IMPROVING SURVIVAL FOR PATIENTS WITH ADVANCED HEART-FAILURE - A STUDY OF 737 CONSECUTIVE PATIENTS
IMPROVING SURVIVAL FOR PATIENTS WITH ADVANCED HEART-FAILURE - A STUDY OF 737 CONSECUTIVE PATIENTS
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DOI：
10.1016/0735-1097(95)00341-x
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发表时间：
1995-11-15
影响因子：
24
通讯作者：
TILLISCH, JH
中科院分区：
文献类型：
--
作者：
STEVENSON, WG;STEVENSON, LW;TILLISCH, JH
目标.本研究旨在确定在8年的时间里，随着医学治疗的进步，考虑进行心脏移植的晚期心力衰竭患者的生存率和猝死风险是否得到改善。最近在轻度至中度心力衰竭患者和心肌梗死后患者中进行的生存试验表明，血管紧张素转换酶抑制剂是有益的，I型抗心律失常药物可能是有害的，胺碘酮可能在某些人群中有益。当应用于严重心力衰竭时，治疗进展的影响可能会增强或减弱。从1986年至1988年，1989年至1990年和1991年至1993年，我们对737例连续的心脏移植患者和出院回家接受药物治疗的患者的一年死亡率和猝死与时间、基线变量和治疗方法的关系进行了测定。医疗护理由一个单一的医生小组指导，政策是通过协商一致确定的。从1986年到1990年，肼苯哒嗪/硝酸异山梨酯复方制剂或血管紧张素转换酶抑制剂是最初的血管扩张剂，仅允许使用I类抗心律失常药物。1990年后，卡托普利是最初的血管扩张剂，86%的患者使用，而1989年前为46%。1989年中期以后，I类药物常规停用，胺碘酮用于频繁的室性异位搏动或房颤（1990年以后53%的患者vs. 1989年以前10%的患者）。总的1年死亡率从1989年前的33%下降到1990年后的16%（p = 0.0001），猝死从20%下降到8%（p = 0.0006）。在多变量比例风险模型中调整临床和血流动力学变量后，1990年后总死亡率和猝死率较低。自1990年以来，晚期心力衰竭的死亡率大幅下降，特别是猝死，这可能反映了大型随机试验中显示的治疗进展的影响增强，当它们被纳入该人群的综合方法时。这种生存率的提高支持了越来越多的实践，即维持潜在的心脏移植候选人接受最佳药物治疗，直到临床失代偿要求移植。
Objectives. This study sought to determine whether survival and risk of sudden death have improved for patients with advanced heart failure referred for consideration for heart transplantation as advances in medical therapy were systematically implemented over an 8-year period.Background. Recent survival trials in patients with mild to moderate heart failure and patients after a myocardial infarction have shown that angiotensin-converting enzyme inhibitors are beneficial, type I antiarrhythmic drugs can be detrimental, and amiodarone may be beneficial in some groups. The impact of advances in therapy may be enhanced or blunted when applied to severe heart failure.Methods. One-year mortality and sudden death were determined in relation to time, baseline variables and therapeutics for 737 consecutive patients referred for heart transplantation and discharged home on medical therapy from 1986 to 1988, 1989 to 1990 and 1991 to 1993. Medical care was directed by a single team of physicians with policies established by consensus. From 1986 to 1990, the hydralazine/isosorbide dinitrate combination or angiotensin-converting enzyme inhibitors were the initial vasodilators, and class I antiarrhythmic drugs mere allowed. After 1990, captopril was the initial vasodilator, given to 86% of patients compared with 46% of patients before 1989. After mid-1989, class I agents were routinely withdrawn, and amiodarone was used for frequent ventricular ectopic beats or atrial fibrillation (53% of patients after 1990 vs. 10% before 1989).Results. The total 1-year mortality rate decreased from 33% before 1989 to 16% after 1990 (p = 0.0001), and sudden death decreased from 20% to 8% (p = 0.0006). Adjusted for clinical and hemodynamic variables in multivariate proportional hazards models, total mortality and sudden death were lower after 1990.Conclusions. The large reduction in mortality, particularly in sudden death, from advanced heart failure since 1990 may reflect an enhanced impact of therapeutic advances shown in large randomized trials when they are incorporated into a comprehensive approach in this population. This improved survival supports the growing practice of maintaining potential heart transplant candidates on optimal medical therapy until clinical decompensation mandates transplantation.