置入心髒複律除顫器(ICD)不被推薦用於心肌梗死(MI)40天以內的患者，因此在MI後過渡期管理期間可能不考慮予患者置入ICD治療。美國學者近期在低射血分數(EF)老年MI患者中評估了ICD置入率和與其相關的死亡率，結果表明，在上述人群中，雖然ICD置入與2年時患者較低的校正死亡風險有關，但不到1/10的適宜患者在MI後1年內接受了ICD置入。相關論文近日在線發表於《美國醫學會雜誌》(簡稱JAMA)。
該回顧觀察性研究納入了MI後EF≤35%的受試者10318例，排除了既往置入過ICD的患者。獲取至2010年12月的患者隨訪數據。對MI後1年內置入ICD和未置入ICD的患者進行對比，以1年內接受ICD置入治療相關的患者特征和2年死亡率作為主要評價指標。
結果顯示，受試者累積1年ICD置入率為8.1% (95% CI, 7.6%-8.7%; n = 785)。與1年內未接受ICD置入患者相比，置入ICD的患者更可能是既往接受過冠狀動脈旁路移植術(CABG)[31% vs 20%; 校正危險比(HR)1.49; 95% CI1.26-1.78]，且其肌鈣蛋白水平(中位數，正常值的85 vs 51倍;校正HR1.02/10倍增加;95% CI, 1.01-1.03)、院內心源性休克(13% vs 8%; 校正HR, 1.57; 95% CI, 1.25-1.97)和安裝後2周內心髒病學隨訪率(30% vs 20%; 校正HR, 1.64; 95% CI, 1.37-1.95)均較高。ICD置入與2年死亡率較低有關[15.3事件/100患者-年(838例患者-年中有128例死亡)]vs[26.4事件/100患者-年(11 479例患者-年中有3033例死亡)];(校正HR 0.64; 95% CI, 0.53-0.78)。
參考文獻：Sean D. Pokorney,et al.JAMA. 2015;313(24):2433-2440. doi:10.1001/jama.2015.6409.
Original Investigation | June 23/30, 2015
Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Acute Myocardial Infarction
Sean D. Pokorney, MD, MBA1,2; Amy L. Miller, MD, PhD3; Anita Y. Chen, MS2; Laine Thomas, PhD2; Gregg C. Fonarow, MD4; James A. de Lemos, MD5; Sana M. Al-Khatib, MD, MHS1,2; Eric D. Peterson, MD, MPH1,2; Tracy Y. Wang, MD, MHS, MSc1,2
[+] Author Affiliations
JAMA. 2015;313(24):2433-2440. doi:10.1001/jama.2015.6409.
ABSTRACT
Importance Implantablecardioverter-defibrillators (ICDs) are not recommended within 40 days of myocardial infarction (MI); thus, ICD implantation might not be considered during the post-MI care transition.
Objective To examine ICD implantation rates and associated mortality among older MI patients with low ejection fraction (EF).
Design, Setting, and Participants Retrospective observational study of Medicare beneficiaries with an EF of 35% or less after MI, treated at 441 US hospitals between 2007 and 2010, excluding patients with prior ICD implantation. Follow-up data were available through December 2010.
Exposures ICD implantation within 1 year of MI vs no ICD implantation within 1 year of MI.
Main Outcomes and Measures Patient characteristics associated with receiving an ICD within 1 year after discharge and 2-year mortality associated with ICD implantation.
Results Among 10 318 MI patients with EF of 35% or lower, the cumulative 1-year ICD implantation rate was8.1% (95% CI, 7.6%-8.7%; n = 785). Patients with ICD implantation were more likely to have prior coronary artery bypass graft procedures (31% vs 20%; adjusted hazard ratio [HR], 1.49; 95% CI, 1.26-1.78),higher peak troponin levels (median, 85 vs 51 times the upper limit of normal; adjusted HR, 1.02 per 10-fold increase; 95% CI, 1.01-1.03),in-hospital cardiogenic shock (13% vs 8%; adjusted HR, 1.57; 95% CI, 1.25-1.97), and cardiology follow-up within 2 weeks after discharge (30% vs 20%; adjusted HR, 1.64; 95% CI, 1.37-1.95) relative to patients who did not receive an ICD within 1 year.Implantation of ICD was associated with lower 2-year mortality (15.3 events per 100 patient-years [128 deaths in 838 patient-years] vs 26.4 events per 100 patient-years [3033 deaths in 11 479 patient-years]; adjusted HR, 0.64; 95% CI, 0.53-0.78).
Conclusions and Relevance In this large registry study of older patients who experienced MI from 2007-2010, fewer than 1 in 10 eligible patients with low EF received an ICD within 1 year after MI, although ICD implantation was associated with lower risk-adjusted mortality at 2 years. Additional research is needed to determine evidence-based approaches to increase ICD implantation among eligible patients.
