Стратификация риска фатальных сердечно-сосудистых событий у больных с ишемической болезнью сердца и имплантированным кардиовертером-дефибриллятором: возможности применения неинвазивных электрофизиологических показателей
Стратификация риска фатальных сердечно-сосудистых событий у больных с ишемической болезнью сердца и имплантированным кардиовертером-дефибриллятором: возможности применения неинвазивных электрофизиологических показателей
Мельник Н.В., Царегородцев Д.А., Ильич И.Л. и др. Стратификация риска фатальных сердечно-сосудистых событий у больных с ишемической болезнью сердца и имплантированным кардиовертером-дефибриллятором: возможности применения неинвазивных электрофизиологических показателей. Consilium Medicum. 2019; 21 (1): 36–45. DOI: 10.26442/20751753.2019.1.190190
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Melnik N.V., Tsaregorodtsev D.A., Ilych I.L. et al. Fatal cardio-vascular events risk stratification in ischemic heart disease patients with implantable cardioverter-defibrillators: role of noninvasive electrophysiological predictors. Consilium Medicum. 2019; 21 (1): 36–45. DOI: 10.26442/20751753.2019.1.190190
Стратификация риска фатальных сердечно-сосудистых событий у больных с ишемической болезнью сердца и имплантированным кардиовертером-дефибриллятором: возможности применения неинвазивных электрофизиологических показателей
Мельник Н.В., Царегородцев Д.А., Ильич И.Л. и др. Стратификация риска фатальных сердечно-сосудистых событий у больных с ишемической болезнью сердца и имплантированным кардиовертером-дефибриллятором: возможности применения неинвазивных электрофизиологических показателей. Consilium Medicum. 2019; 21 (1): 36–45. DOI: 10.26442/20751753.2019.1.190190
________________________________________________
Melnik N.V., Tsaregorodtsev D.A., Ilych I.L. et al. Fatal cardio-vascular events risk stratification in ischemic heart disease patients with implantable cardioverter-defibrillators: role of noninvasive electrophysiological predictors. Consilium Medicum. 2019; 21 (1): 36–45. DOI: 10.26442/20751753.2019.1.190190
Цель. Изучить возможность использования неинвазивных электрофизиологических методов (микровольтная альтернация Т-зубца – мАЗТ) – турбулентность ритма сердца (ТРС), мощность замедления ритма (deceleration capacity – DC) для стратификации риска аритмических событий и летального исхода у пациентов с ишемической болезнью сердца (ИБС) и имплантированным кардиовертером-дефибриллятором (ИКД). Материалы и методы. В исследование были включены 45 пациентов, которые имели верифицированный диагноз ИБС и показания к имплантации ИКД. У всех пациентов определялись уровень креатинина крови и скорость клубочковой фильтрации (СКФ), фракции липидного спектра, а также проводилось 24-часовое мониторирование электрокардиограммы (ЭКГ) по Холтеру с определением показателей ТРС, мАЗТ, DC, мощности ускорения ритма (acceleration capacity – AC), вариабельности сердечного ритма (ВСР). Наблюдение за выжившими пациентами осуществлялось не менее чем 30 мес (средний срок наблюдения составил 48 [42; 51] мес, максимальный – 70 мес). Конечными точками в исследовании явились: летальный исход от любой причины и «аритмическая» конечная точка (оправданное срабатывание ИКД или внезапная сердечная смерть – ВСС). Результаты. За время наблюдения от различных причин умерли 10 (22,2%) пациентов. Аритмическая конечная точка (оправданное срабатывание ИКД или ВСС) возникла в 13 (28,9%) случаях. Умершие больные достоверно отличались от выживших значениями DC и ТРС, уровнем креатинина крови. За время наблюдения не умер ни один пациент, имеющий нормальную ТРС или DC в зоне низкого риска. Пациенты с аритмическими событиями и без них достоверно различались по количеству морфологий желудочковых экстрасистол (ЖЭС) при суточном мониторировании ЭКГ и уровню общего холестерина крови. При многофакторном регрессионном анализе уровень креатинина крови явился независимым фактором риска летального исхода, а независимыми предикторами наступления аритмической конечной точки оказались и наличие политопной ЖЭС, и уровень общего холестерина крови. Заключение. Неинвазивные электрофизиологические показатели продемонстрировали высокую отрицательную значимость в прогнозировании летального исхода у пациентов с ИБС и ИКД. Единственным независимым предиктором смерти оказался уровень креатинина крови. Независимыми предикторами оправданного срабатывания ИКД или ВСС были полиморфный характер ЖЭС и уровень холестерина крови.
Aim. To study possibilities of non-invasive electrophysiological methods (microvolt Т-wave alternance – mTWA) heart rate turbulence (HRT), deceleration capacity (DC) use in stratifying risk of arrhythmic events and mortality in patients with ischemic heart disease (IHD) and implantable cardioverter-defibrillator (ICD). Materials and methods. The study included 45 patients with verified IHD diagnosis and indications for ICD implantation. In all patients serum creatinine level, glomerular filtration rate (GFR), and serum lipid fractions were determined and 24-hour Holter electrocardiogram (ECG) monitoring was performed where HRT, mTWA, and DC as well as acceleration capacity (AC), and heart rate variability (HRV) were determined. Survived patients were followed-up for no less than 30 months (mean follow-up 48 [42; 51] months, maximum – 70 months). The study endpoints were death from any cause and “arrhythmic” endpoint (appropriate ICD discharge or sudden cardiac death – SCD). Results. Ten (22.2%) patients died from different causes during follow-up period. Arrhythmic endpoint (appropriate ICD therapy or SCD) was observed in 13 (28.9%) cases. Significant differences in DC, CRT, and serum creatinine level were observed in patients who survived and died. No patients with normal CRT or in low-risk group died during follow-up. There were significant differences in number of ventricular extrasystoles (VES) morphologies according to 24-hour Holter ECG monitoring and in serum cholesterol level in patients with or without arrhythmic events. Multifactor regression analysis showed serum creatinine level to be an independent risk factor of lethal outcome, and both polytope VES and serum cholesterol level were shown to be independent predictors of arrhythmic endpoint. Conclusion. Non-invasive electrophysiological markers have demonstrated high negative significance in lethal outcome prognosis in patients with IHD and ICD. Serum creatinine level was shown to be the only independent lethal outcome predictor. Polytope VES and serum cholesterol level were demonstrated to be independent predictors of arrhythmic endpoint.
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1. Myerburg RJ, Junttila MJ. Sudden Cardiac Death Caused by Coronary Heart Disease. Circulation 2012; 125: 1043–52.
2. Priori SG, Blomström-Lundqvist C, Mazzanti A et al. ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Eur Heart J 2015; 36 (41): 2793–867.
3. Santangeli P, Epstein AE. Sudden Cardiac Death: Lessons Learned from Cardiac Implantable Rhythm Devices. Card Electrophysiol Clin 2017; 9 (4): 749–59.
4. Katritsis DG, Auricchio A. Do We Need an Implantable Cardioverter-defibrillator for Primary Prevention in Cardiac Resynchronisation Therapy Patients? Arhythm Electrophysiol Rev 2018; 7 (3): 157–8.
5. Beggs SAS, Gardner RS, McMurray JJV. Who Benefits From a Defibrillator-Balancing the Risk of Sudden Versus Non-sudden Death. Curr Heart Fail Rep 2018; 15 (6): 376–89. DOI: 10.1007/s11897-018-0416-6
6. Sabbag A, Suleiman M, Laish-Farkash A et al. Israeli Working Group of Pacing and Electrophysiology. Contemporary rates of appropriate shock therapy in patients who receive implantable device therapy in a real-world setting: From the Israeli ICD Registry. Heart Rhythm 2015; 12 (12): 2426–33. DOI: 10.1016/j.hrthm.2015.08.020
7. Van Rees JB, Borleffs CJ, van Welsenes GH et al. Clinical prediction model for death prior to appropriate therapy in primary prevention implantable cardioverter defibrillator patients with ischaemic heart disease: the FADES risk score. Heart 2012; 98 (11): 872–7.
8. Rodríguez-Mañero M, Abu Assi E, Sánchez-Gómez JM et al. Comparative Evaluation of Four Risk Scores for Predicting Mortality in Patients With Implantable Cardioverter-defibrillator for Primary Prevention. Rev Esp Cardiol (Engl Ed) 2016; 69 (11): 1033–41.
9. Okisheva E.A., Tsaregorodtsev D.A., Sulimov V.A. Pokazateli turbulentnosti ritma serdtsa i mikrovol'tnoi al'ternatsii zubtsa T u bol'nykh, perenesshikh infarkt miokarda. Vestn. aritmologii. 2010; 62: 26–31 (in Russian).
10. Gromova O.I., Kuznetsova E.V., Khotsanian Ch.V., Golukhova E.Z. Prognosticheskie vozmozhnosti markerov elektricheskoi nestabil'nosti miokarda u bol'nykh ishemicheskoi bolezn'iu serdtsa. Kreativnaia kardiologiia. 2015; 3: 26–41 (in Russian).
11. Bokeriia L.A., Revishvili A.Sh., Golitsyn S.P. et al. Klinicheskie rekomendatsii Vserossiiskogo nauchnogo obshchestva spetsialistov po klinicheskoi elektrofiziologii, aritmologii i kardiostimuliatsii po provedeniiu klinicheskikh elektrofiziologicheskikh issledovanii, kateternoi ablatsii i implantatsii antiaritmicheskikh ustroistv. Moscow, 2013 (in Russian).
12. Maron BJ. Contemporary Insights and Strategies for Risk Stratification and Prevention of Sudden Death in Hypertrophic Cardiomyopathy. Circulation 2010; 121: 445–56.
13. Bauer A, Malik M, Schmidt G et al. Heart rate turbulence: standards of measurement, physiological interpretation, and clinical use: International Society for Holter and Noninvasive Electrophysiology Consensus. J Am Coll Cardiol 2008; 52 (17): 1353–65.
14. Bauer A, Kantelhardt JW, Barthel P et al. Deceleration capacity of heart rate as a predictor of mortality after myocardial infarction: cohort study. Lancet 2006; 367: 1674–81.
15. Gerasimov A.N. Meditsinskaia statistika. Moscow: MIA, 2007 (in Russian).
16. Seegers J, Bergau L, Expósito PM et al. Prediction of Appropriate Shocks Using 24-Hour Holter Variables and T-Wave Alternans After First Implantable Cardioverter-Defibrillator Implantation in Patients With Ischemic or Nonischemic Cardiomyopathy. Am J Cardiol 2016; 118 (1): 86–94. DOI: 10.1016/j.amjcard.2016.04.016
17. Costantini O, Hohnloser SH, Kirk MM et al. The ABCD (Alternans Before Cardioverter Defibrillator) Trial: strategies using T-wave alternans to improve efficiency of sudden cardiac death prevention. J Am Coll Cardiol 2009; 53 (6): 471–9.
18. Średniawa B, Kowalczyk J, Lenarczyk R et al. Microvolt T-wave alternans and other noninvasive predictors of serious arrhythmic events in patients with an implanted cardioverter-defibrillator. Kardiol Pol 2012; 70 (5): 447–55.
19. Bloomfield DM, Steinman RC, Namerow PB et al. Microvolt T-Wave Alternans Distinguishes Between Patients Likely and Patients Not Likely to Benefit From Implanted Cardiac Defibrillator Therapy: A Solution to the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II. Conundrum Circulation 2004; 110: 1885–9. DOI: 10.1161/01.CIR.0000143160.14610.53
20. La Rovere MT, Pinna GD, Maestri R et al. GISSI-HF Investigators. Autonomic markers and cardiovascular and arrhythmic events in heart failure patients: still a place in prognostication? Data from the GISSI-HF trial. Eur J Heart Fail 2012; 14 (12): 1410–9.
21. Bauer A, Malik M, Schmidt G et al. Heart rate turbulence: standards of measurement, physiological interpretation, and clinical use: International Society for Holter and Noninvasive Electrophysiology Consensus. J Am Coll Cardiol 2008; 52 (17): 1353–65.
22. Hoshida K, Miwa Y, Miyakoshi M et al. Simultaneous assessment of T-wave alternans and heart rate turbulence on holter electrocardiograms as predictors for serious cardiac events in patients after myocardial infarction. Circ J 2013; 77 (2): 432–8.
23. Bauer A, Barthel P, Schneider R et al. Improved Stratification of Autonomic Regulation for risk prediction in post-infarction patients with preserved left ventricular function (ISAR-Risk). Eur Heart J 2009; 30 (5): 576–83.
24. Bauer A, Barthel P, Müller A et al. Risk prediction by heart rate turbulence and deceleration capacity in postinfarction patients with preserved left ventricular function retrospective analysis of 4 independent trials. J Electrocardiol 2009; 42 (6): 597–601.
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1 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М.Сеченова» Минздрава России. 119991, Россия, Москва, ул. Трубецкая, д. 8, стр. 2;
2 ГБУЗ «Городская клиническая больница им. В.М.Буянова» Департамента здравоохранения г. Москвы. 115516, Россия, Москва, ул. Бакинская, д. 26
Natalia V. Melnik*1, Dmitrii A. Tsaregorodtsev1, Ilya L. Ilych2, Igor A. Khamnagadaev2, Vitalii A. Sulimov1
1 I.M.Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation. 2, 8, Trubetskaia st., Moscow, 119991, Russian
Federation;
2 V.M.Buyanov City Clinical Hospital of the Department of Health of Moscow. 26, Bakinskaya st., Moscow, 115516, Russian Federation
*natali-m05@mail.ru