缺血性及非缺血性心肌病猝死的预防.ppt

T.JaredBunchMD,缺血性及非缺血性心肌病猝死的预防,IntermountainHeartRhythmSpecialists,IntermountainMedicalCenter,ConflictsofInterest,BostonScientific:speakershonorarium,需要急诊植入ICD人数增加,Myerberg:Circ,2019,CP1185382-11,需要植入ICD的人群OREGONSUD研究,CP1201806-4,SteckerandChugh:42:446AJACC,2019(Abstract),%,VF/VT所致的心脏停搏后的存活率,年龄、性别和疾病相匹配的对照组(p=0.68),植入ICD组,U.S.普通人群对照(p=0.02),长期存活率,BunchTJ,WhiteRD,NEJM,2019,p-值,0.27,0.12,0.73,0.14,0.19,0.07,0.65,0.01,0.33,0.19,0,25,50,75,100,身体因素,精神因素,有效性,社会功能,身体角色,情感角色,身体功能,智力健康指数,平时健康情况,认知,疼痛指数,*,预计恶化,长期生活质量,BunchTJ,WhiteRD,NEJM,2019,AVID试验中的存活率（未经过校正）,存活比率,高危病人1,016644333104存活率(%)除颤组89.381.675.4抗心律失常药物组82.374.764.1,年,NEJM337:1576,2019,P40%(n=2,406),DINAMITTrial从ICD中不能获益全因死亡率,CP1182269-1,累计风险,P=0.66,随机化的时间,ICD,Control,近期MI(6-40days)EF0.35HRV,674pt,Hohnloser:NEJM,2019,MI后的LV功能下降的死亡原因,CP1200978-1,OPTIMAALTrialLosartan/CaptoprilMI10天CHF/LV功能失调,180pt尸检报告,Orn:AJM,2019,累计死亡率(%),CABG后预防性应用ICDCABGPATCHTrial,CP1157419-4,900ptCABGsurgery年龄80yrEF0.36+异常的平均电信号心电图,月,Bigger:NEJM,2019,死亡概率,对照组,除颤组,CHF患者中未进行SCD-CASS注册的比例,Holmes:Circ,1986,未猝死患者(%),CP1176240-8,MI后-入选研究的平均时间,39,MUSTT,81,MADIT-II,36,704pt,MUSTT随机对照试验患者心律失常性死亡或心脏停搏,发生事件的病人数(no.),EP-guidedRxNoAAdrugRx,61224364860,P=0.043Hazardratio=0.73(0.53-0.99),月,多中心的自动除颤器植入试验（MADITI）,累计生存率,P=0.009,随机对照后观察的时间,ICD,Control,NYHAI,II,IIIPriorMIEF0.35InducibleVT,196pt,MI后ICD获益的时间依赖性,MADITIIsubstudyLVEF30%PriorMI1mo(mean81mo),累计存活率校正BL不同,存活率的分布曲线,Wilber:Circ,2019,（年）,存活率分布曲线,ICD,常规治疗,ICD,常规治疗,HR=0.97(0.51,1.81),HR=0.55(0.39,0.78),P=0.92,P=0.001,RemoteMI(18mo),近期心梗(1mo)EF0.30NYHAI,II,III,1232pt,QRS时间的意义,QRS,150,ICD获益,ICD无获益,死亡的相对危险性,总体死亡率,猝死率,心衰试验中的猝死率(SCD-HeFT),累计危险度,Bardy:NEJM,2019,年,Placebo,ICD,P=0.05,P=0.06,EF0.35NYHAII,III52%ischemicDCM,2521pt,Amio,Amio,Placebo,ICD,累计危险度,心衰、非缺血性心脏病一级预防,总体死亡率,猝死率,非缺血性心肌病中除颤器治疗的评价,死亡率,Kadish:NEJM,2019,年,死亡率,ICD,Conventional,ICD,Conventional,P=0.08,P=0.006,EF0.36NYHAI,II,IIIAmbientarrhythmias,458pt,亚组分析,性别女性男性年龄65yrLVEF20%QRS120msNYHAIIIIIIAFNoYesAll,ICD获益,ICD未获益,死亡相对危险性,ICD治疗的获益时间(DEFINITETrial),ICD,对照组,ICD,对照组,P=0.049,P=0.483,存活率（天）,NIDCM3mos,Kadish:JACC,2019,总体死亡率,猝死率,心衰试验中的猝死率(SCD-HeFT),CumulativeRisk,Bardy:NEJM,2019,年,Placebo,ICD,P=0.05,P=0.06,EF0.35NYHAII,III52%ischemicDCM,2521pt,Amio,Amio,Placebo,ICD,CumulativeRisk,糖尿病,CABGPatch,ICD一级预防的作用,Sanders:NEJM,2019,CP1234274-3,Buxton:Circ,2019,1,791ptMUSTTtrialEF40%DocumentedCAD,EF比值与死亡模式的关系,CP1230337-1,LVEF的分布,CP1222765-3,正常EF比值的心脏性猝死,Stecker:AHA,2019,MultnomahCounty,Oregon202pt入院存活率,正常,EF.36-.54,36%,42%,38%,20%,AMI42%AMI/有缺血性症状CAD61%无冠脉缺血证据22%,除颤器械的选择及程控,双腔和VVI植入性除颤器的试验(DAVID),506pts,EF40%ICD适应证VFVT有晕厥VT无晕厥，但EF40%,andSBP80mmHg,胸痛,CHF,近似晕厥诱发的VT/VFatEP研究中DDDR-70(60%paced)vsVVI-40(1%paced),WilkoffBL,CookJR,etal.JAMA2019;288:3115,NatriskDDDR2501597621VVI2561589025,P=0.03,随访时间,.4,.3,.2,.1,.0,0,6,12,18,DDDR(70),VVI(40),累计概率,WilkoffBL,CookJR,etal.JAMA2019;288:3115,双腔和VVI植入性除颤器的试验,COMPANION死亡率或入院率,0,20,40,60,80,100,0,120,240,360,480,600,720,840,960,1080,无事件存活(%),随机后观察时间,起搏器-除颤器(390events,P=0.010),起搏器(414events,P=0.014),药物治疗(216events),BristowMR,SaxonLA,etal.NEJM2019;350:2140,COMPANION全因死亡率,50,60,70,80,90,100,0,120,240,360,480,600,720,840,960,1080,无事件存活(%),随机后观察时间（天）,起搏器-除颤器(105events,P=0.003),药物治疗(77events),起搏器(131events,P=0.059),BristowMR,SaxonLA,etal.NEJM2019;350:2140,QRS120,QRS120,QRS120,QRS120,QRS120,QRS120,QRS120,QRS120,PeakO2Consumption,NYHAClass,QOLScores,6MinuteWalk,p=0.24,p=0.02,p=0.63,p=0.24,p=0.31,p=0.76,p=0.04,p=0.01,基线水平变化(%),基线水平变化(%),基线水平变化(%),基线水平变(%),Median,Median,RethinQ研究,172个病人，标准ICD适应证、QRS120msLVEF0.4,CRToff,CRTon,HR恶化,HF改善/未变化,610pt,LindeC.ACCLateBreakingClinicalTrials,2019,植入CRT12个月时对无症状性的左心室功能障碍的影响,CRToff,CRTon,LVESV,LVEDV,EF,-1.3,1.4,0.6,-18.4,-20.5,3.8,All0.0001,LindeC.ACCLateBreakingClinicalTrials,2019,植入CRT12个月时对无症状性的左心室功能障碍的影响,CRToff,CRTon,8.6%,11.9%,GoldMR.HRSLateBreakingClinicalTrials,2019,室颤/心动过速,无症状性的左心室收缩功能异常的流行病学,WangTJ.AnnInternMed2019,StrongHeart,HyperGen,Davies,MONICAEF35,MONICAEF30,2.9,2.1,4.0,3.4,1.8,0.9,7.7,5.9,2.9,1.4,EjectionFraction0.4,EjectionFraction0.4(noCHF),植入ICD患者的心房颤动,植入ICD后通过病史及心房颤动短期发病率判断预后,NoAF,NoHistory,AF,NoHistory,NoAF,AFHistory,AF,AFhistory,Percent(%),Death,HF入院率,Death/HF入院率,ICD休克,P=0.04,P=0.67,P=0.83,P=0.22,P=0.68,P=0.32,P=0.66,P=0.74,BunchTJ,HeartRhythm(inpress),N=1,530,MI后心房颤动及心脏性猝死跟踪注册研究,SC死亡危险比,MI后的时间（月）,Pederson:EurHeartJ,2019,5983ptMIwithCHFRandomizedtoTrandolaprilvsplacebo,AF/AFL,NoAF/AFL,P0.009,ICD的临床试验和临床标记物,需要考虑的因素及其限制性,EF测量的准确性EF界值与可能的致死性室速的关系,BunchTJ,GershBJ.Circu