Zeitler Emily P, Dalgaard Frederik, Abraham William T, Cleland John G F, Curtis Anne B, Friedman Daniel J, Gold Michael R, Kutyifa Valentina, Linde Cecilia, Tang Anthony S, Olivas-Martinez Antonio, Inoue Lurdes Y T, Sanders Gillian D, Al-Khatib Sana M
Dartmouth Health and The Dartmouth Institute, Lebanon, NH.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Nykøbing Falster Sygehus, Nykøbing and Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark.
Am Heart J. 2024 Jan;267:81-90. doi: 10.1016/j.ahj.2023.11.002. Epub 2023 Nov 19.
Cardiac resynchronization therapy (CRT) reduces heart failure hospitalizations (HFH) and mortality for guideline-indicated patients with heart failure (HF). Most patients with HF are aged ≥70 years but such patients are often under-represented in randomized trials.
Patient-level data were combined from 8 randomized trials published 2002-2013 comparing CRT to no CRT (n = 6,369). The effect of CRT was estimated using an adjusted Bayesian survival model. Using age as a categorical (<70 vs ≥70 years) or continuous variable, the interaction between age and CRT on the composite end point of HFH or all-cause mortality or all-cause mortality alone was assessed.
The median age was 67 years with 2436 (38%) being 70+; 1,554 (24%) were women; 2,586 (41%) had nonischemic cardiomyopathy and median QRS duration was 160 ms. Overall, CRT was associated with a delay in time to the composite end point (adjusted hazard ratio [aHR] 0.75, 95% credible interval [CI] 0.66-0.85, P = .002) and all-cause mortality alone (aHR of 0.80, 95% CI 0.69-0.96, P = .017). When age was treated as a categorical variable, there was no interaction between age and the effect of CRT for either end point (P > .1). When age was treated as a continuous variable, older patients appeared to obtain greater benefit with CRT for the composite end point (P for interaction = .027) with a similar but nonsignificant trend for mortality (P for interaction = .35).
Reductions in HFH and mortality with CRT are as great or greater in appropriately indicated older patients. Age should not be a limiting factor for the provision of CRT.
心脏再同步治疗（CRT）可减少符合指南指征的心力衰竭（HF）患者的心力衰竭住院率（HFH）和死亡率。大多数HF患者年龄≥70岁，但此类患者在随机试验中的代表性往往不足。
汇总2002年至2013年发表的8项随机试验的患者水平数据，比较CRT与非CRT（n = 6369）。使用调整后的贝叶斯生存模型估计CRT的效果。将年龄作为分类变量（<70岁与≥70岁）或连续变量，评估年龄与CRT在HFH或全因死亡率或单独全因死亡率复合终点上的相互作用。
中位年龄为67岁，其中2436例（38%）年龄在70岁及以上；1554例（24%）为女性；2586例（41%）患有非缺血性心肌病，中位QRS时限为160毫秒。总体而言，CRT与复合终点时间延迟相关（调整后风险比[aHR] 0.75，95%可信区间[CI] 0.66 - 0.85，P = 0.002）以及单独全因死亡率（aHR为0.80，95% CI 0.69 - 0.96，P = 0.017）。当将年龄作为分类变量时，年龄与CRT对任一终点的效果之间均无相互作用（P > 0.1）。当将年龄作为连续变量时，老年患者在复合终点上似乎从CRT中获得更大益处（相互作用P = 0.027），在死亡率方面有类似但不显著的趋势（相互作用P = 0.35）。
在适当指征的老年患者中，CRT降低HFH和死亡率的效果相同或更大。年龄不应成为提供CRT的限制因素。
