Implantable cardioverter defibrillators for primary prevention of death in left ventricular dysfunction with and without ischaemic heart disease: a meta-analysis of 8567 patients in the 11 trials.
Implantable cardioverter defibrillators for primary prevention of death in left ventricular dysfunction with and without ischaemic heart disease: a meta-analysis of 8567 patients in the 11 trials.
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DOI：
10.1093/eurheartj/ehx028
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发表时间：
2017-06-07
影响因子：
39.3
通讯作者：
Francis DP
中科院分区：
文献类型：
--
作者：
Shun-Shin MJ;Zheng SL;Cole GD;Howard JP;Whinnett ZI;Francis DP
一级预防植入式心律转复除颤器（ICDs）是降低左室收缩功能障碍和缺血性心脏病（IHD）患者死亡率的既定治疗方法。然而，它们对非IHD患者的疗效一直存在争议。我们对全部证据进行了荟萃分析。我们系统地确定了所有比较ICD与非ICD在一级预防中的rct。符合条件的随机对照试验招募了有左心室功能障碍的患者，报告了全因死亡率，并根据是否存在IHD（或仅招募有或没有IHD的患者）将结果分层。我们的主要终点是全因死亡率。我们纳入了11项研究，纳入8567名左心室功能障碍患者，包括3128名非IHD患者和5439名IHD患者。在没有IHD的患者中，ICD治疗降低了24%的死亡率（HR 0.76, 95% CI 0.64 ~ 0.90, P = 0.001）。在IHD患者中，ICD植入（在专门的程序中）也降低了24%的死亡率（HR 0.76, 95% CI 0.60至0.96,P = 0.02）。到目前为止，还没有明确的证据表明COMPANION中没有IHD的患者在添加ICD治疗后表现出显著的生存获益（以CRT为背景）。甚至在丹麦之前，对无缺血性心脏病患者的荟萃分析已经显示死亡率降低。丹麦语与这些数据一致。由于两种病因的死亡率均显著降低24%，因此在决定是否进行一级预防ICD植入时，可能不再需要区分它们。
Primary prevention implantable cardioverter defibrillators (ICDs) are established therapy for reducing mortality in patients with left ventricular systolic dysfunction and ischaemic heart disease (IHD). However, their efficacy in patients without IHD has been controversial. We undertook a meta-analysis of the totality of the evidence. We systematically identified all RCTs comparing ICD vs. no ICD in primary prevention. Eligible RCTs were those that recruited patients with left ventricular dysfunction, reported all-cause mortality, and presented their results stratified by the presence of IHD (or recruited only those with or without). Our primary endpoint was all-cause mortality. We identified 11 studies enrolling 8567 participants with left ventricular dysfunction, including 3128 patients without IHD and 5439 patients with IHD. In patients without IHD, ICD therapy reduced mortality by 24% (HR 0.76, 95% CI 0.64 to 0.90, P = 0.001). In patients with IHD, ICD implantation (at a dedicated procedure), also reduced mortality by 24% (HR 0.76, 95% CI 0.60 to 0.96, P = 0.02). Until now, it has never been explicitly stated that the patients without IHD in COMPANION showed significant survival benefit from adding ICD therapy (to a background of CRT). Even before DANISH, meta-analysis of patients without ischaemic heart disease already showed reduced mortality. DANISH is consistent with these data. With a significant 24% mortality reduction in both aetiologies, it may no longer be necessary to distinguish between them when deciding on primary prevention ICD implantation.