【医学课件】室性心律失常：成功与失败ppt课件.ppt

VentricularArrhythmias:AGeneralCardiologistsAssessmentofTherapiesin2004,C.RichardContiM.D.MACC,天马行空官方博客：,EvaluationofPVCs,StartwiththeHistoryandphysicalexamination.Documentationofthearrhythmiaiscritical.ECG.Holtermonitor.Eventmonitor.Revealmonitor.,Management,ManagementofPVCsdiffersinpatientswithandwithoutstructuralheartdisease.Todefinestructuralheartdisease,consider:Echocardiography.ETT.Leftheartcatheterization.,PVCsintheAbsenceofStructuralHeartDisease,Intheabsenceofstructuralheartdisease,ventricularectopyisgenerallybenign,carryingnoprognosticsignificance.Treatmentwithantiarrhythmictherapyisnotindicatedunlessthepatientisunacceptablysymptomatic.,PVCsintheAbsenceofStructuralHeartDisease,TreatmentReassurance.Avoidanceofstimulants.Caffeine.Cigarettes.Betablockers.Antiarrhythmicdrugsasalastresort.,PVCsintheAbsenceofStructuralHeartDisease,Ifantiarrhythmicdrugsarenecessary:Class1C:Flecainide.Propafenone.Mexilitene.Amiodaroneisrarely,ifever,indicated.,ManagementofVentricularEctopyinthePresenceofStructuralHeartDisease,AVID,AntiarrhythmicsVersusImplantableDefibrillatorsSponsoredby:NationalInstitutesofHealthEntryCriteria:VFVTwithsyncopeVTwithoutsyncope,withEF.40,andSBP80mmHg,chestpain,CHF,ornearsyncopeTreatment:ICDvs.empiricamiodaroneorHolter/EP-guidedsotalolPrimaryendpoint:Totalmortality,AVIDInvestigators.NEnglJMed.1997;337(22):1576-1583.,SurvivalinAVIDPatients,Adaptedfrom:DomanskiMJ,etal.JAmCollCardiol1999;34:1090-1095.,LVEF0.34(Group3),1.0,.9,.8,.7,.6,.4,.3,.2,.1,0,.5,CumulativeSurvival,0,12,24,Device,Drug,1.0,.9,.8,.7,.6,.4,.3,.2,.1,0,.5,CumulativeSurvival,0,12,24,Device,Drug,ICDTherapyforSustainedVentricularArrhythmias:SecondaryPrevention,ConclusionsTheresultsofAVIDsupportusingtheICDasfront-linetherapytoprolongtotalandsuddendeathsurvivalinpatientsathighriskforsuddendeathe.g.PoorLVfunction.Thistrialincludedpatientswithbothischemicandnonischemicsubstrates.,ICDTherapy,PrimaryPreventionICM,MADIT,MulticenterAutomaticDefibrillatorImplantationTrialHypothesis:ICDwillreducemortality(all-cause)inhigh-riskCADpatients.,MossAJ.NEnglJMed.1996;335:1933-1940.,MADITInclusionCriteria,PriorQ-waveMINonsustainedVTEF3weeksfromlastMINorequirementforrevascularization,MossAJ.NEnglJMed.1996;335:1933-1940.,MADITPatientFlow,Non-inducible(n=139),Patientsmeetinginclusioncriteria(N=483),EPstudy,SuppressiblewithIVprocainamide(n=91),Refusedstudy(n=57),Inducible(n=344),Non-suppressible(n=253),Signedconsentform,randomized(n=196),MADITFDAInfoPack.May16,1996.,MADITSurvival,MossAJ.NEnglJMed.1996;335:1933-1940.,1.0,0.8,0.6,0.4,0.2,0.0,0,1,2,3,4,5,Year,Probabilityofsurvival,Conventionaltherapy,Defibrillator,MADITConclusion,InpatientswithapriorMIwhoareatahighriskforventriculartachyarrhythmia,prophylactictherapywithanimplanteddefibrillatorleadstoimprovedsurvivalascomparedwithconventionalmedicaltherapy.,MossAJ.NEnglJMed.1996;335:1933-1940.,MUSTTMulticenterUnSustainedTachycardiaTrial,Sponsors:NHLBIandIndustry,BuxtonAE.NEnglJMed.1999;341:1882-90.,MUSTTHypothesis,Antiarrhythmic(AA)therapyguidedbyEPtestingcanreducetheriskofarrhythmicdeathandcardiacarrestinpatientswith:,CADEF3beats,100bpm),BuxtonAE.NEnglJMed.1999;341:1882-90.,MUSTTEndpoints,Primary:ArrhythmicdeathorcardiacarrestSecondary:TotalmortalityCardiacmortalitySpontaneous,sustainedVT,BuxtonAE.NEnglJMed.1999;341:1882-90.,MUSTTInitialProtocol,EPSN=2202,EvaluateandTreatIschemia,NoSustainedVTInducedN=1435(65%),InducibleSustainedVTN=767(35%),Registry,RandomizedN=704(92%),RefusedRandomizationN=63(8%),CAD,NSVT,EF0.40,BuxtonAE.NEnglJMed.1999;341:1882-90.,MUSTTProtocolRandomizedTreatmentGroups,InducibleSustainedVTN=704,NoEP-GuidedRxACEI341:1882-90.,MUSTTConclusions,ForCADpatientswithEF.40,asymptomaticNSVTandinducibleVT:ICDtherapysignificantlyreducestheincidenceof:Arrhythmicdeathorcardiacarrest(73%76%reduction)Totalmortality(55%60%reduction)EP-guidedpharmacologicantiarrhythmictherapyprovidesnosurvivalbenefit,BuxtonAE.NEnglJMed.1999;341:1882-90.,NonischemicCardiomyopathyandNSVT,DEFIbrillatorsinNonICMTreatmentEvaluation(DEFINITE).Multicenterrandomizedtrial.NonIschemicCardiomyopathyLVEF10PVCs/hror3beatsNSVT.RandomizedICDvs.noICD.Standardheartfailuremedications.Primaryendpointmortality.,Image(HeartFailure/Transplant),DEFINITETrial39KBFileType:GIFClickheretoenlarge/downloadforpresentationuse(ie.PowerPoint),DEFINITE,OverallConclusions,Asymptomaticpatientswithventriculararrhythmiasandnounderlyingheartdiseasedonotneedtobetreated.SymptomaticpatientswitharrhythmiasshouldbetreatedwithstandardtherapyandICD.Managementdependsonthefrequencyandseverityofthepatientsarrhythmia.,Conclusions,TheresultsofAVIDsupportusingtheICDasfirst-linetherapytoprolongtotaland/orsuddendeathsurvivalinpatientswithdocumentedunstableVTorVF.,Conclusions,MUSTTisconcordantwithMADIT,suggestingthatriskstratificationusinginvasivetechniquesshouldbethestandardofca