心源性猝死的预防和治疗.ppt

SuddenCardiacDeath:PreventionandTreatment,LexinWang,M.D.,Ph.D.ProfessorofClinicalPharmacologyHead,CardiovascularResearch,IncidenceofSCD,SCD(causedbysuddencardiacarrest)isthemostcommoncauseofdeathinWesternsocietiesIncidence:300,000to400,000eachyear(U.S.)only2%15%reachthehospitalHalfoftheseearlysurvivorsdiebeforedischarge,RiskFactorsofSCD,LeftventricularfailureCHD,cardiomyopathySuddencardiacdeathsyndromesLongQTsyndromesBrugadasyndromePolymorphiccatecholaminergicVTIsolatedventricularfibrillation,CADhasbecomeamaincauseofSCD,HuikuriHV.NEnglJMed.2019;345:1473-1482.MyerburgRJ.HeartDisease,ATextbookofCardiovascularMedicine.6thed.W.B.Saunders,Co.2019.,*ion-channelabnormalities,valvularorcongenitalheartdisease,othercauses,BaysdeLunaA.AmHeartJ.1989;117:151-159.,Bradycardia17%,MonomorphicVT62%,PrimaryVF8%,TdP13%,PrevalenceofarrhythmiaatSCD,HeartFailureandSCD,MorethanonemillionnewheartfailurepatientseveryyearintheUSA25%mortalityin2.5yearsinmoderatetosevereCHFAtotalof15%ofCHFpatientsdieofSCD,Gorgels,PMA.EurHeartJ.2019;24:1204-1209.,LVEF,%SCDVictims,7.5%,5.1%,2.8%,1.4%,LVEFandSCD,CausesofdeathsinHF:mainlySCDinNYHAII-III,heartfailureinNYHAIV,MERIT-HFStudyGroup.LANCET.2019;353:2019-2019.,NYHAClassIIIn=103,NYHAClassIIn=103,NYHAClassIVn=27,64%,12%,24%,11%,56%,33%,59%,15%,26%,MyocardialinfarctionandSCDAcutephase:ischemia-provokedVF;ormechanicaldysfunctions(e.g.ventricularorpapillaryrupture)Chronicphase:structuralremodellingoftheLV,leadingtore-entryorheartfailure,RiskstratificationofSCD,RiskassessmentClinicaldataAetiology;familyhistory;LVEFEPSTwavealternansQTdispersionArrhythmiaduringHoltermonitoringorstresstest,IdekaT,etalJACC2019;48:2268,PredictivevaluesofpositiveTWA,nonsustainedVTandventricularLatepotentials,Sowhatwedo?,ThemostimportantcriterionisreducedleftventricularfunctionLVEF35%and40daysafterMI,PreventionofSCD,Anti-arrhythmicdrugsAmiodaroneisprobablythemosteffectivedrugforsecondarypreventionofVTMarginallyreduceSCDandmortalityICDMosteffectivewhenLVEF30%OtherSurgeryLongQT()Ventricularaneurysm,hearttransplantCatheterablation,PreventionofSCD,SecondaryPreventioninthosewhohadahistoryofSCAPrimaryPreventioninthosewithahighriskbutnohistoryofSCA,80,85,2000,90,95,AVID,CASH,CIDS,SCD-HeFT,MADIT-II,MUSTT,MADIT,二级,Secondary,Primary,DEFINITE,MUSTT,MulticenterUnsustainedTachycardiaTrial(MUSTT),arandomizedcontrolledtrialCanelectrophysiologicallyguidedantiarrhythmictherapyreducetheriskofsuddendeath?Lookedatcoronaryarterydiseasepatientswithaleftventricularejectionfraction4weeks);leftventricularEF21yearsPatientsrandomlyassignedina3:2ratiotoreceiveICDorconventionalmedicaltherapy,MADIT-II,TrialstartedJuly8,2019TrialstoppedprematurelyinNovember20,2019becauseICDsavedlives1,232patientsenrolledfrom76centersinU.S.andEurope,MADITTII-Mortality,CONVDEFIB(n=490)(n=742)Deaths9719.8%10514.2%-HazardRatio(ICD:CONV)0.69(31%mortality)(95%CI)(0.51,0.93)P-value0.016,MADIT-II,MossAJ.NEnglJMed.2019;346:877-83.,Defibrillator,Conventional,P=0.007,1.0,0.9,0.8,0.7,0.6,0.0,ProbabilityofSurvival,0,1,2,3,4,Year,No.AtRiskDefibrillator742502(0.91)274(0.94)110(0.78)9Conventional490329(0.90)170(0.78)65(0.69)3,SCD-HeFT,SuddenCardiacDeathinHeartFailureTrial(SCD-HeFT)NYHAclass2-3HFandLVEF35%Largestinternal-cardioverter-defibrillator(ICD)trialeverconductedICDvsplaceboMedianfollow-upof45months,SCD-HeFT,Bardyetal.NEngJMed2019;352(3):225,SCD-HeFT:All-causemortality,JaredBunchT,etal.Circulation2019;115:2451-57,JaredBunchT,etal.Circulation2019;115:2451-57,Summary,MostSCDareduetocoronaryarterydiseaseandheartfailureLVEFisthemostreliablenon-invasivepredictorforSCDSCDunder30yearsofageisusuallyduetoinheritedheartdisease,Summary,Anti-arrhythmicdrugstopreventsuddendeatharenotasimportantasoncethought-blockersaremoreeffectivethanamiodaroneorsotalolinptswithCHForCHD,Summary,ICDisthemosteffectivepreventionforSCDProphylacticICDtherapyisreadyforprime-timeuseinpatientswithCHDa