Bundle-branch block morphology and other predictors of outcome after cardiac resynchronization therapy in Medicare patients.
Bundle-branch block morphology and other predictors of outcome after cardiac resynchronization therapy in Medicare patients.
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DOI：
10.1161/circulationaha.110.956011
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发表时间：
2010-11-16
期刊：
影响因子：
37.8
通讯作者：
Stukenborg GJ
中科院分区：
文献类型：
--
作者：
Bilchick KC;Kamath S;DiMarco JP;Stukenborg GJ
心脏再同步化治疗（CRT）的临床试验已经招募了一组精选的患者，很少有患者属于亚组，如右束支阻滞（RBBB）。以人群为基础的结果分析提供了一种方法来确定CRT结果的现实预测因素。医疗保险植入式心律转复除颤器登记（2005年至2006年）数据与患者预后数据合并。Cox比例风险模型评估了使用CRT和植入式心律转复除颤器（CRT- d）患者的死亡和死亡/心力衰竭住院结果。14946例注册的CRT-D患者（中位随访40个月）的1年、3年和总死亡率分别为12%、32%和37%。纽约心脏协会IV级心力衰竭状态（1年风险比[HR]， 2.23； 3年风险比，1.98，P<0.001）和年龄≥80岁（1年风险比，1.74；3年风险比，1.75，P<0.001）与CRT-D术后早期和晚期死亡率增加相关。RBBB（1年HR， 1.44； 3年HR， 1.37， P<0.001）和缺血性心肌病（1年HR， 1.39； 3年HR， 1.44， P<0.001）是早期和晚期死亡率的第二强调整预测因子。RBBB和缺血性心肌病的校正死亡风险（HR, 1.99； P<0.001）是左血脑屏障和非缺血性心肌病的两倍。QRS持续时间至少150 ms预测左血脑屏障的预后更有利，但对右血脑屏障没有影响。另一项分析显示，与标准植入式心律转复除颤器相比，左血脑屏障的CRT-D风险较低。在医保患者中，RBBB、缺血性心肌病、纽约心脏协会IV级状态和高龄是ct - d后不良预后的有力调整预测因子。ct - d后3至4年的实际死亡率似乎高于先前认识到的水平。
Clinical trials of cardiac resynchronization therapy (CRT) have enrolled a select group of patients, with few patients in subgroups such as right bundle-branch block (RBBB). Analysis of population-based outcomes provides a method to identify real-world predictors of CRT outcomes. Medicare Implantable Cardioverter-Defibrillator Registry (2005 to 2006) data were merged with patient outcomes data. Cox proportional-hazards models assessed death and death/heart failure hospitalization outcomes in patients with CRT and an implantable cardioverter-defibrillator (CRT-D). The 14 946 registry patients with CRT-D (median follow-up, 40 months) had 1-year, 3-year, and overall mortality rates of 12%, 32%, and 37%, respectively. New York Heart Association class IV heart failure status (1-year hazard ratio [HR], 2.23; 3-year HR, 1.98; P<0.001) and age ≥80 years (1-year HR, 1.74; 3-year HR, 1.75; P<0.001) were associated with increased mortality both early and late after CRT-D. RBBB (1-year HR, 1.44; 3-year HR, 1.37; P<0.001) and ischemic cardiomyopathy (1-year HR, 1.39; 3-year HR, 1.44; P<0.001) were the next strongest adjusted predictors of both early and late mortality. RBBB and ischemic cardiomyopathy together had twice the adjusted hazard for death (HR, 1.99; P<0.001) as left BBB and nonischemic cardiomyopathy. QRS duration of at least 150 ms predicted more favorable outcomes in left BBB but had no impact in RBBB. A secondary analysis showed lower hazards for CRT-D compared with standard implantable cardioverter-defibrillators in left BBB compared with RBBB. In Medicare patients, RBBB, ischemic cardiomyopathy, New York Heart Association class IV status, and advanced age were powerful adjusted predictors of poor outcome after CRT-D. Real-world mortality rates 3 to 4 years after CRT-D appear higher than previously recognized.