T-wave alternans in risk stratification of patients with nonischemic dilated cardiomyopathy: Can it help to better select candidates for ICD implantation?
T-wave alternans in risk stratification of patients with nonischemic dilated cardiomyopathy: Can it help to better select candidates for ICD implantation?
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DOI：
10.1016/j.hrthm.2008.10.008
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发表时间：
2009-03-01
期刊：
影响因子：
5.5
通讯作者：
Sanzo, Antonio
中科院分区：
文献类型：
--
作者：
De Ferrari, Gaetano M.;Sanzo, Antonio
背景：预防性植入式心律转复除颤器（ICD）治疗可降低心力衰竭（HF）和左心室射血分数（LVEF）降低患者的死亡率，但绝对风险降低相对较小。因此，有一个强烈的需要，以确定可靠的风险分层，特别是在患者与非缺血性心肌病（NIDCM），在其中的风险预测的搜索一直特别令人沮丧。目的本研究旨在审查数据有关的T波电交替（TWA）在NIDCM患者，并讨论其潜在的role.METHODS我们纳入了荟萃分析临床试验，纳入>= 50 NICDM患者，随访>= 1年，并提供了混合人群中NIDCM患者的详细数据。相对风险来自于异常（阳性+不确定的测试，只要可能）TWA与正常（阴性）TWA group.Results8研究1,456例患者（平均年龄56岁，LVEF 30%，随访25个月）的事件的绝对数量。33%的患者TWA试验阴性，21%的患者TWA试验不确定。主要终点（VT+VF+猝死或全因死亡）发生在14.7%的异常TWA患者中，而正常TWA患者为3.8%。累积数据的相对风险为2.99（95%置信区间：1.88 - 4.75）。结论TWA检测正常的NIDCM患者中有1/3预后良好，ICD治疗对NIDCM患者的预后无明显影响。一项评价TWA在指导治疗中的效用的随机临床试验似乎是必要的，可能是一项在TWA阴性患者中仅使用药物治疗与ICD相比的非劣效性试验。
BACKGROUND Prophylactic implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF), but the absolute risk reduction is relatively small. Thus, there is a strong need to identify reliable risk stratifiers, particularly among patients with nonischemic cardiomyopathy (NIDCM), in whom the search for risk predictors has been particularly frustrating.OBJECTIVE This study sought to review data regarding T-wave alternans (TWA) in patients with NIDCM and to discuss its potential role.METHODS We included in a meta-analysis clinical trials that enrolled >= 50 NICDM patients, had a follow-up of >= 1 year, and provided detailed data on NIDCM patients, in case of mixed population. Relative risks were derived from absolute numbers of events in abnormal (positive + indeterminate test whenever possible) TWA versus normal (negative) TWA group.RESULTS Eight studies with 1,456 patients (mean age 56 years, LVEF 30%, follow-up 25 months) were included. A negative TWA test occurred in 33%, and was indeterminate in 21% of the patients. The primary end point (VT+VF+sudden or all-cause death) occurred in 14.7% abnormal versus 3.8% normal TWA patients. The relative risk for the cumulative data was found to be 2.99 (95% confidence interval: 1.88 to 4.75). The negative predictive value was 96.2%.CONCLUSION A normal TWA test identifies one-third of NIDCM patients who have a very good prognosis and are unlikely to significantly benefit from ICD therapy. A randomized clinical trial evaluating the utility of TWA in guiding therapy seems warranted, possibly a noninferiority trial of medical therapy only versus ICD in TWA-negative patients.