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【medical-news】美国国家心血管数据注册显示：美
美国国家心血管数据注册显示：美国近1/4的ICD植入不符合指南要求并导致并发症。回顾了自2006年-2009年111，707例，22.5% 的ICD安装不符合AHA、ACC、ESC、HRS的指南条件。美国专家惊呼22.5% 比例太高。
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Nearly a quarter of ICD implants are not recommended by professional guidelines
Jan 4, 2011 Reed Miller
Durham, NC - New data from the National Cardiovascular Data Registry (NCDR) reveal that deviations from the evidence-based guidelines for implantable cardioverter defibrillators (ICDs) are widespread and that ICD implants not recommended by the professional guidelines are more likely to result in in-hospital complications [1].
A retrospective study of 111 707 ICD implants in the NCDR from 2006 through June 2009 shows that 22.5% of these procedures did not meet the criteria for an ICD implant in the 2006 or 2008 guidelines from the American Heart Association, American College of Cardiology, European Society of Cardiology, and Heart Rhythm Society. Results of the study, led by Dr Sana M Al-Khatib (Duke Clinical Research Institute, Durham, NC) are published in the January 5, 2011 issue of the Journal of the American Medical Association.
Previous studies have shown wide disparities in ICD implants between different subpopulations and that many patients who could benefit from ICD therapy are not getting them, so Al-Khatib and colleagues decided to look at the other side of the issue, she told heartwire. "The biggest surprise to me was the substantial number of non-evidence-based implants. I was not expecting to find 22.5%—I was expecting to find 5% or 10%," Al Khatib said in an interview. "I'm sure some of these implants were reasonable, but even if you account for that, I would not have expected to find 22.5%."
All of the patients in this study had at least one prior MI and a left ventricular ejection fraction <30% or prior congestive heart failure and left ventricular ejection fraction <35%.
In most of these cases, the ICD implant was deemed "non-evidence-based" because of its timing. The guidelines recommend against implanting an ICD within three months of an initial heart-failure diagnosis or within 40 days of an MI. But of the 24 145 non-evidence-based ICD implants in the study, 15 604 were performed within three months of the initial heart-failure diagnosis, 5601 within 40 days of an MI, and another 3656 in patients who had an MI more than 40 days prior to the ICD implant and then another MI within 40 days of the implant. There were also 3022 implants in patients with NYHA class 4 heart-failure symptoms, although the guidelines say that ICD therapy is not indicated for patients with NYHA class 4 symptoms.
Compared with the ICD patients who met the guidelines criteria, the non-evidence-based ICD recipients had a significantly higher risk of in-hospital death (0.57% vs 0.18%; p<0.001) and a higher risk of suffering a postprocedure complication (3.23% vs 2.41%; p<0.001). The non-evidence-based ICD patients were generally older and sicker than the evidence-based ICD recipients, but the difference in complications persisted after adjustment for baseline differences, Al-Khatib explained.
There was substantial variation in the percentage of non-evidence-based ICDs by center, and the rate of non-evidence-based ICD implants was significantly lower for electrophysiologists (20.8%) than nonelectrophysiologists (24.8%), with the highest rate among thoracic surgeons (36.1%) (p<0.001).
In an accompanying editorial [2], Dr Alan Kadish (Touro College, New York, NY) and Dr Jeffrey Goldberger (Northwestern University, Chicago, IL) write that the study by Al-Khatib et al adds to the evidence that "that intensive training may improve both the preoperative evaluation of patients as well as the operative and immediate postoperative care of patients undergoing ICD implantation."
The finding that nonspecialists perform more non-evidence-based ICD implants and that these implants have a higher complication rate is consistent with previous studies that show that ICD implants by trained electrophysiologists have a lower complication rate than ICD implants by nonelectrophysiologists, Al-Khatib pointed out. Another recent analysis of the NCDR database suggests that inadequate training leads to a higher risk of lead dislodgements.
Opportunities for improvement
"We do not have the data to accurately determine why physicians implanted these devices, so [all] I can tell you is the fact that electrophysiologists—who do these procedures day in and day out and are more likely to be more familiar with the guidelines and the evidence that supports ICD use—were significantly less likely to use these non-evidence-based devices," Al-Khatib said. "[That is] indirect evidence that partly the reason we're seeing these high percentages of non-evidence-based implants is lack of knowledge and lack of awareness of the guidelines.
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作者:admin@医学,生命科学 2011-01-09 11:42
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