心脏性猝死的预防泸州

心 脏 性 猝 死 的 预 防,重庆医科大学附属第一医院心内科何 泉,心脏性猝死流行病学心脏性猝死高危人群的识别心脏性猝死的防治,心脏性猝死也许就在我们身边！,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？,Kim SG. Standardized reporting of ICD patient outcome: the report of a North American Society of Pacing and Electrophysiology Policy Conference, February 9-10, 1993. PACE 1993;16:1358-1362.,SCD的定义,在症状发生1小时内出现致命性事件已知先天或后天致命性心脏疾病尸检证实心脏或血管性疾病为可能原因未发现心脏外致命性因素，推测为恶性心律失常,心脏性猝死发生率,0.10.2%/year 300,000350,000/year,0.0360.128%/year,0.042%/year544,000/year,0.5million 1.3 billion,SCD发生率:中国 vs 美国,Escobedo LG，et al. Circulation. 1996;93:2033 6.Wei Hua, et al .JACC .2009;54(12):11108,中国人口基数大，SCD总数居全球首位！,在中国,每年SCD的发病率为54万每天将近有1480个SCD死亡病例,SCD 发 生 场 所, SCD事件发生在院外!抢救成功率极低!,华伟,张澍等.J American College of Cardiology 2009;54(12):11108,Adapted from text: Cummins RO, Annals Emerg Med. 1989, 18:1269-1275.,SCD复苏成功机会与时间,每延迟一分钟成功机会减少7%-10%,SCD survival,American Heart Association. Heart Disease and Stroke Statistics. 2003 Update. Dallas, Texas: American Heart Association; 2002:3.Buxton AE et al.N Engl J Med 1999;331:1882-90.,Only one out of twenty SCA could survive!,不同人群心脏猝死发病率及事件总数,成人总发病率,Source: Myerburg RJ. Circulation. 1992;85(suppl I):I-2 I-10.,冠心病危险因素患者,冠心病的患者,EF 30%的心衰病人,院外心脏骤停幸存者,心梗后康复期伴VT/VF,近半数猝死患者生前无明确心血管病史（高血压、心绞痛、心梗、心衰）,SCD. 防？,治？,.,SCD,SCD high-risk,Primary prevention,Secondary prevention,心脏性猝死的流行病学心脏性猝死高危人群的识别心脏性猝死的防治,Ventricular fibrillation - 62.4%Bradyarrhythmias (including advanced AV block and asystole) - 16.5%Torsades de pointes - 12.7%Primary VT - 8.3%,Mechanisms of Sudden Cardiac Death-in 157 Ambulatory Patients,Bayes de Luna et al. Am Heart J 1989;117:1519.,猝死高危人群识别,详细的病史采集无创性诊断技术: 心电图、UCG（LVEF)、Holter(HRV)遗传学检查心内电生理检查,SCD相关的基础疾病,冠心病 -心肌梗死心衰心肌病 -DCM -HCM -ARVC -心肌致密化不全瓣膜疾病,浸润性心肌病遗传性原发性心律失常综合症 -LQTS440ms -SQTS（QTc300ms) -Brugada syndrome, -CPVT -ERPS 特发性VT、VF,心脏性猝死与冠状动脉疾病,冠状动脉疾病患者中50%男性、63%女性以猝死为首发表现1西方国家猝死基础病因中80%系冠状动脉疾患3，尸检显示90%的心脏性猝死者存在冠心病证据,1 American Heart Association. Heart Disease and Stroke Statistics2003 Update. Dallas, Tex.: American Heart Association; 2002.2 Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, 2001.3 Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. P. 895.,心脏性猝死病因2,3,* ion-channel abnormalities, valvular or congenital heart disease, other causes,5075%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,心脏性猝死与心肌梗死,1. American Heart Association. Heart Disease and Stroke Statistics2003 Update. Dallas, Tex.: American Heart Association; 2002. 2. Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia: WB Saunders Co; 1997:chapter 24.3. Lombardi G. JAMA. 1994;271:678-683.4. Bigger JT. Circulation. 1984;69:250-258.,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SCD 1, 2,1 Bardy G. Arrhythmia Treatment and Therapy, Copyright 2000 by Marcel Dekker, Inc. , pp. 323-342.2 Sweeney, MO. PACE 2001;24:871-888.,轻度到中度心衰患者最常见的死亡模式是SCD,n = 103,NYHA II,n = 103,NYHA III,在缺血和非缺血心衰患者中，EF越低的患者，SCD风险越高晕厥是心衰患者心脏性猝死的独立危险因子(p0.00001)有晕厥病史的患者一年SCD发生率为45%而没有晕厥病史患者的发生率为12%,心脏性猝死与心力衰竭,LVEF和SCA发生率,Vreede-Swagemakers JJ. J Am Coll Cardiol. 1997;30:1500-1505.,LVEF,% SCA Victims,此外.,肥厚性心肌病,猝死是肥厚性心肌病患者死亡的常见原因之一合并猝死家族史或VT的患者， 半数将发生心脏性猝死,Risk Factors for Sudden Cardiac Death in Hypertrophic Cardiomyopathy,Major Risk Factors,Possible in Individual Patients,Cardiac arrest (VF)Spontaneous sustained VTFamily history of premature sudden deathUnexplained syncopeLV thickness greater than or equal to 30 mmAbnormal exercise BPNonsustained spontaneous VT,AFMyocardial ischemiaLV outflow obstructionHigh-risk mutationIntense (competitive) physical exertion,Modified with permission from Maron BJ et al. J Am Coll Cardiol 2003;42:1687-713.,ARVC-showing Epsilon wave,Brugada Syndrome(Typical ST-T -abnormality V1-V2),Long QT Syndrome ：QT=520 ms;,Torsades de Pointes,有过心脏骤停史 有心脏骤停家族史 充血性心力衰竭，EF35% 心肌梗死后伴左室射血分数低下，EF40%,心脏性猝死的强烈预测因素,室性心律失常晚电位TWAQRS波时限延长是总死亡率和SCD增加的独立预测因子。左束支阻滞是心衰患者SCD高危因素。,猝死的高危因素心电不稳定,T波电交替（ TWA）是指T波每隔一个激动形态/幅度/极性交替变化。,心内电生理检查,（EPS）是评估室性心律失常和对SCD进行危险分层的技术，用于冠心病：评估心梗后症状与室性心律失常的关系、指导治疗，也可对心梗后患者进行危险评定晕厥：左室功能受损或器质性心脏病患者，晕厥原因不明时，推荐电生理检查。非侵入性检查不能确定，怀疑晕厥的原因是缓慢性或快速心律失常,心脏性猝死的流行病学心脏性猝死高危人群的识别心脏性猝死的防治,SCD的防治,预防心律失常的上游 - 糖尿病 - 高血压 - 高脂血症针对心律失常的病理生理 - ARB/ACEI/MRA - Statins - blocker,抗心律失常药物 -类：改善预后 -类：对预后为中性作用 -类：对IVT有效 -类：可能有害器械及手术 -起搏器/ICD/SICD/WCD/CRT -导管射频消融,早期心肺复苏、电复律是挽救SCD患者唯一有效措施:自动体外除颤器(AED)植入式心脏转复除颤器 (ICD),SCD的预防,二级预防：对已发生过心脏骤停的患者实施预防有过SCD一级预防：对未发生过心脏骤停的, 但有高危因素的人群实施预防心肌梗死后 (MI)EF40%充血性心力衰竭 (CHF)有家族SCA史,ICD降低总死亡率方面的对照研究,1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583.2 Kuck, et al. Circulation. 2000; 102:748-754.3 Connolly, et al. Circulation. 2000; 101:1247-1302.,4 Moss AJ. N Engl J Med. 1996;335:1933-1940.5 Buxton AE. N Engl J Med. 1999;341:1882-1890.6 Moss. Investor Conference Call. November 27, 2001.,二级预防临床试验结果,1 Moss AJ. N Engl J Med. 1996;335:1933-40.2 Buxton AE. N Engl J Med. 1999;341:1882-90.3 Moss AJ. N Engl J Med. 2002;346:877-834 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002.,5 The AVID Investigators. N Engl J Med. 1997;337:1576-83.6 Kuck K. Circ. 2000;102:748-54.7 Connolly S. Circ. 2000:101:1297-1302.,1 Moss AJ. N Engl J Med. 1996;335:1933-40.2 Buxton AE. N Engl J Med. 1999;341:1882-90.3 Moss AJ. N Engl J Med. 2002;346:877-834 Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, 2002.,一级预防临床试验结果,5 The AVID Investigators. N Engl J Med. 1997;337:1576-83.6 Kuck K. Circ. 2000;102:748-54.7 Connolly S. Circ. 2000:101:1297-1302.,ACC / AHA/HRS2008年心脏节律异常器械治疗指南,ICD I类建议:非可逆性原因引起的室颤或血流动力学不稳定的持续室速所致的心脏骤停。伴有器质性心脏病的自发的持续性室性心动过速，无论血流动力学是否稳定。原因不明的晕厥，在心电生理检查时能诱发有血流动力学显著临床表现的持续室速或室颤。心肌梗死所致LVEF35%，且心肌梗死40天以上，NYHA心功能II或III级。NYHA心功能II或III