心性猝死

心性猝死PreventionandTreatmentofSuddenCardiacArrestZhangzheng1stAffiliatedHospitalofLANZHOUMedicalCollegeSuddenCardiacArrest在美国每年SCA发生病例为25-30万，在工业化国家年发病率为156/100，000，年平均生存率仅5%，能到达医院率1%在SCA病人中检出高危因素和进行EPS非常重要，可预防SCA的发生EPS可提供进行ICD治疗的证据，ICD能对99%的SCA有效广泛增加AED的使用可大大降低SCA的死亡率，提高其生存率美国的各主要疾病的死亡率050,000100,000150,000200,000250,000300,000AIDSBreastCancerLungCancerStrokeSCASource:StatisticalAbstractoftheU.S.1998,Hoover’sBusinessPress,118thEditionPrimaryVF8%导致SCA的潜在心律失常AdaptedfromBayésdeLunaA.AmHeartJ.1989;117:151-159.TorsadesdePointes13%Bradycardia17%VT62%3020105210(%)Incidence(%/Year)3002001000(x1000)TotalEvents(#/Year)SuddenCardiacDeath发生率和总事件率OverallIncidenceinAdultPopulationSource:MyerburgRJ.Circulation.1992;85(supplI):I-2–I-10.HighCoronaryRiskSub-GroupAnyPriorCoronaryEventEF30%HeartFailureOut-of-HospitalCardiacArrestSurvivorsConvalescentPhaseVT/VFAfterMISCA可以预防吗?在临床研究中发现SCA大部分病人有高危因素在病人发生SCA之前，可以评价这些已知的危险因素对这些危险因素进行尽可能的治疗，就能预防SCA的发生RiskFactorsforSuddenCardiacArrest以往的SCA病史（晕厥史）室性心动过速（VT）病史既往心肌梗塞病史冠心病（CAD）病史心衰病史（CHF）肥厚性心肌病LQT综合症多个危险因素合并增加SCA的发生MyerburgRJ.HeartDisease,ATextbookofCardiovascularMedicine,5thed,Vol1.Philadelphia:WBSaundersCo;1997:ch24.FogorosRN.PracticalCardiacDiagnosis:ElectrophysiologicTesting,2nded.BlackwellScience,pp172.TheAVIDInvestigators.NEnglJMed.1997;337:1576-1583.MyerburgRJ.AnnInternMed..1993;119:1187-1197.DemirovicJ.ProgrCardiovascDis.1994;37:39-48.FriedlanderY.Circulation.1998;97:155-160.既往SCA病史有SCA病史的患者都有再次发生的危险30-50%的SCA幸存者在一年内将有另一SCA发作其中最为相关的危险因素是MI（50%)和既往SCA史MyerburgRJ.HeartDisease,ATextbookofCardiovascularMedicine,5thed,Vol1.Philadelphia:WBSaundersCo;1997:ch24.FogorosRN.PracticalCardiacDiagnosis:ElectrophysiologicTesting,2nded.BlackwellScience,pp172.TheAVIDInvestigators.NEnglJMed.1997;337:1576-1583.既往VT病史VT伴晕厥或LVEF低（LVEF40%)是引起SCA的主要诱发因素室性心律失常的年SCA发生率为20-50%MyerburgRJ.HeartDisease,AtextbookofCardiovascularMedicine.5thed,Vol1.Philadelphia:WBSaundersCo;1997:ch24.DeVreede-SwagemakersJJ.JAmCollCardiol.1997;30:1500-1505.KannelWB.Circulation.1975;51:606-613.ShenWK.MayoClinProc.1991;66:950-962.BiggerJT.Circulation.1984;69:250-258.RubermanW.Circulation.1981;64:297-305.BuxtonAE.NEnglJMed.1999;341:1882-1890.既往心肌梗塞病史研究表明75%的SCA病人能发现心肌梗塞病史在单一危险因素心肌梗塞年增加5%的SCA发生率在既往心梗病人（LVEF40%）5年SCA危险因素，EPS可诱发的非持续性VT是32%FuttermanLG.AmJCritCare.1997;6:472-482.DemirovicJ.ProgrCardiovascDis.1994;37:39-48.MossAJ.NEnglJMed.1996;335:1933-1940.FriedlanderY.Circulation.1998;97:155-160.冠状动脉粥样硬化心脏病在SCA尸检中95%的患者具有CAD50%的SCA死亡病人在发生猝死前没有表现CAD的症状SCA为首发症状占心脏病的20-50%MyerburgRJ.HeartDisease,ATextbookofCardiovascularMedicine.5thed,Vol1.Philadelphia:WBSaundersCo;1997:ch24.MiddlekaufHR.JAmCollCardiol.1993;21:110-116.StevensonWE.Circulation.1993;88:2953-2961.心力衰竭大约一半心衰病人的死亡是由于心律失常引起的猝死在左室功能恶化时（LVEF降低）SCA的发生明显增加在心功能II-IV（NYHA）的病人有不明原因的晕厥预示SCAMyerburgRJ.HeartDisease,ATextbookofCardiovascularMedicine.5thed,Vol1.Philadelphia:WBSaundersCo;1997:ch24.MaronBJ.NewEnglJMed.2000;342:365-373.肥厚性心肌病SCA是HCM常见的死亡原因之一HCM的流行在总人群中大约为0.2%，10%的病人有SCA的风险最近的研究表明在十年中50%的高危病人（高度肥厚，早年发病，明确的家族史，症状恶化）有过SCA35岁的运动员的猝死中HCM是最常见原因SchwartzPJ.CurrProblCardiol.1997;22:297-351.SmithWM.AnnInternMed.1980;93:578-584.GarsonAJr.Circulation.1993;87:1866-1872.LongQTSyndrome特发性LQT是一种先天性疾病，可引起不明原因的晕厥，癫癇样发作和SCA病人既可无症状或很易发生症状和潜在的致命心律失常在60%LQT病人表现有家族史或SCA由于遗传的关系，需要判定家族其它成员的危险性SCA的危险性评价电生理学家在过去15年中在评价和治疗有SCA危险的病人取得了巨大的进展EPS在心律失常的诊断上很有帮助，作用包括：-窦房结和房室结功能-传导功能-旁路的传导-VT的电生理EPS也是ICD治疗和射频消融的基础体积小，可经皮胸部植入经静脉植入电极，单一切口局部麻醉，病人有意识住院时间短并发症很少手术死亡率1%可程控治疗程序单，双腔，双室可选电池寿命9年以上80,000例以上的植入量（2000年）植入式心律转复器（ICD）First-linetherapyforpatientsatriskforSCA1MorganStanleyDeanWitter.InvestorsGuidetoICDs.2000.Atrium&VentricleVentricleTherapiesProvidedbyToday’sDual-ChamberICDsAntitachycardiapacingCardioversionDefibrillationBradycardiasensingBradycardiapacing植入ICD的进展ImplantingPhysicianCardiacsurgeonEPorsurgeonDevicesize120-140cc40ccImplantSiteAbdominalPectoralProcedureMediansternotomySkinincisionLateralthoracotomyProceduretime2-4hours1hourPerioperative2.5%0.5%mortalityPost-implant3-5days1dayhospitalizationBatterylongevity18monthsUpto9years#Implants0-2,000/yr80,000/yr(E)11980’s20001MorganStanleyDeanWitter.InvestorsGuidetoICDs.2000.NumberofWorldwideICDImplantsPerYear*UnderclinicalinvestigationintheUS010,00020,00030,00040,00050,00060,00070,00080,00090,000100,00019801985199019952000EICD治疗的演变:1980toPresent1980•FirstHumanImplant1985•FDAApprovalofICDs1999•MUSTT1993•SmallerDevices1996•SteroidLeads•MADIT1989•TransvenousLeads•BiphasicWaveform1997/98•DCICDs•ATTherapies•AVID•CASH•CIDS1988•TieredTherapy2000•CardiacResynchro-nization*ICD与抗心律失常药物对SCA治疗的试验VT/VFpatients:–AntiarrhymicsVersusImplantableDefibrillators(AVID)–CardiacArrestStudyHamburg(CASH)–CanadianImplantableDefibrillatorStudy(CIDS)High-riskpost-MIpatients:–MulticenterAutomaticDefibrillatorImplantationTrial(MADIT)–MulticenterUnsustainedTachycardiaTrial(MUSTT)60%MUSTT55years54%MADIT42years20%CIDS33years37%CASH22years31%AVID13years与抗心律失常药物比较ICD减少SCA的死亡率0%10%20%30%40%50%60%%MortalityReduction1TheAVIDInve