Department of Cardiology, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Türkiye.
Department of Cardiology, Faculty of Medicine, Mersin University, Mersin, Türkiye.
BMC Med. 2024 Nov 18;22(1):539. doi: 10.1186/s12916-024-03761-w.
In the contemporary management of heart failure with reduced ejection fraction (HFrEF), the recommended quadruple guideline-directed medical therapy (GDMT) consists of angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter-2 inhibitors (SGLT-2i). This study explored the impact of adding implantable cardioverter-defibrillator (ICD) therapy to this comprehensive regimen in HFrEF patients.
Utilizing deidentified data from the National Electronic Database of the Turkish Ministry of Health, we conducted a nationwide retrospective cohort study on 5450 HFrEF patients receiving quadruple GDMT, including ARNI. Among them, 709 patients underwent additional ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Propensity score matching ensured balanced baseline characteristics between groups. Primary endpoint was determined as all-cause mortality.
In the matched cohort, all-cause mortality occurred in 108 out of 619 patients (17.4%) in the GDMT group and 101 out of 619 patients (16.3%) in the ICD group, with a hazard ratio (HR) of 0.74 and a 95% confidence interval (CI) ranging from 0.57 to 0.98. The median follow-up time was 1365 days in the matched cohort, 1283 days in the GDMT group. Subgroup analyses consistently demonstrated benefits, particularly among individuals aged 61 years and older (HR: 0.60, 95% CI: 0.42-0.87, p = 0.006), those with sinus rhythm (HR: 0.55, 95% CI: 0.34-0.89, p = 0.013), individuals not using amiodarone (HR: 0.61, 95% CI: 0.42-0.89, p = 0.011), and those with an estimated glomerular filtration rate lower than 61.9 (HR: 0.66, 95% CI: 0.48-0.91, p = 0.011).
This study may offer a glimmer of hope that even after achieving the best current optimal medical therapy, the addition of device therapy could still yield positive outcomes in the management of patients with HFrEF.
在射血分数降低的心力衰竭（HFrEF）的当代管理中，推荐的四重指南指导的药物治疗（GDMT）包括血管紧张素受体-脑啡肽酶抑制剂（ARNI）、基于证据的β受体阻滞剂（BB）、盐皮质激素受体拮抗剂（MRA）和钠-葡萄糖共转运蛋白 2 抑制剂（SGLT-2i）。本研究探讨了在 HFrEF 患者中，将植入式心脏复律除颤器（ICD）治疗添加到此综合治疗方案中的影响。
利用土耳其卫生部国家电子数据库的匿名数据，我们对接受四重 GDMT 治疗的 5450 例 HFrEF 患者进行了全国性回顾性队列研究，其中包括 ARNI。其中，709 例患者接受了 ICD 或心脏再同步治疗除颤器（CRT-D）植入。采用倾向评分匹配确保两组间基线特征平衡。主要终点为全因死亡率。
在匹配队列中，GDMT 组 619 例患者中有 108 例（17.4%）和 ICD 组 619 例患者中有 101 例（16.3%）发生全因死亡，风险比（HR）为 0.74，95%置信区间（CI）为 0.57 至 0.98。匹配队列的中位随访时间为 1365 天，GDMT 组为 1283 天。亚组分析一致显示获益，特别是在年龄 61 岁及以上的患者（HR：0.60，95%CI：0.42-0.87，p=0.006）、窦性心律患者（HR：0.55，95%CI：0.34-0.89，p=0.013）、未使用胺碘酮的患者（HR：0.61，95%CI：0.42-0.89，p=0.011）和估计肾小球滤过率低于 61.9 的患者（HR：0.66，95%CI：0.48-0.91，p=0.011）。
本研究可能带来一线希望，即在实现目前最佳的优化药物治疗后，添加设备治疗仍可能为 HFrEF 患者的管理带来积极结果。
