Ansalone G, Giannantoni P, Santini M
Dipartimento delle Malattie del Cuore, Azienda Ospedaliera San Filippo Neri, Roma.
G Ital Cardiol. 1998 Nov;28(11):1288-302.
The challenge of preventing arrhythmic sudden death is one of the major issues in today's treatment of heart failure. To achieve this ambitious goal, an accurate selection of the candidates for sudden death is needed on the one hand, while on the other hand, the assessment of the real cost/benefit ratio of the implantable cardioverter-defibrillator in selected patients, as compared to ACE inhibitors, beta-blockers and antiarrhythmic drug therapy, should no longer be delayed. As is well known, the incidence of sudden death is higher in ischemic dilated cardiomyopathy than it is in non-ischemic dilated cardiomyopathy. Moreover, tachyarrhythmic sudden death is prevalent in NYHA classes I and II (80%), whereas its incidence is lower (50%) in NYHA classes III and IV, since bradyarrhythmia, electromechanical dissociation and thromboembolic events characterize the other 50% of sudden deaths in patients in the latter NYHA class. The stratification of arrhythmic risk in non-ischemic dilated cardiomyopathy is questionable from any point of view, considering the poor predictive power of invasive and non-invasive indexes. However, some subgroups of high-risk patients should be selected, such as patients waiting for heart transplant or those with a severe disease but without an extreme degree of ventricular dysfunction, in whom the prognosis in terms of pump failure events is better and life expectancy is longer if the risk of arrhythmia is properly assessed and sudden death prevented. Consequently, the ICD implant may be effective in order to pursue the aim of reducing the tachyarrhythmic and bradyarrhythmic mortality in patients with a more severe disease and of minimizing the tachyarrhythmic risk in those with a less severe disease. Further studies will be developed to identify the ideal candidates for ICD implants.
预防心律失常性猝死是当今心力衰竭治疗中的主要问题之一。为实现这一宏伟目标，一方面需要准确筛选猝死候选人，另一方面，与血管紧张素转换酶抑制剂、β受体阻滞剂和抗心律失常药物治疗相比，应不再拖延对选定患者植入式心脏复律除颤器实际成本效益比的评估。众所周知，缺血性扩张型心肌病的猝死发生率高于非缺血性扩张型心肌病。此外，快速心律失常性猝死在纽约心脏协会（NYHA）心功能I级和II级患者中较为普遍（80%），而在NYHA心功能III级和IV级患者中发生率较低（50%），因为缓慢性心律失常、电机械分离和血栓栓塞事件是后一组NYHA分级患者中另外50%猝死的特征。从任何角度来看，非缺血性扩张型心肌病心律失常风险的分层都存在疑问，因为有创和无创指标的预测能力较差。然而，应选择一些高危患者亚组，如等待心脏移植的患者或患有严重疾病但心室功能障碍程度不太严重的患者，如果心律失常风险得到正确评估并预防猝死，这些患者在泵衰竭事件方面的预后较好，预期寿命较长。因此，植入式心脏复律除颤器可能有效，以实现降低病情较重患者快速心律失常和缓慢性心律失常死亡率以及将病情较轻患者的快速心律失常风险降至最低的目标。将开展进一步研究以确定植入式心脏复律除颤器的理想候选人。
