室性心律失常与ICD适应证

室性心律失常与ICD 适应证,课程目标,复习 VT/VF ECG 讨论症状& 表现讨论VT/VF管理策略里的 ICD 疗法回顾当前的ICD治疗指南,室性心律失常,识别心律失常,这是什么节律?,.Level IV_PrintedvideoVT.wmv室颤单形性室速房颤多形性室速,起源: 心室 (Wandering Single Focus)机制: Reentry with movement in the circuit initiated by abnormal automaticity or triggered activity特征: Wide and irregular QRS Complex that changes in axis,What Rhythm is this?,室颤单形性室速房颤多形性室速,What rhythm is this?,.Level IV_PrintedvideoVF.wmv室颤单形性室速房颤多形性室速,What rhythm is this?,室颤单形性室速房颤多形性室速,有室性心律失常和SCD的患者的临床表现,无症状的患者有或无心电图异常,医生，你看，自从上次心梗后，我觉得我现在完全好了，一点事都没有了。,患者有症状，可能是由室性心律失常所致心悸Palpitations呼吸困难胸痛晕厥及晕厥前兆室速可以是血流动力学稳定的，也可能是血流动力学不稳定的,我差点死在车里！,有室性心律失常和SCD的患者的临床表现,心脏停搏心房无收缩+ 房室阻滞心室无收缩无脉电活动,为了不使我脑部受损，他们不得不用电击把我给抢救回来！,有室性心律失常和SCD的患者的临床表现,心脏性猝死（Sudden Cardiac Death）,(1)在急性症状发生1小时内，(2)先有骤然发生的意识丧失的，(3)因心脏性原因导致的自然死亡。SCD不能预料的，之前24小时是正常的,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.,导致心脏骤停的心律失常,Adapted from Bays de Luna A. Am Heart J. 1989;117:151-159.,每延迟一分钟减少成功机会7 10%,Adapted from text: Cummins RO, Annals Emerg Med. 1989, 18:1269-1275.,SCD复苏成功机会与时间,如果抢救不及时,SCA 一个公众健康问题,爱滋,乳腺癌,肺癌,SCD3,每年死于SCD 的人数多于其他疾病的总合,事实:在美国，是严重的健康杀手95% fatal without ICD protection5 - 98% survival with ICD protection每天将近1000人死于SCA ICDs are Class I indicated for most at-risk Pts788% of SCA 是由心律失常所致,在中国,每年SCD的发病率为54万每天将近有1480 SCD死亡 每分钟有1人发生SCD,室性心律失常的急诊治疗,室颤,Immediately life-threatening严重的血流动力学表现治疗必须及时/aggressive除颤CPR / ACLS药物,单形性室速,血流动力学可能稳定/可能不稳定持续性血流动力学不稳定VT电复律静脉滴注胺碘酮Amiodarone (如果电复律不成功）持续性血流动力学稳定VT药物治疗潜在原因分析,ICD防止SCD最有效！Shock &ATP,.Level IV_Printedvideoatp_vs_shock.wmv,VT and VF 管理,Evaluation,常用的评估方法 (Non-acute),病史和体检12-Lead ECGECG 运动试验Ambulatory ECG (Holter monitor / ILR)T-wave 振荡心超电生理检查,Ventricular Arrhythmia And SuddenCardiac Death Related To Specific Pathology,Treatment,典型的治疗方案,纠正病因例如：Revascularization药物治疗针对心衰的优化的药物治疗是否是ICD 的适应证?,85,2000,90,95,AVID,CASH,CIDS,SCD-HeFT,MADIT-II,MUSTT,MADIT,Secondary,Primary,DEFINITE,SCD-HeFT,80,PK,+,Moss AJ. N Engl J Med. 2002;346:877-83.,MADIT-II结果,Hazard Ratio=0.69 (p= 0.016),31% Relative Reduction,N= 490,N= 742,Mortality rate,During an average follow-up of 20 months,MADIT-II结果,Moss AJ. N Engl J Med. 2002;346:877-83.,Defibrillator,Conventional,P = 0.007,1.0,0.9,0.8,0.7,0.6,0.0,Probability of Survival,0,1,2,3,4,Year,No. At RiskDefibrillator 742 502 (0.91) 274 (0.94) 110 (0.78) 9Conventional 490 329 (0.90) 170 (0.78) 65 (0.69) 3,适应证练习,When is an ICD indicated?,一级 & 二级 预防,这个病例是什么预防?答案: 二级预防题外话，最早的ICD 植入适应证的患者需要发生几次心脏骤停？,我差点死过一次。还会不会再发生？,心脏性猝死（Sudden Cardiac Death）,二级预防是指在发生心脏骤停或持续性室速的幸存者中预防SCD的发生。一级预防是指未发生过心脏骤停或持续性室速的患者预防SCD。 具有SCD的高危因素，曾经发生过不明原因的晕厥， 推测晕厥可能是由于室性心律失常导致者属于二级预防的范畴。,心衰患者的一级预防,What is a current Class I ICD indication for NYHA Class II or III patients (primary prevention) ?,EF,正常 55%,Class II: patients with mild limitation of activity; comfortable with rest or with mild exertion. Class III: patients with marked limitation of activity; they are comfortable only at rest.,一级预防: NYHA Class I 患者,What is a current Class I ICD indication for NYHA Class I Ischemic patients (一级预防) ?,EF,Class I HF = 活动不受限; 日常活动无症状。,某些先天性心脏病,长QTBrugada综合征致心律失常性右室发育不良/心肌病肥厚型心肌病,我们来练习,Here we Go!,哪些是一级预防？哪些是二级预防?,陈旧性心梗, 感觉良好, EF = 32%,Shocked by EMTs, hopefully no brain damage,Nearly passed out in his car,Primary,Secondary,Secondary,病例四,男性 31岁； 由于其父患H