ヨーロッパの循環器医は心臓再同期療法の有効性を確信している

ヨーロッパCRT調査：ヨーロッパにおいて心臓再同期療法はガイドラインで推奨されているよりもより一般的になっている

European CRT Survey: Use of cardiac resynchronization therapy in Europe more common than guidelines recommend

ヨーロッパの循環器医は、心臓再同期療法（CRT）単独または除細動機能付き（CRT-D）によるCRTの有効性を、強力なエビデンスに基づく適応ではない患者に対しても確信しているとESC 2009ホットラインセッションで発表された。ヨーロッパCRT調査には、平均年齢68歳（31%は75歳以上）の患者2,438人を組み入れた。CRT療法を受ける患者には高齢者や洞調律でない者または軽度の心不全のみの患者や心電図上定義された心室dyssynchronyを有さない患者なども含まれた。CRT-PおよびCRT-Dを挿入された患者群間の患者背景に差は認められた；理由は多くあったが、人口統計学および経済因子は一部を構成していた。若年患者、男性および虚血性疾患患者はCRT-Dデバイスを植え込まれる確率が高かった。データから、今回のスタディのコホートは無作為化臨床試験に組み入れられたコホートと著明に類似している（CRTを受ける女性の割合は少なかった）ことが示された。しかし、今回の調査の患者はより高齢で、症状の軽い者が多かった。相当数の患者がnarrow QRSであり、心房細動を有する頻度が高かった。合併症率は無作為化トライアルで報告されたのと同様であった。

The European cardiac resynchronization therapy (CRT) Survey is a joint initiative taken by the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology. Its primary objective is to describe current European practice and routines associated with the implantation of a CRT device with or without an ICD (implantable cardioverter defibrillator) capability in patients with heart failure.

The data collected from the survey provide useful information in CRT for heart failure on patient demographics and selection, clinical characteristics, diagnostic criteria, implantation routines and techniques, short-term outcomes, adverse experience, and assessment of adherence to guideline recommendations. These data should be useful for benchmarking individual patient management and national practice against wider experience. The data from randomized trials of CRT are limited and based largely on selected patients at high-volume centers with experienced operators. In contrast, the European CRT Survey describes current routine practice in CRT implantation based on a wide range of sampling.

Data were collected between 1st November 2008 and 30th June 2009 from 140 volunteer centers in 13 countries (Austria, Belgium, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Spain, Sweden, Switzerland, UK). Information was provided on consecutive patients successfully implanted with a CRT device with or without an ICD (CRT-P, CRT-D). All patients agreeing to participate will have a follow-up visit approximately one-year after CRT implantation.

The survey enrolled 2438 patients, with a mean age of 68 years (31% were 75 years or older). There are characteristic differences between those receiving CRT-P and CRT-D; the reasons are many, but it is clear that demographic and economic factors play a part. However, the Survey data show that younger patients, men and those with ischemic etiology are more likely to receive a CRT-D device.

The data also show that the cohort is remarkably similar to the cohorts recruited in randomized clinical trials (with a low proportion of women receiving CRT). However, patients in the Survey were older, and more frequently had mild symptoms. A substantial number had a narrow QRS complex (although a broadening is a typical finding in many trials) and more frequently had atrial fibrillation. However, in this real-world population, complication rates were similar to those reported in the randomized trials.

Says lead author Dr. Nigussie Bogale from Stavanger University Hospital in Norway: "This European CRT Survey represents a reasonably large sample reflecting current European practice in the use of CRT devices in the management of patients with heart failure. Our findings show that many patients who do not strictly conform to current guideline recommendations frequently receive a CRT device. Clinicians, researchers and healthcare providers should find these data useful in designing strategies for patient management, trial design and resource allocation."