心律失常及心脏起搏新进展

2013心律失常及心脏起搏新进展深圳市孙逸仙心血管医院衣为民,1. Connolly et al, 2009; 2. Wallentin et al, 2009; 3. Oldgren et al, 2010; 4. Patel et al, 2010; 5. Lopez et al, 2010 6. NCT00781391,新型口服抗凝药物在房颤卒中预防领域中的应用,RELY、ROCKET AF 和ARISTOTLE研究均已完成,Edoxaban vs. Warfarin in Patients with AFENGAGE AF-TIMI 48 Clinical Trials,Methods randomized, double-blind, double-dummy trial comparing two once-daily regimens of edoxaban with warfarin in 21,105 patients with moderate-to-high-risk AFmedian follow-up, 2.8 years. The primary efficacy end point was stroke or systemic embolism. tested for noninferiority to warfarin. The principal safety end point was major bleeding.,N Engl J Med. 2013 Nov 19,Edoxaban vs. Warfarin in Patients with AFENGAGE AF-TIMI 48 Clinical Trials,Results The annualized rate of the primary end point during treatment was 1.50% with warfarin , as compared with: 1.18% with high-dose edoxaban (HR, 0.79; 97.5% CI, 0.63 to 0.99; P0.001 for noninferiority) 1.61% with low-dose edoxaban (HR, 1.07; 97.5% CI, 0.87 to 1.31; P=0.005 for noninferiority).,N Engl J Med. 2013 Nov 19,intention-to-treat analysis,Edoxaban vs. Warfarin in Patients with AFENGAGE AF-TIMI 48 Clinical Trials,N Engl J Med. 2013 Nov 19,The annualized rate of major bleeding: 3.43% with warfarin 2.75% with high-dose edoxaban 1.61% with low-dose edoxaban.,Edoxaban vs. Warfarin in Patients with AFENGAGE AF-TIMI 48 Clinical Trials,N Engl J Med. 2013 Nov 19,Edoxaban vs. Warfarin in Patients with AFENGAGE AF-TIMI 48 Clinical Trials,Results The corresponding annualized rates of death from cardiovascular causes were 3.17% versus 2.74% (HR, 0.86; 95% CI, 0.77 to 0.97; P=0.01), and 2.71% (HR, 0.85; 95% CI, 0.76 to 0.96; P=0.008)The corresponding rates of the key secondary end point (a composite of stroke, systemic embolism, or death from cardiovascular causes) were 4.43% versus 3.85% (HR, 0.87; 95% CI, 0.78 to 0.96; P=0.005), and 4.23% (HR, 0.95; 95% CI, 0.86 to 1.05; P=0.32).,N Engl J Med. 2013 Nov 19,Edoxaban vs. Warfarin in Patients with AFENGAGE AF-TIMI 48 Clinical Trials,Conclusions Both once-daily regimens of edoxaban were noninferior to warfarin with respect to the prevention of stroke or systemic embolism and were associated with significantly lower rates of bleeding and death from cardiovascular causes.,N Engl J Med. 2013 Nov 19,Edoxaban versus Warfarin for the Treatment of Symptomatic Venous ThromboembolismThe Hokusai-VTE study,Hokusai-VTE study 结论,急性深静脉血栓和肺动脉栓塞患者，依度沙班 30-60mg/天 疗效不劣于标准的华法林治疗 出血风险优于标准的华法林治疗,Dabigatran versus warfarin in patients with mechanical heart valves.,RE-ALIGN试验 使用达比加群酯与应用华法林的心脏机械瓣膜置入患者相比：卒中、心肌梗死和血栓形成的风险更高 出血风险更高该研究在2012年底被 终止,N Engl J Med 2013;369:1206-14,儿童心律失常,儿童心律失常,儿童心律失常,儿童心律失常,儿童心律失常,2013 HIGHLIGHT ON CARCIAC PACING and CRT,主要亮点,建立了新的缓慢性心律失常分类系统 根据患者的临床表现和心电图 而非病因 强调应首先进行间歇性与持续性心动过缓综合征的鉴别诊断 形式简洁、比以往更加重视临床实用性 以便多个专业的临床医师参考 根据不同临床状况建立了不同起搏模式的“逻辑决策树” 每个章节增加“临床前景展望” ESC指南中首部有此内容的指南,Indication for upgraded or de novo cardiacresynchronization therapy in patients with conventional pacemaker indications and HF,Echo CRT试验 结论,严重心衰患者，即便有心室壁活动不同步的情况，如果QRS波 130 ms，则不能从 CRT安装治疗获益,甚至可能有害不降低心力衰竭死亡或住院率死亡率可能增加。,Adaptive CRT Trial: 同步化左心室起搏的临床结果,研究背景近期有研究表明左室起搏的患者获益可能超过双室起搏。当患者自身AV间期正常时，Adaptive CRT (aCRT)算法使将左室同步起搏与自身激动融合。随机、双盲研究证明aCRT算法不劣于超声优化的双室起搏（对照组）。目的检验同步左室起搏（sLVP）是否产生更好的临床结果。方法CRT-D病人2:1随机分为aCRT算法组（治疗组）和超声优化组（对照组）首先，在治疗组中行%sLVP 50%者与%sLVP50%者之间比较其次，aCRT组与对照组（AV间期正常亚组)进行比较。一级终点12月内死亡或首次心衰住院时间6、12月CCS改善次级终点6、12月心脏结构和功能改变,Heart Rhythm 2013;10:1368,Adaptive CRT Trial: 同步化左心室起搏的临床结果,Time to all-cause death or first heart failure hospitalization over the12-month follow-up stratified by percent synchronized left ventricular pacing in the adaptive CRT arm.,Heart Rhythm 2013;10:1368,Adaptive CRT Trial: 同步化左心室起搏的临床结果,Proportion of patients improved in CCS at 6- and 12-month follow-ups stratified by %sLVP in the aCRT arm.,Heart Rhythm 2013;10:1368,Adaptive CRT Trial: 同步化左心室起搏的临床结果,Time to all-cause death or first HF hospitalization over the12-month follow-up in the aCRT and control patients with normal intrinsic AV interval at randomization.,Heart Rhythm 2013;10:1368,Adaptive CRT Trial: 同步化左心室起搏的临床结果,Proportion of patients improved in CCS at 6- and 12-month follow-ups in the subgroup with normal intrinsic AV interval at randomization.,Heart Rhythm 2013;10:1368,Adaptive CRT Trial: 同步化左心室起搏的临床结果,结论采用aCRT算法治疗时，%sLVP50%的患者具有较好的临床结果。在AV传导正常的病人中，与超声优化的双室起搏相比，aCRT算法可提供最好的左室同步起搏，并取得更好的临床结果。,Heart Rhythm 2013;10:1368,2013 HIGHLIGHT ON CARCIAC PACING and CRT,Indication for pacing in patients with persistent Sinus node disease,In general, SB is only an indication for pacing if bradycardia is symptomatic.It is crucial to distinguish between physiological bradycardia,inappropriate bradycardia . SB (even when it is 4050 bpm while at rest or as slow as 30 bpm while sleeping) is accepted as a physiological finding that does not require cardiac pacing in trained athletes.,Indication for pacing in patients with persistent Acquired AV block,In contrast to SB, AV block may require PM therapy for prognostic reasons and pacing may be indicated in asymptomatic patients.,Indication for pacing in patients with persistent Acquired AV block,Severity of symptomsRisk of progression to complete AVB.delay occurs at intra- or infra-His levelsthere is a wide QRS complex.,Several observational studies suggest that pacing prevents recurrence of syncope and improves survival in adults.,1,Choice of pacing mode for SSS,Routine use of DDDR, rather than AAIRDisadvantage of AAIR is that AV block develops in 0.61.9% of patients with sinus node disease every year.DANPACE trialNo difference in all-cause mortality (primary endpoint). AAIR pacing was associated with a higher incidence of paroxysmal AF(HR: 1.27) and a two-fold increased risk of PM re-operation (HR:1.99).,Eur Heart J2011;32:686-696.,Indication for pacing in intermittent documented bradycardia,6.1 Pacing from alternative right ventricular sites,14 RCTs for a total of 754 patients,6.1 Pacing from alternative right