Age and Outcomes of Primary Prevention Implantable Cardioverter-Defibrillators in Patients With Nonischemic Systolic Heart Failure
Age and Outcomes of Primary Prevention Implantable Cardioverter-Defibrillators in Patients With Nonischemic Systolic Heart Failure
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DOI：
10.1161/circulationaha.117.028829
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发表时间：
2017-11-07
期刊：
影响因子：
37.8
通讯作者：
Thune, Jens Jakob
中科院分区：
文献类型：
--
作者：
Elming, Marie Bayer;Nielsen, Jens C.;Thune, Jens Jakob
背景资料：DANISH研究（评估ICD [植入式心律转复除颤器]在非缺血性心力衰竭患者中对死亡率的有效性的丹麦研究）未证明ICD植入对全因死亡率的总体影响。然而，预先指定的亚组分析表明ICD植入与死亡率之间可能存在年龄依赖性相关性，仅在最年轻的患者中观察到生存获益。年龄与非缺血性收缩性心力衰竭患者的一级预防ICD结果之间的关系的性质值得进一步研究。方法：所有1116例来自DANISH研究的患者均纳入本预先指定的亚组分析。我们通过年龄评估ICD植入与死亡率之间的关系，并使用选择影响曲线非参数估计最佳年龄截止值。死亡模式分为心源性猝死和非猝死，并使用（2）分析比较了年龄小于和大于该年龄临界值的患者。结果：研究人群的中位年龄为63岁（范围，21-84岁）。ICD和死亡率随年龄呈线性下降关系（风险比[HR]，1.03; 95%置信区间[CI]，1.003-1.06; P=0.03）。ICD植入的最佳年龄截止值为70岁。在70岁患者中，全因死亡率降低与ICD相关（HR，0.70; 95% CI，0.51-0.96; P=0.03），但在>70岁患者中则无关（HR，1.05; 95% CI，0.68-1.62; P=0.84）。对于70岁的患者，心源性猝死率为1.8（95%CI，1.3-2.5），非猝死率为2.7（95% CI，2.1-3.5）例事件/100患者年，而对于>70岁的患者，心源性猝死率为1.6（95% CI，0.8-3.2），非猝死率为5.4（95% CI，3.7-7.8）起事件/100患者-年。这两个年龄组之间的死亡模式的差异有统计学意义（P=0.01）。结论：在收缩性心力衰竭的患者不是由缺血性心脏病，ICD和生存之间的关联随年龄的增加呈线性下降。在该研究人群中，植入ICD的年龄截止值为70岁，总体上获得了最高的生存率。临床试验注册：URL：https://www.clinicaltrials.gov。唯一标识符：NCT 00542945。
Background: The DANISH study (Danish Study to Assess the Efficacy of ICDs [Implantable Cardioverter Defibrillators] in Patients With Non-Ischemic Systolic Heart Failure on Mortality) did not demonstrate an overall effect on all-cause mortality with ICD implantation. However, the prespecified subgroup analysis suggested a possible age-dependent association between ICD implantation and mortality with survival benefit seen only in the youngest patients. The nature of this relationship between age and outcome of a primary prevention ICD in patients with nonischemic systolic heart failure warrants further investigation.Methods: All 1116 patients from the DANISH study were included in this prespecified subgroup analysis. We assessed the relationship between ICD implantation and mortality by age, and an optimal age cutoff was estimated nonparametrically with selection impact curves. Modes of death were divided into sudden cardiac death and nonsudden death and compared between patients younger and older than this age cutoff with the use of (2) analysis.Results: Median age of the study population was 63 years (range, 21-84 years). There was a linearly decreasing relationship between ICD and mortality with age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.003-1.06; P=0.03). An optimal age cutoff for ICD implantation was present at 70 years. There was an association between reduced all-cause mortality and ICD in patients 70 years of age (HR, 0.70; 95% CI, 0.51-0.96; P=0.03) but not in patients >70 years of age (HR, 1.05; 95% CI, 0.68-1.62; P=0.84). For patients 70 years old, the sudden cardiac death rate was 1.8 (95% CI, 1.3-2.5) and nonsudden death rate was 2.7 (95% CI, 2.1-3.5) events per 100 patient-years, whereas for patients >70 years old, the sudden cardiac death rate was 1.6 (95% CI, 0.8-3.2) and nonsudden death rate was 5.4 (95% CI, 3.7-7.8) events per 100 patient-years. This difference in modes of death between the 2 age groups was statistically significant (P=0.01).Conclusions: In patients with systolic heart failure not caused by ischemic heart disease, the association between the ICD and survival decreased linearly with increasing age. In this study population, an age cutoff for ICD implantation at 70 years yielded the highest survival for the population as a whole.Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00542945.