置入心脏复律除颤器(ICD)不被推荐用于心肌梗死(MI)40天以内的患者,因此在MI后过渡期管理期间可能不考虑予患者置入ICD治疗。美国学者近期在低射血分数(EF)老年MI患者中评估了ICD置入率和与其相关的死亡率,结果表明,在上述人群中,虽然ICD置入与2年时患者较低的校正死亡风险有关,但不到1/10的适宜患者在MI后1年内接受了ICD置入。相关论文近日在线发表于《美国医学会杂志》(简称JAM
置入心脏复律除颤器(ICD)不被推荐用于心肌梗死(MI)40天以内的患者,因此在MI后过渡期管理期间可能不考虑予患者置入ICD治疗。美国学者近期在低射血分数(EF)老年MI患者中评估了ICD置入率和与其相关的死亡率,结果表明,在上述人群中,虽然ICD置入与2年时患者较低的校正死亡风险有关,但不到1/10的适宜患者在MI后1年内接受了ICD置入。相关论文近日在线发表于《美国医学会杂志》(简称JAMA)。
该回顾观察性研究纳入了MI后EF≤35%的受试者10318例,排除了既往置入过ICD的患者。获取至2010年12月的患者随访数据。对MI后1年内置入ICD和未置入ICD的患者进行对比,以1年内接受ICD置入治疗相关的患者特征和2年死亡率作为主要评价指标。
结果显示,受试者累积1年ICD置入率为8.1% (95% CI, 7.6%-8.7%; n = 785)。与1年内未接受ICD置入患者相比,置入ICD的患者更可能是既往接受过冠状动脉旁路移植术(CABG)[31% vs 20%; 校正危险比(HR)1.49; 95% CI1.26-1.78],且其肌钙蛋白水平(中位数,正常值的85 vs 51倍;校正HR1.02/10倍增加;95% CI, 1.01-1.03)、院内心源性休克(13% vs 8%; 校正HR, 1.57; 95% CI, 1.25-1.97)和安装后2周内心脏病学随访率(30% vs 20%; 校正HR, 1.64; 95% CI, 1.37-1.95)均较高。ICD置入与2年死亡率较低有关[15.3事件/100患者-年(838例患者-年中有128例死亡)]vs[26.4事件/100患者-年(11 479例患者-年中有3033例死亡)];(校正HR 0.64; 95% CI, 0.53-0.78)。
参考文献:Sean D. Pokorney,et al.JAMA. 2015;313(24):2433-2440. doi:10.1001/jama.2015.6409.
Original Investigation | June 23/30, 2015
Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Acute Myocardial Infarction
Sean D. Pokorney, MD, MBA1,2; Amy L. Miller, MD, PhD3; Anita Y. Chen, MS2; Laine Thomas, PhD2; Gregg C. Fonarow, MD4; James A. de Lemos, MD5; Sana M. Al-Khatib, MD, MHS1,2; Eric D. Peterson, MD, MPH1,2; Tracy Y. Wang, MD, MHS, MSc1,2
[+] Author Affiliations
JAMA. 2015;313(24):2433-2440. doi:10.1001/jama.2015.6409.
ABSTRACT
Importance Implantablecardioverter-defibrillators (ICDs) are not recommended within 40 days of myocardial infarction (MI); thus, ICD implantation might not be considered during the post-MI care transition.
Objective To examine ICD implantation rates and associated mortality among older MI patients with low ejection fraction (EF).
Design, Setting, and Participants Retrospective observational study of Medicare beneficiaries with an EF of 35% or less after MI, treated at 441 US hospitals between 2007 and 2010, excluding patients with prior ICD implantation. Follow-up data were available through December 2010.
Exposures ICD implantation within 1 year of MI vs no ICD implantation within 1 year of MI.
Main Outcomes and Measures Patient characteristics associated with receiving an ICD within 1 year after discharge and 2-year mortality associated with ICD implantation.
Results Among 10 318 MI patients with EF of 35% or lower, the cumulative 1-year ICD implantation rate was8.1% (95% CI, 7.6%-8.7%; n = 785). Patients with ICD implantation were more likely to have prior coronary artery bypass graft procedures (31% vs 20%; adjusted hazard ratio [HR], 1.49; 95% CI, 1.26-1.78),higher peak troponin levels (median, 85 vs 51 times the upper limit of normal; adjusted HR, 1.02 per 10-fold increase; 95% CI, 1.01-1.03),in-hospital cardiogenic shock (13% vs 8%; adjusted HR, 1.57; 95% CI, 1.25-1.97), and cardiology follow-up within 2 weeks after discharge (30% vs 20%; adjusted HR, 1.64; 95% CI, 1.37-1.95) relative to patients who did not receive an ICD within 1 year.Implantation of ICD was associated with lower 2-year mortality (15.3 events per 100 patient-years [128 deaths in 838 patient-years] vs 26.4 events per 100 patient-years [3033 deaths in 11 479 patient-years]; adjusted HR, 0.64; 95% CI, 0.53-0.78).
Conclusions and Relevance In this large registry study of older patients who experienced MI from 2007-2010, fewer than 1 in 10 eligible patients with low EF received an ICD within 1 year after MI, although ICD implantation was associated with lower risk-adjusted mortality at 2 years. Additional research is needed to determine evidence-based approaches to increase ICD implantation among eligible patients.
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