非缺血性心力衰竭患者原发性预防ICD治疗的临床决策差异：一项欧洲心律协会调查

《EP Europace》：Primary prevention implantable cardioverter-defibrillator therapy in non-ischaemic heart failure with reduced left ventricular ejection fraction: a European Heart Rhythm Association survey

本刊推荐：针对非缺血性HFrEF患者原发性预防ICD植入指征存在争议的现状，欧洲心律协会开展多国医师问卷调查。结果显示临床决策受SCD家族史、CRT指征、LGE范围等因素显著影响，强调需建立个性化SCD风险评估体系以优化治疗策略（Europace 2025）。

　　

在心血管疾病领域，植入式心律转复除颤器（ICD）作为预防心源性猝死（SCD）的利器，其临床应用始终备受关注。虽然早期里程碑式的MADIT-II和SCD-HeFT试验证实了ICD在缺血性或混合病因心力衰竭（HF）患者中的生存获益，但针对非缺血性心力衰竭伴左心室射血分数降低（HFrEF）患者的DANISH和DEFINITE试验却未能显示出全因死亡率的显著降低。这一矛盾结果使得非缺血性HFrEF患者接受原发性预防ICD治疗的获益与风险比陷入了“灰色地带”，成为临床实践中亟待厘清的关键问题。非缺血性心力衰竭本身具有高度异质性，其病因涵盖遗传、炎症、浸润性病变等多种类型，导致患者的 arrhythmic risk（心律失常风险）存在显著差异。在这种背景下，如何精准筛选出最可能从ICD治疗中获益的非缺血性HFrEF患者，避免不必要的器械植入及其相关风险，同时又不遗漏高危个体，对临床医师而言是一项严峻挑战。欧洲心律协会（EHRA）为此开展了一项跨国性医师调查，旨在深入探索临床医师在面对符合欧洲心脏病学会（ESC）指南标准的非缺血性HFrEF患者时，其决策过程中的考量因素与偏好差异，相关成果发表于《EP Europace》期刊。

本研究采用问卷调查法，由EHRA科学倡议委员会设计在线问卷，通过EHRA及其青年电生理医师组织、ESC下属各国心脏学会的邮件列表以及社交媒体渠道分发。数据收集于2025年2月18日至3月27日进行，最终纳入258份有效回复。数据分析使用Microsoft Excel和GraphPad Prism软件完成。

医师植入ICD的频率差异

调查显示，对于符合2021年ESC指南标准（即NYHA心功能II-III级、LVEF≤35%、经过至少3个月优化药物治疗、预期生存期>1年且功能状态良好）的非缺血性HFrEF患者，临床医师的ICD植入意向存在明显差异。30.9%的医师表示几乎总是（>95%的情况下）会建议植入ICD，37.4%的医师在75-95%的情况下会这样做，而7.0%的医师则很少在此适应症下植入ICD。这表明，尽管存在指南推荐，但临床实践中的执行力度并不统一。

影响决策的关键因素

在患者选择过程中，某些临床因素被赋予了极高的重要性。SCD家族史和心脏再同步化治疗（CRT）植入指征被视为最关键的影响因素，分别有93.6%和92.3%的医师认为它们“相当重要”或“非常重要”。不明原因晕厥和患者年轻年龄也被超过90%的受访者认为是重要的决策因素。心脏磁共振（CMR）显示的晚期钆增强（LGE）范围被88.6%的参与者（43.0%认为相当重要，45.6%认为非常重要）视为重要参考。高风险遗传学背景也被多数医师看重（35.0%认为相当重要，52.7%认为非常重要）。相比之下，提示室性心律失常高风险的风险评分其重要性看法不一（40.5%认为相当重要，34.6%认为非常重要，但也有19.0%认为相当不重要，5.9%认为完全不重要），而患者性别则被认为是所列因素中影响力最小的。

疾病病因对决策的影响

心力衰竭的病因显著影响医师的ICD植入倾向。遗传病因最能鼓励医师进行植入（54.0%感到受鼓励，31.2%感到强烈鼓励）。先天性心脏病（CHD）、浸润性疾病和神经肌肉疾病（NMD）也被超过50%的医师视为鼓励预防性ICD植入的因素。相反，心律失常性心肌病（AiCM）和酒精性心肌病（AC）这两种被认为可能可逆的病因，则被超过50%的医师视为 discouraging（ discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging discouraging 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