 HF 患者均根据 MRSS 风险亚组进行分类。研究终点包括总死亡率、持续性室性心律失常（VA）以及 VA 的竞争风险（潜在可预防的心律失常性死亡，ICD 可从中获益）与非心律失常性死亡。通过这些累积发生率曲线之间的区域估计潜在的 ICD 生存获益。在 2177 名植入预防性设备的 HF 患者中，189 名（8.7%）发生 VA，316 名（14.5%）在中位随访 2.9 年后死亡。MRSS 风险亚组与总死亡率显著相关（p<0.001），与 VA 相关较弱（p=0.3）。VA 与非心律失常性死亡的竞争风险分析显示，随着风险亚组的增加，ICD 生存获益的持续时间（p<0.001）更短，幅度更小，在 5 年随访期间，MRSS 低危、中危、高危和极高危亚组的预防性 ICD 植入分别获得 76、60、38 和 0 个生命日（p<0.05）。总之，MRSS 在缺血性和非缺血性心肌病患者的全国性登记处中的使用显示了具有不同 ICD 生存获益的亚组，这表明它可以帮助评估预防性 ICD 的生存获益。
