Gouda Pishoy, Alemayehu Wendimagegn, Voors Adriaan A, Lam Carolyn S P, Ezekowitz Justin, Pieske Burkert, Butler Javed, Westerhout Cynthia M, Yogasundaram Haran, Sandhu Roopinder K, Armstrong Paul W
Division of Cardiology, University of Alberta, Edmonton, AB, Canada.
Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada.
Eur J Heart Fail. 2025 Jun 20. doi: 10.1002/ejhf.3731.
Guidelines recommend the use of implantable cardioverter-defibrillators (ICDs) to reduce the risk of sudden cardiac death (SCD) among individuals with heart failure (HF) with reduced ejection fraction (HFrEF). However, the magnitude of benefit from ICD therapy remains unclear in those with a non-ischaemic aetiology of HF.
Participants with HFrEF and recent HF decompensation in the VICTORIA trial were categorized based on the utilization of a baseline ICD and HF aetiology. A propensity-score adjusted model was used to assess the effect of the presence of an ICD on SCD, cardiovascular death (including SCD) and all-cause death. Of 5040 participants with HFrEF (53.6% ischaemic; 46.4% non-ischaemic), 1399 (27.8%) had an ICD. Over a median of 10.8 months, pre-existing ICD was associated with an overall reduction in SCD (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.43-0.96), but no difference in cardiovascular death (aHR 0.99, 95% CI 0.83-1.18) or all-cause death (aHR 1.02, 95% CI 0.87-1.19). HF aetiology did not modify the effects of ICD on SCD (ischaemic HF: aHR 0.61, 95% CI 0.38-0.98; non-ischaemic HF: aHR 0.72, 95% CI 0.36-1.43; p = 0.69). Despite relative underuse of ICDs in women as compared to men (16.4% vs. 26.8%), women with an ischaemic cause of their HF had a significant reduction in SCD (aHR 0.2, 95% CI 0.05-0.82; p = 0.029). The presence of atrial fibrillation modulated ICD treatment effect on SCD (p = 0.015), with no benefit observed in those with atrial fibrillation.
Among patients with HFrEF with recent decompensation, presence of an ICD was associated with a reduction in SCD, but did not translate to a reduction in the risk of cardiovascular or all-cause death. Future research is required to evaluate which patients with HFrEF benefit from ICD implantation.
指南推荐使用植入式心脏复律除颤器（ICD）以降低射血分数降低的心力衰竭（HFrEF）患者的心源性猝死（SCD）风险。然而，在非缺血性病因的心力衰竭患者中，ICD治疗的获益程度仍不明确。
VICTORIA试验中近期发生心力衰竭失代偿的HFrEF参与者根据基线ICD的使用情况和心力衰竭病因进行分类。采用倾向评分调整模型评估ICD的存在对SCD、心血管死亡（包括SCD）和全因死亡的影响。在5040例HFrEF参与者中（53.6%为缺血性；46.4%为非缺血性），1399例（27.8%）有ICD。在中位10.8个月的时间里，既往有ICD与SCD总体降低相关（调整后风险比[aHR]0.64，95%置信区间[CI]0.43 - 0.96），但在心血管死亡（aHR 0.99，95% CI 0.83 - 1.18）或全因死亡（aHR 1.02，95% CI 0.87 - 1.19）方面无差异。心力衰竭病因并未改变ICD对SCD的影响（缺血性心力衰竭：aHR 0.61，95% CI 0.38 - 0.98；非缺血性心力衰竭：aHR 0.72，95% CI 0.36 - 1.43；p = 0.69）。尽管与男性相比，女性ICD的使用相对不足（16.4%对26.8%），但缺血性心力衰竭病因的女性SCD显著降低（aHR 0.2，95% CI 0.05 - 0.82；p = 0.029）。心房颤动的存在调节了ICD对SCD的治疗效果（p = 0.015），在有心房颤动的患者中未观察到获益。
在近期失代偿的HFrEF患者中，ICD的存在与SCD降低相关，但并未转化为心血管或全因死亡风险的降低。需要进一步研究以评估哪些HFrEF患者从ICD植入中获益。
