Sei  Iwai   美国纽约州立大学石溪分校医学中心

  <International Circulation>: If a patient presents with an ejection fraction greater than 35% and the goal is prevention of sudden cardiac death， which is the optimal treatment choice – an implantable cardiac defibrillator or anti-arrhythmic drugs? 

   《国际循环》：对于射血分数＞35%的患者，为预防心源性猝死，最佳治疗策略是什么？ICD或抗心律失常药物？ 

    Dr Iwai:  Unfortunately， that patient population presents a real quandary to us in that the current guidelines largely cover patients with an ejection fraction of 35% or less. There is a small subset of patients with ischemic cardiomyopathy with ejection fractions of 40% or less， so therefore in the 36-40% range there is the possibility of further risk stratification with electrophysiology study based on the MUSTT trial and if these patients are inducible for a sustained VT then an ICD would be implanted. However， in the non-ischemic population and patients with ischemic cardiomyopathy and ejection fraction above 40% we currently have no trials that help us guide whether they get a defibrillator. Personally， in that population， in general， I would do neither. This is a primary prevention population and we know that the use of anti-arrhythmic drugs in the wrong population can actually be pro-arrhythmic and cause more events. This has been seen repeatedly in anti-arrhythmic drug trials and we know that none of these drugs prolong life so unless they can have an ICD implanted， really the best medical therapy is treatment of their underlying coronary disease or underlying left ventricular dysfunction and congestive heart failure.

    Iwai博士：不幸的是，这一患者群体向我们展现了一个真正的窘境，目前的指南主要涉及射血分数≤35%的患者。现有一个射血分数≤40%的缺血性心肌病亚组，EF 在36%~40%范围内，基于MUSTT试验，采用电生理研究进行危险分层，若这些患者可诱发持续性VT，那么将植入ICD。然而，对于非缺血性患者以及有缺血性心肌病但EF＞40%的患者中，目前尚无试验指导我们是否需植入ICD。就个人而言，在这一群体中，一般情况下，上述两种措施我都不会选择。这是一个一级预防人群，且我们知道抗心律失常药物在错误人群中的应用实际上可以致心律失常，从而导致更多临床事件的发生，这已经在抗心律失常药物试验反复观察到。同时，我们知道，这些药物无一种能延长寿命，因此，除非他们能植入ICD，否则真正最佳的药物治疗即是治疗基础冠状动脉疾病或左室功能不全以及充血性心力衰竭。

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