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心肌梗死后的可穿戴式心律转复除颤器治疗
Wearable Cardioverter–Defibrillator after Myocardial Infarction


Jeffrey E. Olgin ... 心脑血管疾病 • 2018.09.27
相关阅读
• 可穿戴式除颤器未能在心肌梗死后早期减少心律失常性死亡

历时10年,首次发表可穿戴式心脏复律除颤器治疗心肌梗死的研究

 

高微

复旦大学附属中山医院心内科

 

心肌梗死后猝死的发生率较高,尤其是那些射血分数(EF)下降的患者。研究显示,即使EF值下降(≤35%)的患者接受基于指南的药物治疗,其90日内的死亡率也高达4.9%1。然而,两项RCT研究发现早期应用植入式心脏复律除颤仪(ICD)并不能改善心肌梗死患者的死亡率2,3,因此指南推荐,至少在心肌梗死后40日或血运重建后90日再考虑植入ICD4。在ICD植入之前的这几个月内,患者有较高的恶性心律失常发生率和猝死率。

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摘要


背景

虽然射血分数低的患者在心肌梗死后的猝死率高,但植入式心律转复除颤器在心肌梗死后40日或90日内是禁忌的。我们尚不清楚可穿戴式心律转复除颤器能否降低这一高风险期间的猝死发生率。

 

方法

我们(以2∶1的比例)将射血分数≤35%的急性心肌梗死患者随机分组,接受可穿戴式心律转复除颤器+指南指导下的治疗(器械组)或仅接受指南指导下的治疗(对照组)。主要结局是由90日时的猝死或室性快速性心律失常所致死亡(心律失常性死亡)组成的复合结局。次要结局包括任何原因死亡和非心律失常性死亡。

 

结果

在2,302例参与者中,1,524例被随机分配至器械组,778例被分配至对照组。器械组参与者每日穿戴器械的中位时间为18.0小时(四分位距,3.8~22.7小时)。器械组1.6%的参与者和对照组2.4%的参与者发生了心律失常性死亡(相对危险度,0.67;95%置信区间[CI],0.37~1.21;P=0.18)。在器械组和对照组中,任何原因死亡的发生率分别为3.1%和4.9%(相对危险度,0.64;95% CI,0.43~0.98;未校正P=0.04),非心律失常性死亡的发生率分别为1.4%和2.2%(相对危险度,0.63;95% CI,0.33~1.19;未校正P=0.15)。在死亡的器械组48例参与者中,12例在死亡时穿戴了器械。共有器械组20例参与者(1.3%)接受了适当的电击,9例参与者(0.6%)接受了不当的电击。

 

结论

在射血分数≤35%的近期心肌梗死患者中,可穿戴式心律转复除颤器与对照相比未显著降低主要结局心律失常性死亡的发生率(由美国国立卫生研究院和卓尔医学[Zoll Medical]资助;VEST在ClinicalTrials.gov注册号为NCT01446965)。





作者信息

Jeffrey E. Olgin, M.D., Mark J. Pletcher, M.D., M.P.H., Eric Vittinghoff, Ph.D., Jerzy Wranicz, M.D., Ph.D., Rajesh Malik, M.D., Daniel P. Morin, M.D., M.P.H., Steven Zweibel, M.D., Alfred E. Buxton, M.D., Claude S. Elayi, M.D., Eugene H. Chung, M.D., Eric Rashba, M.D., Martin Borggrefe, M.D., Ph.D., Trisha F. Hue, Ph.D., M.P.H., Carol Maguire, R.N., Feng Lin, M.S., Joel A. Simon, M.D., M.P.H., Stephen Hulley, M.D., M.P.H., and Byron K. Lee, M.D., M.A.S. for the VEST Investigators*
From the Division of Cardiology, Department of Medicine, the UCSF Center for the Prevention of Sudden Death (J.E.O., C.M., B.K.L.) and the Department of Epidemiology and Biostatistics (M.J.P., E.V., T.F.H., F.L., J.A.S., S.H.), University of California, San Francisco, San Francisco; the Department of Electrocardiology, Medical University of Lodz, Lodz, Poland (J.W.); McLeod Regional Medical Center, Florence, SC (R.M.); Ochsner Medical Center and Ochsner Clinical School, University of Queensland School of Medicine, New Orleans (D.P.M.); Hartford Healthcare Heart and Vascular Institute and University of Connecticut School of Medicine, Hartford (S.Z.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston (A.E.B.); Gill Heart Institute, University of Kentucky, and Veterans Affairs Medical Center, Lexington (C.S.E.); the Department of Internal Medicine, University of Michigan, Michigan Medicine, Ann Arbor (E.H.C.); Stony Brook Medicine, Stony Brook, NY (E.R.); and First Department of Medicine–Cardiology, University Medical Center Mannheim, Mannheim, and DZHK (German Center for Cardiovascular Research), Heidelberg — both in Germany (M.B.). Address reprint requests to Dr. Olgin at the Division of Cardiology, University of California, San Francisco, 505 Parnassus Ave., Box 0124, San Francisco, CA 94143, or at jeffrey.olgin@ucsf.edu. *A complete list of the VEST investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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