射血分数降低的心力衰竭（LV-EF＆lt;35％）在应用程序中诊断。全球11,000,000名患者。为了治疗这些患者，指南指导的药物治疗已被证明可以降低死亡率和再住院率，而与疾病的病因无关。通过改善左心室射血分数来治疗临床症状。具有暂时性室性心动过速和心源性猝死风险的患者可以通过除颤器背心得到保护。除颤器背心能够在指导医学治疗（GDMT）期间检测和终止室性心律失常。它是基于3个月的欧洲心脏病学会的建议。之后,WCD的磨损时间可能会延长，或者，在持续低射血分数（LV-EF≤35％）的情况下，应植入植入式心律转复除颤器(ICD),如WEARIT-II注册表中所示。我们的目标是评估GDMT对在除颤器背心保护下的LV恢复和ICD植入减少的影响-取决于GDMT的上调。
方法：通过图表回顾对2017年8月至2020年9月期间339例新诊断心肌病且EF≤35％的患者进行回顾性分析。所有患者均使用可穿戴的心律转复除颤器（WCD）进行保护。ESC建议的GDMT在出院时开始。在第4周，第8周和第12周（在WCD佩戴时间延长的情况下）通过经胸超声心动图确定左心室射血分数（LV-EF）。在4周和8周之后在患者就诊期间进行向上滴定。我们关注根据GDMT的基线药物和在第4、8和12周的剂量增加。目的是向上滴定至患者耐受的最大剂量。我们还比较了有和没有增加药物剂量的组的LV-EF改善。
结果：患者年龄为,平均而言,63.2年（标准差±11.9年）。共有129名患者(38%)患有ICM，196（58％）患有NICM（包括66例DCM（19％）和51例心肌炎（15％），79名(24%)来源不明)和14名(4%)有其他实体(例如，心动过速心肌病）。总的来说,21名患者（6%）的LV-EF低于16%，130分（38%）在16-25%之间，183分（54%）在26-35%之间。GDMT在出院时开始，包括327名患者（96.5％）的β受体阻滞剂治疗，ACE抑制剂/血管紧张素/ARNI为283例（83.5％），盐皮质激素受体拮抗剂（MRA）为334例（88.4％）。所有组均以82.3%的比例进行了向上滴定，91.1%，4周后81.0%，64.7%，50.3%,8周后66.3%,分别。4周后,25分（7.4%）和，8周后,171名患者（50.4%）的EF增加5%或更多（平均14.2%）。4周后,81例患者的LV-EF超过35%。总共169名患者的佩戴时间为12周，LVEF改善超过35％。有趣的是,在我们的研究中,我们未发现无上调组和有上调组的LV-EF改善有显著差异.
结论：在WCD保护下的指导药物治疗可减少植入ICD的需求，并可改善射血分数。有趣的是,LV-EF的改善取决于放电时的GDMT。目前的指南建议启动GDMT的所有治疗列（沙库巴曲/缬沙坦，ACE抑制剂/AT1阻断剂，盐皮质激素受体阻滞剂，β受体阻滞剂)，并进一步上调至最大剂量(ESC指南2021)。进一步增加GDMT的所有药物应导致LV-EF的改善，从而减少ICD的植入。
Heart failure with reduced ejection fraction (LV-EF < 35%) is diagnosed in app. 11,000,000 patients worldwide. For the treatment of these patients,
guideline directed medical therapy has proven to reduce mortality and rehospitalization regardless of the disease’s etiology. It is implemented to treat clinical symptoms by improving the left ventricular ejection fraction. Patients with a transient risk of ventricular tachycardia and sudden cardiac death can be protected by a defibrillator vest. The defibrillator vest is capable to detect and terminate ventricular arrhythmias during
Guideline Directed Medical Therapy (GDMT). It is based on the recommendations of the European society of cardiology for 3 months. Afterwards, the WCD wear time could be prolonged, or, in case of persistent low ejection fraction (LV-EF ≤ 35%), an implantable cardioverter defibrillator (ICD) should be implanted, as shown in the WEARIT-II-registry. Our goal was to evaluate the effects of GDMT on LV-recovery and reduction of ICD implantations under protection with a defibrillator vest—depending on the uptitration of GDMT. Methods: 339 consecutive patients between August 2017 and September 2020 with newly diagnosed cardiomyopathy and an EF ≤ 35% were analyzed retrospectively by chart review. All patients were protected by a wearable cardioverter defibrillator (WCD). GDMT as recommended by the ESC started at discharge from hospital. The left ventricular ejection fraction (LV-EF) was determined by transthoracic echocardiography at week 4, 8 and at week 12 (in case of prolonged WCD wear time). Uptitration was performed after 4 and 8 weeks during patient visits. We focused on baseline medication as per GDMT and the dosage increase at week 4, 8 and 12. The aim was the uptitration to the maximum dosage tolerated by the patient. We also compared the LV-EF improvement in the group with and without uptitration of medication dosage. Results: The patient age was, on average, 63.2 years (SD ± 11.9 years). A total of 129 pts (38%) had
ICM, 196 (58%) had NICM (incl 66 pts (19%) with DCM and 51 pts (15%) with Myocarditis, 79 pts (24%) with unknown origin) and 14 pts (4%) had other entities (e.g., Tachycardiomyopathy). In total, 21 pts (6%) had an LV-EF of less than 16%, 130 pts (38%) between 16−25% and 183 pts (54%) between 26−35%. GDMT started at discharge from the hospital included treatment with beta blocker for 327 pts (96.5%), ACE-inhibitors/Angiotensin/ARNI for 283 pts (83.5%) and Mineralcorticoid receptor antagonists (MRA) for 334 pts (88.4%). Uptitration was performed in all groups at a rate of 82.3%, 91.1% and 81.0% after 4 weeks and 64.7%, 50.3% and 66.3% after 8 weeks, respectively. After 4 weeks, 25 pts (7.4%) and, after 8 weeks, 171 pts (50.4%) had an EF increase of 5% or more (mean 14.2%). After 4 weeks, 81 patients had an LV-EF more than 35%. A total of 169 pts had a wear time of 12 weeks and an improvement of LVEF of more than 35%. Interestingly, in our study we did not find a significant difference in LV-EF improvement between the group with no uptitration and the group with uptitration. Conclusions: Guideline-directed medical therapy under protection with a WCD from ventricular arrhythmia can reduce the need for implantation of an ICD and can lead to an improvement of ejection fraction. Interestingly, the LV-EF improvement depends on the GDMT at discharge. Current
guidelines recommend an initiation of all therapy columns of GDMT (sacubitril/valsartan, ACE-inhibitor/AT1-blocker, mineralcorticoidreceptorblocker, beta blocker) at once and further uptitration to the maximal dosage (ESC
Guidelines 2021). A further uptitration of all drugs of GDMT should lead to improvement of LV-EF and consequently to a reduction in ICD implantations.
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