室性心律失常的临床处理原则

室性心律失常的临床处理,贵州省人民医院杨 龙,内容,特发性室性早搏特发性室性心动过速获得性尖端扭转型室速急性心肌梗死相关室速慢性心力衰竭相关室速,一、特发性室性早搏,治疗与否？药物？消融？,（一）选择治疗的理由,症状。心脏重构：导致心脏扩大、心功能减退。,In patients with frequent PVCs and no organic heart disease, who are at low risk of sudden cardiac death, a decrease in QOL(Quality Of Life) and severity of symptoms are the main indications for treatment with antiarrhythmic agents .,Zipes DP, et al. J Am Coll Cardiol, 2006.Aliot EM, et al. Heart Rhythm, 2009.,Two hundred and thirty-nine consecutivepatientspresenting withfrequentPVCs (1000 beats/day)originatingfrom the RVOT orLVOTwithout any detectable heart disease were enrolled in the study. During an observation period of 5.6 (1.7) years, there was a significant negative correlation between the PVC prevalence and Delta LVEF (p0.001) and positive correlation between the PVC prevalence and Delta LVDd (p 20,000 beats/day) or baseline decreased LVEF exhibit a significant decrease in LVEF during long-term follow-up.,Niwano S, et al. Heart,2009.Bogun F, et al. Heart Rhythm, 2007.,The use of metoprolol, propafenone and verapamil is recommended in patients with PVCs of RVOT origin.,Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Am Coll Cardiol, 2006.,（二）药物治疗,Beta-blockers have been tested in patients with idiopathic PVCs. Their efficacy was modest (25% for metoprolol) or not superior to a placebo (atenolol) .,Capucci A, et al. Clin Cardiol, 1989.Saikawa T, et al. Jpn Heart J, 2001.Krittayaphong R, et al.Am Heart J, 2002.,Patients were included in the study if they had: (1) symptomatic ( 4 weeks) monomorphic PVCs 2,500/24 h; or (2) persistent ( 3 months) monomorphic PVCs 2,500/24 h with similar PVCs (65岁心脏病：各种基础心脏病QT间期：原有QT/QTc延长电解质：低钾、低镁室性心律失常：室早、短长短现象警告性心电图：QT延长、TU波变形、T波电交替药物：服用一种或一种以上延长QT药物其他：缓慢性心律失常,一旦发生TdP及室颤，迅速采取有效措施（12字方针）停药除颤补镁 （2-4g）补钾 （4.5mmol/L）起搏 提高心率（90ppm）药物 提高心率（异丙肾等）,TdP抢救及治疗措施,四、急性心肌梗死相关室性心律失常,2012 Ventricular arrhythmias,（一）Ventricular premature beats,心梗首日几乎皆发生PVC，表现形式多样，如多形态、RonT，并非VF预兆，无需特殊治疗。,（二）Ventricular tachycardia,非持续性室速（NSVT ；lasting 30 s）并非预测VF发作的可靠因子，通常可耐受。没有证据支持抑制无症状NSVT能改善存活率；不提倡特别针对NSVT抗心律失常治疗，除非伴随血流动力学不稳定。,如果持续存在的心肌缺血导致的VT引起血流动力学不稳定，可静脉推注amiodarone, sotalol 或lidocaine以期终止，但成功率低。 对心梗合并左室功能减退者，amiodarone是唯一一种无严重致心律失常作用的抗心律失常药，因此对此类患者优先选择。,（三）Ventricular fibrillation,lidocaine可减少AMI者VF的发生率，但有增加心脏停搏的危险。对于持续VT或VF反复发作3小时以上AMI患者，amiodarone增加死亡率, 而lidocaine不增加。,Piccini JP,et al. Crit Care Med. 2011,对于左室功能明显减退或发作持续单形性VT，即使心肌短暂缺血始动VT/VF导致心脏停搏，血运重建并不能有效阻止心脏停搏复发。对于VF/SVT发作幸存者，ICD置入较之AADs (主要是amiodarone) 能明显改善生存率。对于危及生命的室性心律失常，除beta-blockers外，AADs作为一线药预防SCD无效。,Brugada J, et . J Am Coll Cardiol 2001.Natale A, et al. J Cardiovasc Electrophysiol 1994.Lee DS, et al. J Am Coll Cardiol 2003.Zipes DP, et al. J Am Coll Cardiol, 2006.,对于直接电复律无效的持续性单形性VT，可考虑静推amiodarone、lidocaine或sotalol.对于反复发作的症状性非持续性单形性VT，可采取继续观察或i.v. beta-blocker、 sotalol或 amiodarone治疗.,monomorphic VT,Polymorphic VT,must be treated by i.v. beta-blockeror i.v. amiodarone不排除心肌缺血所致者必须行冠脉造影检查可考虑静推lidocaine立即判断并纠正电解质紊乱，如补充镁离子可采用右心室超速起搏或静滴 isoprotenerol,Management of ventricular arrhythmias and risk evaluation for sudden death on long term,ICD作为SCD二级预防：合并明显左室功能不全、在心梗急性期后仍发作血流动力学不稳定VT或VF者，通过心电生理检查支持。ICD作为SCD二级预防：合并明显左室功能不全、在心梗急性期后发作血流动力学不稳定VT或VF者，即使在心梗急性期没有血流动力学不稳定VT/VF发作。ICD作为一级预防：急性心梗40天后， LVEF 40%.,五、心力衰竭相关室速,HF患者室性心律失常高发，尤其是左室增大和EF减低者。动态心电图监测所有HF患者皆可见PVCs，无症状性NSVT亦常见。,Zipes DP, et al. Eur Heart J 2006.,对有室性心律失常发作的HF患者，建议：寻找并纠正导致心律失常发作及恶化的因素，如电解质紊乱、药物致心律失常作用、心肌缺血。优化ACEI (or ARB)、beta-blocker和盐皮质激素受体拮抗剂治疗。对合并冠心病者，行冠脉血运重建。,建议置入ICD：症状性或持续性VT/VF，心功能状态合适，治疗目的在于提高存活率。建议Amiodarone：置入ICD，优化药物治疗和ICD程控，仍有症状性VT或反复放电者。 建议Catheter ablation：置