心脏性猝死的预防之路

CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege心脏性猝死的预防之路温州医学院附属第二医院季亢挺CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege主要内容心脏性猝死简介心脏性猝死的高危因素心脏性猝死的预防及ICD指南解读二级预防和一级预防（病例回顾）CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege他们的猝然离世为人们敲响了警钟：警惕心脏性猝死！我们身边也会有这样的病人！2007年6月23日18时，著名相声演员侯耀文在北京家中逝世，医生诊断为心脏性猝死，享年59岁。2006年12月20日，72岁的中国著名相声演员马季在家因心脏病突发去世。心脏性猝死离我们有多远？CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege病例一•女性，71岁•因昏倒被送至急诊室。ECG提示持续性VT（心室率240次/分），给予200J同步电复律成功•10年前有心梗史•超声检查：前侧壁运动减弱，EF40%她现在是否有SCA的危险性？CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege病例二•患者，男性，55岁，大学教授•二年前因急性前壁心肌梗死，行PTCA+支架术，当时EF=65%，没有室性心律失常，每月来院门诊他现在是否有SCA的危险性？需要如何进行识别的？CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege病例三•患者，男性，65岁，退休干部•冠心病病史10年，心力衰竭病史5年，长期服用倍他洛克，ACEI，和利尿剂，每年冬季患者因急性心衰住院治疗，平时每月在门诊定期随访他现在是否有SCA的危险性？需要如何进行识别的？CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege病例四•患者，男性，28岁•一月内反复晕厥3次入院。均为运动时发生。入院体检、心电图、心超均未见异常。该患者有无SCA风险？应该如何评估？CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollegeKimSG.StandardizedreportingofICDpatientoutcome:thereportofaNorthAmericanSocietyofPacingandElectrophysiologyPolicyConference,February9-10,1993.PACE1993;16:1358-1362.现代SCD的定义•在急性症状发生1小时内•因心脏性原因导致的死亡CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege突发性—从发作到死亡在1小时之内隐蔽性—发生之前24小时内无预兆紧迫性—发生后有效营救时间短暂（仅7—10分钟），致使近99%的患者失去救治机会，而死于心脏性猝死心脏性猝死的特点因此，预防心脏性猝死在于措施采取要早！CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege在中国…•每年SCD的发病率为54万•每天将近有1480SCD死亡（相当于四架波音747飞机坠毁）•许多高危患者需要我们的及时救治CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege主要内容•心脏性猝死简介•心脏性猝死的高危因素•心脏性猝死的预防及ICD指南解读•二级预防和一级预防（病例回顾）CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege心脏猝死发病率成人总发病率Source:MyerburgRJ.Circulation.1992;85(supplI):I-2–I-10.发病率(%/年)3020105210(%)冠心病高危患者冠心病的患者EF30%的心衰病人院外心脏骤停幸存者心梗后康复期伴VT/VFCardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege发生过心脏骤停是心脏性猝死最危险预测因子•一年内30%的心脏骤停幸存者仍将发生心脏性猝死心脏性猝死与心脏骤停（SuddenCardiacArrest）1SCASCA幸存者SCD6-8分钟内及时除颤CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege•尸检显示90%的心脏性猝死者存在冠心病证据•50～75%的心脏性猝死患者确认为心梗后•以往发生过心梗的患者，其SCD的发生率比正常人高出4-6倍•心肌梗死后发生心脏性猝死的高危因素室性心律失常左室功能障碍心脏性猝死与冠心病和心肌梗死1.AmericanHeartAssociation.HeartDiseaseandStrokeStatistics—2003Update.Dallas,Tex.:AmericanHeartAssociation;2002.2.MyerbergRJ.HeartDisease,ATextbookofCardiovascularMedicine.6thed.Philadelphia:WBSaundersCo;1997:chapter24.3.LombardiG.JAMA.1994;271:678-683.4.BiggerJT.Circulation.1984;69:250-258.2CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege心脏性猝死与心力衰竭•诊断为心衰，并有症状的患者SCD发生率是普通人群的6-9倍2.5年时间内，死亡率约为20-25%,其中约50%的死因为SCD1,21BardyG.ArrhythmiaTreatmentandTherapy,Copyright2000byMarcelDekker,Inc.,pp.323-342.2Sweeney,MO.PACE2001;24:871-888.3CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege轻度到中度心衰患者中最常见的死亡模式是SCD12%24%64%慢性心衰其它心源性猝死n=103NYHAII26%15%59%慢性心衰其它心源性猝死n=103NYHAIII心脏骤停泵衰竭纽约心功能II级64%12%纽约心功能III级59%26%CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege常见的遗传性心律失常•QT延长综合征（LQTS）•Brugada综合征•儿茶酚胺敏感性多形性VT与基因异常有关，平常无症状，常以晕厥、猝死首发就诊，体检正常，心电图检查可有异常。心脏性猝死与遗传性心律失常4CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollegeQT延长综合征（LQTS）•发病年龄多为21±15岁，女性多见•常有晕厥或猝死家族史•ECG表现为QT延长，异常的TU形态•特征性TdP（尖端扭转性室速）•部分基因型TdP发作与运动有关•发作常呈间隙依赖性（多为成人）•可分为先天遗传性和后天获得性CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege获得性LQTS药物性抗心律失常药物抗组织胺有机磷农药口服降糖药抗生素抗真菌药抗忧郁药(三环类)抗精神病药电解质异常急性低血钾慢性低血钙慢性低血镁慢性低血钾CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollegeCardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollegeQT间期延长QT离散度增加T-U波异常和T波动态变化心动过缓心电图特征CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege正常QTLQT1LQT2LQT3CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege受体阻滞剂基因为基础的药物治疗LCSD（左侧交感神经节切除）起搏器ICDLQTS治疗CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege仍是治疗LQTS第一线药物治疗后发生SCD的机率为10%/5年剂量应最大化(运动试验HR130次/分)所有均有效，心得安最常用不应突然停药心动过缓或窦性静止+起搏治疗受体阻滞剂治疗CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege占所有意外猝死4～12％在南亚50岁心脏结构正常者该病为猝死最常见原因窦律时心电图可显示RBBB和STv1-v3抬高(外向电流所致)晕厥和猝死由多形性室速或室颤所致Brugada综合征CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollegeA,B分别代表两种不同的突变基因类型引起的不同的ECG改变（穹窿型、马鞍型）CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollegeBrugada综合征12leadECGCardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege电生理诱发的多形性室性心动过速CardiologyResearchdepartmentTheSecondAffiliatedHospitalofWenzhouMedicalCollege唯一的有效治疗措施是置入ICD，随访10年死亡率0％有症状者需要ICD治疗，间隙性和持续性心电图异常患者预后相同无症状者有自发的心电图异常，EPS可诱发多形性室速或室颤，需要ICD治疗胺碘酮和ß阻滞剂等不能预防猝死