Rav-Acha Moshe, Dadon Ziv, Wolak Arik, Hasin Tal, Goldenberg Ilan, Glikson Michael
Jesselson Integrated Heart Center Share Zedek Medical Center, Jerusalem 9103102, Israel.
Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel.
J Clin Med. 2024 Sep 7;13(17):5307. doi: 10.3390/jcm13175307.
Current guidelines advocate for the use of prophylactic implantable cardioverter defibrillators (ICDs) for all patients with symptomatic heart failure (HF) with low ejection fraction (EF). As many patients will never use their device and some are prone to device-related complications, scoring systems for delineating subgroups with differential ICD survival benefits are crucial to maximize ICD benefit and mitigate complications. This review summarizes the main scores, including MADIT trial-based Risk Stratification Score (MRSS) and Seattle Heart Failure Model (SHFM), which are based on randomized trials with a control group (HF medication only) and validated on large cohorts of 'real-world' HF patients. Recent studies using cardiac MRI (CMR) to predict ventricular arrhythmia (VA) are mentioned as well. The review shows that most scores could not delineate sustained VA incidence, but rather mortality without prior appropriate ICD therapies. Multiple scores could identify high-risk subgroups with extremely high probability of early mortality after ICD implant. On the other hand, low-risk subgroups were defined, in whom a high ratio of appropriate ICD therapy versus death without prior appropriate ICD therapy was found, suggesting significant ICD survival benefit. Moreover, MRSS and SHFM proved actual ICD survival benefit in low- and medium-risk subgroups when compared with control patients, and no benefit in high-risk subgroups, consisting of 16-20% of all ICD candidates. CMR reliably identified areas of myocardial scar and 'channels', significantly associated with VA. We conclude that as for today, multiple scoring models could delineate patient subgroups that would benefit differently from prophylactic ICD. Due to their modest-moderate predictability, these scores are still not ready to be implemented into clinical guidelines, but could aid decision regarding prophylactic ICD in borderline cases, as elderly patients and those with multiple co-morbidities. CMR is a promising technique which might help delineate patients with a low- versus high-risk for future VA, beyond EF alone. Lastly, genetic analysis could identify specific mutations in a non-negligible percent of patients, and a few of these mutations were found to predict an increased arrhythmic risk.
当前指南提倡对所有有症状的心力衰竭（HF）且射血分数（EF）低的患者使用预防性植入式心脏复律除颤器（ICD）。由于许多患者永远不会使用他们的设备，并且一些患者容易出现与设备相关的并发症，因此用于区分具有不同ICD生存获益亚组的评分系统对于最大化ICD获益和减轻并发症至关重要。本综述总结了主要评分，包括基于MADIT试验的风险分层评分（MRSS）和西雅图心力衰竭模型（SHFM），它们基于有对照组（仅使用HF药物）的随机试验，并在大量“真实世界”HF患者队列中得到验证。还提到了最近使用心脏磁共振成像（CMR）预测室性心律失常（VA）的研究。该综述表明，大多数评分无法区分持续性VA的发生率，而是区分未经适当ICD治疗的死亡率。多个评分可以识别ICD植入后早期死亡概率极高的高危亚组。另一方面，定义了低风险亚组，在这些亚组中发现适当ICD治疗与未经适当ICD治疗死亡的比例很高，表明ICD有显著的生存获益。此外，与对照患者相比，MRSS和SHFM在中低风险亚组中证明了实际的ICD生存获益，而在占所有ICD候选者16% - 20%的高风险亚组中没有获益。CMR可靠地识别出与VA显著相关的心肌瘢痕和“通道”区域。我们得出结论，就目前而言，多个评分模型可以区分从预防性ICD中获益不同的患者亚组。由于它们的预测性为中等程度，这些评分仍未准备好纳入临床指南，但可以帮助在临界情况下，如老年患者和有多种合并症的患者中做出关于预防性ICD的决策。CMR是一种有前景的技术，它可能有助于除了EF之外，区分未来发生VA风险低与高的患者。最后，基因分析可以在不可忽视比例的患者中识别特定突变，并且发现其中一些突变可预测心律失常风险增加。
