老年营养风险指数对冠状动脉慢性完全闭塞病变患者经皮冠状动脉介入治疗术后远期预后的预测价值

目的 探讨经皮冠状动脉介入治疗（PCI）老年慢性完全闭塞（CTO）病变患者的营养状态与远期预后的关系。方法 纳入2013年6月至2017年10月于西安交通大学第一附属医院346例行PCI的老年CTO病变患者,根据老年营养风险指数（GNRI）分为3组：无营养不良风险组（GNRI≥98,186例）,营养不良低风险组（92≤GNRI<98,114例）,营养不良中度/高度风险组（GNRI<92,46例）。主要终点事件为全因死亡,次要终点事件为心血管死亡。结果 纳入的346例患者平均年龄为72岁,中位随访33个月,Kaplan-Meier生存分析显示,营养不良中/重度风险患者在全因死亡及心血管死亡方面的预后均比其他两组差（Log-rank检验,全因死亡：P=0.004,心血管死亡：P=0.003）。多因素Cox回归分析提示全因死亡与中/重度营养不良、淋巴细胞计数及左心室射血分数相关,心血管死亡只与中/重度营养不良相关。与无营养不良风险患者相比,营养不良中/重度风险患者全因死亡及心血管死亡风险显著增加（HR 2.580,95%CI 1.139～5.842,P=0.023;HR4.709...     

血氯水平与老年急性心力衰竭患者短期不良预后的相关研究

目的 评估入院血氯水平对老年急性失代偿性心力衰竭（心衰）患者短期预后的影响。方法 对发表在PhysioNet的中国成人住院心衰数据进行回顾性分析。根据血氯三分位数将患者分为T1组（Cl≤100.2 mmol/L,n=604）、T2组（100.3104.8 mmol/L,n=609）。主要终点为90 d全因死亡和心衰再住院复合终点。采用Kaplan-Meier曲线评估终点事件的发生情况,建立Cox回归模型分析终点事件的风险预测因子。结果 Kaplan-Meier分析显示,三组全因死亡和心衰再住院复合风险显著不同（P=0.010）;组间心衰再住院风险存在显著差异（P=0.021）,但全因死亡风险无显著差异（P=0.470）。多因素调整的Cox模型显示,入院血氯水平与全因死亡和心衰再入院复合终点风险负相关（HR=0.96,95%CI:0.94～0.99,P=0.012）。与T2组相比,T1组的全因死亡或心衰再住院风险显著增高（HR=1.29,95%CI:1.16～1.77,P<0.001）;T3组与T2组之间比较...     

血小板体积分布宽度评估急性心力衰竭患者预后的价值

目的 观察血小板体积分布宽度（PDW）对急性心力衰竭患者预后评估的价值。方法 回顾性分析2011年1月至2021年1月我院收治的急性心力衰竭患者873例,根据PDW的测量值分为3组：低PDW组（PDW <15.9 fL）、中PDW组（PDW15.9～16.8 fL）及高PDW组（PDW≥16.9 fL）,每3个月通过电话或门诊随访1次,主要终点为全因死亡,次要终点包括心源性死亡和心脏事件,终点事件的中位生存时间分别为1380 d、1380 d及1098 d。结果 与低PDW组相比,全因死亡发生率：中PDW组升高3.3%,(HR=1.033, 95%CI 0.714～1.494, P=0.865),高PDW组升高55.3%(HR=1.553, 95%CI 1.113～2.168,P=0.0096);心源性死亡发生率：中PDW组降低16.2%(HR=0.838, 95%CI 0.497～1.413, P=0.508),高PDW组升高68.5%(HR=1.685, 95%CI 1.082～2.623, P=0.021);心脏事件发生率：中PDW组降低27.7%(HR=0.723, 95...     

肺血管阻力对左心衰竭患者植入埋藏式心脏复律除颤器后室性心律失常事件的预测价值

目的:探讨肺血管阻力(PVR)对左心衰竭患者植入埋藏式心脏复律除颤器(ICD)后室性心动过速(室速)以及因心力衰竭再住院或全因死亡的复合终点事件的预测价值。方法:入选2010-01至2016-12期间在南京市第一医院因左心衰竭植入ICD或心脏再同步化治疗除颤器(CRT-D)进行一级或二级预防的122例患者。所有患者植入装置前接受超声心动图检查,记录肺动脉收缩压(PASP)、平均肺动脉圧(m PAP)和PVR。每6个月随访一次,记录程控数据及终点事件,主要终点为出现室速并接受ICD恰当治疗(包括抗心动过速治疗及电击治疗),次要终点为因心力衰竭再住院或全因死亡的复合终点。结果:平均随访4.2年,36例(29.5%)患者共记录到121次ICD恰当治疗,其中32例(26.3%)接受抗心动过速治疗72次,16例(13.1%)接受电击治疗39次。多因素Cox回归分析表明,PVR是左心衰竭患者植入ICD后出现室速并接受ICD恰当治疗的独立危险因素(HR=1.630,95%CI:1.170~2.010,P0.01)。31例患者发生次要终点事件,其中29例(23.7%)因心力衰竭再住院共31次,18例(14.7%)死亡。多因素Cox回归分析显示,PVR是心力衰竭患者植入ICD后因心力衰竭再住院或死亡复合事件的独立预测因素(HR=2.030,95%CI:1.210~3.120,P0.01)。结论:PVR是左心衰竭患者植入ICD后出现室速并接受ICD恰当治疗以及因心力衰竭再住院或全因死亡复合终点事件的独立预测因素。     

缺血性心肌病合并射血分数改善的心力衰竭患者的临床特征及预后研究

目的 探讨缺血性心肌病（ICM）合并射血分数改善的心力衰竭（HFimpEF）患者的临床特征及预后。方法 选取2018年6月至2021年5月河北省人民医院心脏中心收治的ICM合并慢性心力衰竭（HF）患者425例。根据基线、复查左心室射血分数（LVEF）将其分为HFimpEF组（基线LVEF≤40%，复查LVEF>40%,n=95）、射血分数中间值的心力衰竭（HFmrEF）组（复查LVEF为41%～49%,n=84）、射血分数降低的心力衰竭（HFrEF）组（基线LVEF≤49%，复查LVEF≤40%,n=178）、射血分数保留的心力衰竭（HFpEF）组（基线LVEF及复查LVEF均≥50%,n=68）。比较四组一般资料、超声心动图检查指标、实验室检查指标、治疗情况、全因死亡率、全因再入院率。采用单因素、多因素Cox比例风险回归分析探讨ICM合并HFimpHF患者全因死亡、全因再入院的影响因素。结果 HFimpEF组年龄小于HFpEF组，收缩压（SBP）低于HFpEF组，舒张压（DBP）低于HFrEF组（P<0.05）;HFimpEF组基线左心室收缩末期内径（LVESD）、左心室...     

左心室射血分数减低患者冠状动脉慢性完全闭塞病变介入治疗的安全性及远期疗效

目的:评价左心室射血分数(LVEF)减低(LVEF≤50%)对冠状动脉慢性完全闭塞(CTO)病变经皮冠状动脉介入治疗(PCI)安全性及远期(5年)疗效的影响。方法:回顾性分析2010年1月至2013年12月于中国医学科学院阜外医院成功行CTO-PCI的患者资料,选取术前LVEF≤50%患者303例(LVEF≤50%组),经倾向性评分匹配(1:1) LVEF 50%患者303例(LVEF 50%组)。随访5年,以复合终点(心原性死亡+靶血管相关心肌梗死+靶血管再次血运重建)作为主要研究终点;以手术成功率、并发症发生率、心原性死亡、靶血管相关心肌梗死、靶血管再次血运重建、心力衰竭再住院作为次要研究终点。结果:LVEF≤50%组SYNTAX评分明显高于LVEF 50%组[(19.27±9.03)分vs.(17.09±9.22)分,P=0.00]。两组间支架成功置入率(71.9%vs. 74.3%,P=0.52)和并发症发生率(35.0%vs. 34.3%,P=0.86)相近。548例(90.4%)患者完成5年随访,LVEF≤50%组5年主要研究终点事件率明显高于LVEF 50%组(18.5%vs. 12.5%,P0.05),差异主要由靶血管再次血运重建事件(12.9%vs.7.9%,P0.05)驱动。LVEF≤50%组5年次要研究终点事件,除靶血管再次血运重建率高于LVEF 50%组外,其余次要研究终点心原性死亡、靶血管相关心肌梗死、心力衰竭再住院,差异均无统计学意义(P均 0.05)。Logistic多因素分析发现,长期服用氯吡格雷可降低主要研究终点事件发生风险(HR=0.52,95%CI:0.31～0.88,P=0.02)。结论:LVEF≤50%的CTO患者PCI后即刻手术安全性、有效性良好,但远期主要研究终点事件风险高于LVEF 50%组,特别是靶血管再次血运重建风险突出,长期服用氯吡格雷可降低相关风险。     

肺高压与维持性血液透析患者心血管预后的关系

目的 探讨肺高压（pulmonary hypertension,PH）对维持性血液透析（maintenance hemodialysis,MHD）患者全因死亡及心血管并发症的影响.方法 我们于2009年至201 1年期间随访了278例MHD患者（98例PH、180例无PH）,随访终点为死亡和主要心血管事件.PH定义为心脏超声心动图检测肺动脉收缩压（PASP）≥35 mm Hg（1 mm Hg=0.133 kPa）.结果 随访2年,278例MHD患者中,53例（19.1％）死亡,其中28例死于主要心血管事件,87例（31.3％）患者有新发主要心血管事件.生存分析结果显示伴有PH的MHD患者全因死亡、心血管死亡及新发主要心血管事件发生率均高于不伴PH患者,差异有统计学意义（P＜0.05）.Cox回归分析显示PH患者校正后的风险值分别为HR=1.85,95％CI：1.03～3.34;HR =2.36,95％CI：1.05～5.31和HR =2.27,95％ CI：1.44～3.58.结论 PH是MHD患者全因死亡、心血管死亡及新发主要心血管事件的独立危险因素.建议MHD患者常规每年行一次心脏超声检查筛查PH以便更好地进行预后的危险分层.     

“新四联”背景下伊伐布雷定治疗慢性心力衰竭的有效性和安全性

目的：评估“新四联”背景下伊伐布雷定用于治疗慢性心力衰竭的有效性及安全性。方法：回顾性收集2021年3月至2022年6月在南京鼓楼医院住院治疗的656例慢性心力衰竭患者的临床资料,应用伊伐布雷定患者为观察组（n=295）,未使用伊伐布雷定患者为对照组（n=361）。两组患者均采用“新四联”药物治疗方案治疗。倾向性评分匹配后观察组和对照组分别有268例患者匹配成功。比较两组患者治疗1年的有效性（主要终点为出院后1年内心血管死亡和心力衰竭恶化再住院的复合终点事件,次要终点为心力衰竭恶化再住院、全因再住院、心血管死亡和全因死亡）和安全性指标（包括心动过缓、心房颤动、视力模糊、肾功能损伤、高血压）。绘制Kaplan-Meier生存曲线,采用Cox比例风险回归模型分析两组与终点结局的相关性,并进行亚组分析。结果：匹配后,两组患者基线特征差异均无统计学意义。Kaplan-Meier生存曲线分析显示,观察组主要终点事件（P=0.031）、心力衰竭恶化再住院（P=0.020）和全因再住院（P=0.036）的发生率均低于对照组。多因素Cox比例风险回归模型分析显示,观察组的主要终点事件发生率（P=0.0...     

性别差异对多支血管病变不完全血运重建的影响

目的 探讨经皮冠状动脉介入治疗（PCI）不完全血运重建（IR）对不同性别预后的影响。方法 回顾性分析2012年1月至2017年12月于郑州人民医院接受PCI治疗的多支血管病变（MVD）的IR患者1536例。按照性别分为男性组875例,女性组661例。主要终点为全因死亡、心源性死亡、心肌梗死;次要终点为主要不良心脑血管事件（MACCE）的复合终点,包括心源性死亡、非致死性心肌梗死、缺血驱动的再次血运重建、支架内血栓和脑卒中。结果 PCI后36个月内女性组与男性组主要终点事件对比：全因死亡（8.93%vs. 5.94%）、心源性死亡（4.38%vs. 3.09%）、心肌梗死（3.93%vs. 2.71%）有显著性差异（P<0.05）;次要终点MACCE事件比较差异有统计学意义（P=0.000）,其中缺血驱动的再次血运重建率分别是7.87%(52/661)、5.26%(46/875),支架内血栓发生率分别是1.2%(8/661)、0.34%(3/875);女性组心绞痛发生率、再次住院率和大出血发生率显著高于男性组（P=0.000,P<0.05）;脑卒中的发生率比较差异均无统计学意...     

肺动脉高压对心脏再同步治疗术后生存的预测价值

目的：分析肺动脉高压（ PAH ）对心脏再同步治疗（ CRT ）临床获益的预测价值。方法2007年3月至2012年6月在上海复旦大学附属中山医院植入CRT的165例患者回顾性分析,根据术前肺动脉收缩压（SPAP）将其分为SPAP〈50 mmHg（1 mmHg=0．133 kPa,n=107）与SPAP≥50 mmHg （n=58）两组。以全因死亡为主要终点事件,心力衰竭再住院为次要终点事件,分析两组生存函数差异,并通过Cox回归模型分析终点事件的预测因子。结果 SPAP≥50 mmHg组与SPAP〈50 mmHg组死亡例数分别为13例（22．4%）和8例（7．5%）,心力衰竭再住院例数分别为25例（43．1%）和21例（19．6%）,两者差异有统计学意义（P〈0．01）。 Kaplan-Meier生存分析显示,与SPAP〈50 mmHg组比较, SPAP≥50 mmHg者累积生存率较低（ P〈0．05）,累积再住院率则较高（ P〈0．01）。多因素回归分析显示,SPAP≥50 mmHg者主要终点事件风险比3．089（95%CI 1．117-8．543,P=0．03）,次要终点事件风险比2．465（95%CI 1．318－4．611,P=0．005）。结论中-重度PAH患者CRT后临床获益不佳,且是全因死亡和心力衰竭再住院的独立预测因子。     

Impact of Successful Chronic Coronary Total Occlusion Recanalization on Recurrence of Ventricular Arrhythmias in Implantable Cardioverter-Defibrillator Recipients for Ischemic Cardiomyopathy (VACTO PCI Study)

BackgroundCoronary chronic total occlusion lesions (CTOs) confer an increased risk of arrhythmic events among patients with ischemic cardiomyopathy (ICM) and implantable cardioverter-defibrillator (ICD) carriers, however the impact of CTO recanalization in this population remains unassessed.AimsEvaluate the impact of CTOs percutaneous coronary interventions (PCI) on arrhythmic events.MethodsPatients with ICM and ICD from the VACTO I-II registries: patients with medically treated CTO (CTO-OMT group) and without CTO (no-CTO group) were compared after inverse-probability-weighting adjustment (IPWT) with a similar population of consecutive patients undergoing CTO-PCI. The primary endpoint was appropriate ICD therapy. The secondary endpoint was all-cause mortality.ResultsThe total of 622 patients (mean age 67 ± 10 years, mean left ventricular ejection fraction 36 ± 11%) included in the analysis was composed by: CTO-PCI patients n = 113, CTO-OMT patients n = 286, no-CTO patients n = 223. In the CTO-PCI group, compared to the CTO-OMT group, 5-year Kaplan Meier estimates for appropriate ICD therapy (20.4% vs. 56.4%, IPW-adjusted HR: 0.45, 95% CI 0.29–0.71) and mortality (8.8% vs. 23%, IPW-adjusted HR: 0.43, 95% CI 0.22–0.85) were lower, driven by infarct related artery CTO (IRA-CTO) PCI, while similar to those occurring in the no-CTO group.ConclusionsIn this large population, those with CTO receiving PCI had lower arrhythmic event rates and lower mortality compared to the CTO-OMT group, while showing an event rate similar to no-CTO patients. Sensitivity analyses suggest that the beneficial effect on the arrhythmic outcome was driven by IRA-CTO revascularization.ClassificationChronic total occlusion.     

Predictors of death and occurrence of appropriate implantable defibrillator therapies in patients with ischemic cardiomyopathy

Most patients with chronic ischemia and an implantable cardiac defibrillator (ICD) for primary prevention do not experience therapies for ventricular arrhythmias on follow-up. The present study aimed to identify independent clinical, electrocardiographic, and echocardiographic predictors of death and occurrence of ICD therapy in patients with chronic ischemic cardiomyopathy and ICD for primary prevention. A total of 424 patients with chronic ischemic cardiomyopathy, ejection fraction ≤ 35%, and New York Heart Association (NYHA) class ≥ II were recruited. All patients underwent echocardiography before ICD insertion. Primary outcome was all-cause mortality; secondary outcome was occurrence of appropriate ICD therapy on follow-up. Primary and secondary outcomes occurred in 84 and 95 patients, respectively. Patients who died were more likely to have diabetes (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.00 to 2.79, p = 0.049), higher NYHA class (HR 1.96, 95% CI 1.15 to 3.33, p = 0.013), lower peri-infarct strain on echocardiogram (HR 1.25, 95% CI 1.07 to 1.46, p = 0.005), and lower glomerular filtration rate (HR 1.01, 95% CI 1.00 to 1.03, p = 0.022). Only peri-infarct strain (HR 1.22, 95% CI 1.09 to 1.36, p < 0.001) predicted the occurrence of ICD therapy on follow-up. In conclusion, in chronic ischemic patients with an ICD for primary prevention, the presence of diabetes, renal dysfunction, higher NYHA class, and impaired peri-infarct zone function were predictors of all-cause mortality. In contrast, only impaired peri-infarct zone function determined the occurrence of appropriate ICD therapy on follow-up.     

Predictive value of microvolt T-wave alternans in patients with left ventricular dysfunction.

OBJECTIVES: The purpose of this study was to prospectively evaluate the utility of microvolt T-wave alternans (TWA) in predicting arrhythmia-free survival and total mortality in patients with left ventricular (LV) dysfunction. BACKGROUND: Microvolt TWA has been proposed as a useful tool in identifying patients unlikely to benefit from prophylaxis with implantable cardioverter-defibrillator (ICD) prophylaxis. METHODS: We evaluated 286 patients with an LV ejection fraction 相似文献   

Catheter Ablation of Well Tolerated Ventricular Tachycardia in Patients With Structural Heart Disease and Without Automatic Defibrillator Implantation: Long Term Follow-up

The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered related to poor prognosis. The purpose of our work was to evaluate if these patients could benefit from radiofrequency (RF) ablation, and the defibrillator (ICD) implantation could be deferred during follow-up. We reviewed consecutive patients with well-tolerated SMVT, SHD and left ventricular ejection fraction over 30%. These patients were treated by RF ablation and were discharged without ICD. The primary outcome was a composite of all-cause death and recurrence of SMVT; the secondary outcome was death from all causes. Sixty-two patients were selected. After a median follow-up of 38.8 months, the primary outcome occurred in 24 (38.7%) and the secondary in 11 (17.7%) patients. The annual mortality rate was 4.3% and no patient died from sudden death. RF ablation as a first-choice therapy seems to represent an effective and beneficial therapeutic approach.     

High risk of ventricular arrhythmias in patients with nonischemic dilated cardiomyopathy presenting with syncope

It is not entirely clear whether the presentation of syncope in patients with nonischemic dilated cardiomyopathy (NIDC) is an ominous prognostic indicator, because randomized controlled implantable cardioverter-defibrillator (ICD) trials generally exclude such patients. This study compared 108 consecutive patients with NIDC presenting with syncope with 71 consecutive patients with NIDC who presented with sustained ventricular arrhythmias, with regard to freedom from any ventricular arrhythmias or life-threatening arrhythmias and all-cause mortality. There was no significant difference between the groups in the 3 outcomes during the follow-up of 43.5 +/- 32.1 months. Male gender and ICD therapy predicted increased risk for any ventricular arrhythmias. A reduced left ventricular ejection fraction and increased age were predictive of increased mortality. In conclusion, patients with NIDC presenting with syncope are a high-risk group, with event rates similar to patients with NIDC presenting with sustained arrhythmias, and should be considered for ICD therapy.     

Long-term follow-up of sudden cardiac arrest survivors and electrophysiologically guided antiarrhythmic therapy

Sudden cardiac arrest survivors have a high risk of suffering from recurrent arrhythmic events. Recent studies have shown that these patients have a significantly decreased mortality rate, if they are supplied with an implantable cardioverter/defibrillator (ICD). The aim of this study was to evaluate the long-term prognosis of patients with electrophysiologically guided antiarrhythmic drug therapy in comparison to patients with ICD. 204 consecutive survivors of sudden cardiac arrest were enrolled in this study. All patients were examined with an initial electrophysiologic study (EPS) with programmed ventricular stimulation. Patients were treated with antiarrhythmic drugs (if the inducible tachycardia was suppressed) or with the implantation of an ICD. The maximal follow-up period was 120 months, the mean period was 53.3 +/- 31.4 months (ICD) versus 60.3 +/- 35.5 months (EPS, nonsignificant). Patients with ICD showed an overall mortality rate of 14.6%, whereas EPS-guided patients had a mortality rate of 43.2% (p < 0.001). The cardiac and arrhythmogenic mortality rates were significantly lower in the ICD group (12 vs. 43%, p < 0.01, and 1 vs. 16%, p < 0.001, respectively). A reduction of the mortality risk was observed in the ICD group by up to 61% (all-cause mortality), 52% (cardiac mortality) and 97.2% (arrhythmogenic mortality). In arrhythmic event survivors with ICD, arrhythmic and overall mortality rates are significantly lower compared to patients with an EPS-guided drug therapy. In the secondary prevention of sudden cardiac death, ICD should be the first choice of antiarrhythmic therapy.     

Effectiveness of implantable cardioverter-defibrillators in patients with ischemic heart disease and left ventricular dysfunction

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) have been shown in primary prevention efficacy trials to reduce mortality in patients with ischemic heart disease and left ventricular dysfunction. To investigate the generalizabilty of this mortality reduction, we examined the effectiveness of ICDs in clinical practice. METHODS: We developed a prospective multicenter cohort of 770 patients with ischemic left ventricular dysfunction (ejection fraction < or =35%) and without a history of ventricular arrhythmia, of whom 395 (52%) received ICDs. Mean +/- SD follow-up was 27 +/- 12 months. We assessed the degree to which ICDs decreased mortality risk using Cox proportional hazards analyses that controlled for clinical predictors of death, receipt of ICD (a propensity score analysis), and predictors of arrhythmic death (including electrophysiologic variables). RESULTS: Multivariate Cox analyses showed that those with ICDs had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.33-0.86). This mortality reduction was mediated through dramatically lower arrhythmia-related mortality (HR, 0.35; 95% CI, 0.17-0.73), with no significant effect on cardiovascular nonarrhythmic (HR, 0.81; 95% CI, 0.34-1.96) and noncardiovascular (HR, 0.76; 95% CI, 0.29-2.05) mortality. No differences were found between the ICD and non-ICD groups for a composite outcome of all-cause mortality, appropriate ICD shocks, or documented symptomatic ventricular arrhythmia, which suggests that the 2 groups had similar baseline risk for life-threatening arrhythmic events (HR, 0.96; 95% CI, 0.63-1.45). CONCLUSION: In clinical practice, ICDs appear to reduce all-cause and arrhythmic rates of mortality at levels similar to those found in primary prevention trials.     

Poor prognosis in chronic heart failure patients with reduced ejection fraction in China

Most Chinese cardiologists are challenged by the high mortality rate of heart failure (HF) in patients with reduced ejection fraction in China. This study was designed as a single-center, retrospective study. All consecutive HF patients with left ventricular ejection fraction (LVEF) ≤ 45% from January 1, 2007, to December 31, 2009, were enrolled. The primary outcome was all-cause mortality. The secondary outcome was all-cause mortality or the first cardiovascular readmission event. A total of 187 patients comprised the study population, classified into two groups: LVEF ≤ 35% (n=83) and LVEF 36% to 45% (n=104). The median follow-up was 18 months (2-41 months). All-cause mortality was 27% among patients with LVEF ≤ 35%, as compared with 14% among those with LVEF 36% to 45% (P=.025). All-cause mortality or first cardiovascular readmission rates were 53% and 32% among patients with LVEF ≤ 35% and 36% to 45% (P=.003), respectively. The predictors of all-cause mortality were advanced age and New York Heart Association functional class, chronic kidney disease, oral β-blockers, and statins at discharge. The prognosis of chronic HF patients with LVEF ≤ 45% was poor in China, especially for patients with LVEF ≤ 35%. Cardiologists should provide further efforts to improve the prognosis of HF in Chinese patients.     

Long-term follow-up of implantable cardioverter-defibrillator for secondary prevention in chagas' heart disease

Assessing the efficacy of implantable cardioverter-defibrillators (ICD) in patients with Chagas' heart disease (ChHD) and identifying the clinical predictors of mortality and ICD shock during long-term follow-up. ChHD is associated with ventricular tachyarrhythmias and an increased risk of sudden cardiac death. Although ChHD is a common form of cardiomyopathy in Latin American ICD users, little is known about its efficacy in the treatment of this population. The study cohort included 116 consecutive patients with ChHD and an ICD implanted for secondary prevention. Of the 116 patients, 83 (72%) were men; the mean age was 54 ± 10.7 years. Several clinical variables were tested in a multivariate Cox model for predicting long-term mortality. The average follow-up was 45 ± 32 months. New York Heart Association class I-II developed in 83% of patients. The mean left ventricular ejection fraction was 42 ± 16% at implantation. Of the 116 patients, 58 (50%) had appropriate shocks and 13 (11%) had inappropriate therapy. A total of 31 patients died (7.1% annual mortality rate). New York Heart Association class III (hazard ratio [HR] 3.09, 95% confidence interval 1.37 to 6.96, p = 0.0064) was a predictor of a worse prognosis. The left ventricular ejection fraction (HR 0.972, 95% confidence interval 0.94 to 0.99, p = 0.0442) and low cumulative right ventricular pacing (HR 0.23, 95% confidence interval 0.11 to 0.49, p = 0.0001) were predictors of better survival. The left ventricular diastolic diameter was an independent predictor of appropriate shock (HR 1.032, 95% confidence interval 1.004 to 1.060, p = 0.025). In conclusion, in a long-term follow-up, ICD efficacy for secondary sudden cardiac death prevention in patients with ChHD was marked by a favorable annual rate of all-cause mortality (7.1%); 50% of the cohort received appropriate shock therapy. New York Heart Association class III and left ventricular ejection fraction were independent predictors of worse prognosis, and low cumulative right ventricular pacing defined better survival.     

Microvolt T-wave alternans identifies patients with ischemic cardiomyopathy who benefit from implantable cardioverter-defibrillator therapy.

OBJECTIVES: This study sought to assess whether implantable cardioverter-defibrillators (ICDs) have different mortality benefits among patients with ischemic cardiomyopathy who screen negative and non-negative (positive and indeterminate) for microvolt T-wave alternans (MTWA). BACKGROUND: Microvolt T-wave alternans has been proposed as an effective tool for risk stratification. However, no studies have examined whether ICD benefits differ by MTWA group. METHODS: We developed a prospective cohort of 768 patients with ischemic cardiomyopathy (left ventricular ejection fraction < or =35%) and no prior sustained ventricular arrhythmia, of which 392 (51%) received ICDs. The mean follow-up time was 27 +/- 12 months. Propensity scores for ICD implantation based on the variables most likely to influence defibrillator implantation were developed for each MTWA cohort. Multivariable Cox analyses that controlled for propensity score, demographics, and clinical variables evaluated the degree to which ICDs decreased mortality risk for each MTWA group. RESULTS: We identified 514 (67%) patients with a non-negative MTWA test result. After multivariable adjustment, ICDs were associated with lower all-cause mortality in MTWA-non-negative patients (hazard ratio [HR] 0.45, 95% confidence interval [CI] 0.27 to 0.76, p = 0.003) but not in MTWA-negative patients (HR 0.85, 95% CI 0.33 to 2.20, p = 0.73) (for interaction, p = 0.04), with the mortality benefit in MTWA-non-negative patients largely mediated through arrhythmic mortality reduction (HR 0.30, 95% CI 0.13 to 0.68, p = 0.004). The number needed to treat with an ICD for 2 years to save 1 life was 9 among MTWA-non-negative patients and 76 among MTWA-negative patients. CONCLUSIONS: In patients with ischemic cardiomyopathy and no prior history of ventricular arrhythmia, mortality reduction with ICD implantation differs by MTWA status, with implications for risk stratification and health policy.