Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.).
William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow).
Circ Arrhythm Electrophysiol. 2024 Mar;17(3):e012446. doi: 10.1161/CIRCEP.123.012446. Epub 2024 Jan 22.
Antimicrobial envelopes reduce the incidence of cardiac implantable electronic device infections, but their cost restricts routine use in the United Kingdom. Risk scoring could help to identify which patients would most benefit from this technology.
A novel risk score (BLISTER [Blood results, Long procedure time, Immunosuppressed, Sixty years old (or younger), Type of procedure, Early re-intervention, Repeat procedure]) was derived from multivariate analysis of factors associated with cardiac implantable electronic device infection. Diagnostic utility was assessed against the existing PADIT score (Prior procedure, Age, Depressed renal function, Immunocompromised, Type of procedure) in both standard and high-risk external validation cohorts, and cost-utility models examined different BLISTER and PADIT score thresholds for TYRX (Medtronic; Minneapolis, MN) antimicrobial envelope allocation.
In a derivation cohort (n=7383), cardiac implantable electronic device infection occurred in 59 individuals within 12 months of a procedure (event rate, 0.8%). In addition to the PADIT score constituents, lead extraction (hazard ratio, 3.3 [95% CI, 1.9-6.1]; <0.0001), C-reactive protein >50 mg/L (hazard ratio, 3.0 [95% CI, 1.4-6.4]; =0.005), reintervention within 2 years (hazard ratio, 10.1 [95% CI, 5.6-17.9]; <0.0001), and top-quartile procedure duration (hazard ratio, 2.6 [95% CI, 1.6-4.1]; =0.001) were independent predictors of infection. The BLISTER score demonstrated superior discriminative performance versus PADIT in the standard risk (n=2854, event rate: 0.8%, area under the curve, 0.82 versus 0.71; =0.001) and high-risk validation cohorts (n=1961, event rate: 2.0%, area under the curve, 0.77 versus 0.69; =0.001), and in all patients (n=12 198, event rate: 1%, area under the curve, 0.8 versus 0.75, =0.002). In decision-analytic modeling, the optimum scenario assigned antimicrobial envelopes to patients with BLISTER scores ≥6 (10.8%), delivering a significant reduction in infections (relative risk reduction, 30%; =0.036) within the National Institute for Health and Care Excellence cost-utility thresholds (incremental cost-effectiveness ratio, £18 446).
The BLISTER score (https://qxmd.com/calculate/calculator_876/the-blister-score-for-cied-infection) was a valid predictor of cardiac implantable electronic device infection, and could facilitate cost-effective antimicrobial envelope allocation to high-risk patients.
抗菌封套可降低心脏植入式电子设备感染的发生率，但由于其成本限制，在英国无法常规使用。风险评分有助于确定哪些患者将从这项技术中获益最大。
从与心脏植入式电子设备感染相关的多变量分析中得出了一种新的风险评分（BLISTER [血检结果、手术时间长、免疫抑制、60 岁及以下、手术类型、早期再干预、重复手术]）。在标准和高风险外部验证队列中，评估了该评分与现有 PADIT 评分（既往手术、年龄、肾功能降低、免疫功能低下、手术类型）的诊断效用，并通过成本效用模型研究了不同 BLISTER 和 PADIT 评分阈值对 TYRX（美敦力公司；明尼苏达州明尼阿波利斯市）抗菌封套分配的影响。
在一个 7383 人的队列中，心脏植入式电子设备感染在术后 12 个月内发生于 59 例患者（发生率为 0.8%）。除了 PADIT 评分组成部分外，导线拔除（危险比，3.3[95%置信区间，1.9-6.1]；<0.0001）、C 反应蛋白>50mg/L（危险比，3.0[95%置信区间，1.4-6.4]；=0.005）、2 年内再干预（危险比，10.1[95%置信区间，5.6-17.9]；<0.0001）和前四分位手术时间（危险比，2.6[95%置信区间，1.6-4.1]；=0.001）是感染的独立预测因素。BLISTER 评分在标准风险（n=2854，发生率：0.8%，曲线下面积 0.82 比 0.71；=0.001）和高风险验证队列（n=1961，发生率：2.0%，曲线下面积 0.77 比 0.69；=0.001）以及所有患者（n=12198，发生率：1%，曲线下面积 0.8 比 0.75，=0.002）中均优于 PADIT 评分。在决策分析模型中，最佳方案将抗菌封套分配给 BLISTER 评分≥6（10.8%）的患者，在国家卫生与保健卓越研究所成本效益阈值内显著降低了感染率（相对风险降低 30%；=0.036）（增量成本效益比，18446 英镑）。
