03_Pacemaker Indication_TT

1、1 Indications for Device Therapy Paul A. Levine, M.D., FACC Vice President and Medical Director St. Jude Medical CRMD Clinical Professor of Medicine Loma Linda University School of Medicine Updated December 3, 2001, Re-edited 2 起搏器治疗适应证起搏器治疗适应证 SJM internal use ONLY Causes of Conduction Defects Coro

2、nary Artery Disease Idiopathic Degeneration Calcification Endocarditis Heart Surgery RF Ablation SJM internal use ONLY 传导缺陷的病因传导缺陷的病因 冠状动脉疾病冠状动脉疾病 特发性退化特发性退化 钙化钙化 心内膜炎心内膜炎 心脏手术心脏手术 射频消融射频消融 SJM internal use ONLY Symptomatology + Documented Events ECG documentation in the medical record is essential

3、! Reliable Indications for Pacing = Indications For Pacing SJM internal use ONLY 症状症状 + 记录到的事件记录到的事件 病历中的病历中的ECG记录非常重要记录非常重要! 可靠的起搏适应证可靠的起搏适应证= 起搏适应证起搏适应证 SJM internal use ONLY Symptoms May be varied and can include: Irritability Fatigue Forgetfulness Palpitations Chest Pain Dyspnea SJM internal use

4、 ONLY 症状症状 可能有所不同，但可以包括可能有所不同，但可以包括: 易怒易怒 易疲劳易疲劳 健忘健忘 心悸心悸 胸痛胸痛 呼吸困难呼吸困难 SJM internal use ONLY Documented Events 24-hour Holter Moniter Tilt Table Test EP Testing Temporary Pacing SJM internal use ONLY 记录的事件记录的事件 24h Holter监测监测 倾斜试验倾斜试验 EP测试测试 临时起搏临时起搏 SJM internal use ONLY Diagnosing Indications No

5、ninvasive History ECG Ambulatory Monitoring Stress Test Carotid Massage SJM internal use ONLY 诊断诊断 非侵入性非侵入性 病史病史 心电图心电图 动态心电图（动态心电图（Holter） 负荷试验负荷试验 颈动脉按摩颈动脉按摩 SJM internal use ONLY Diagnosing Indications Invasive Catheterization Lab EP Lab SJM internal use ONLY 诊断诊断 侵入性侵入性 心导管检查心导管检查 EP检查检查 SJM int

6、ernal use ONLY ACC/AHA/HRS 起搏适应证指南起搏适应证指南 美国心脏病学会美国心脏病学会 （American College of Cardiology ACC) 美国心脏协会美国心脏协会 （American Heart Assioation AHA) 美国心律协会美国心律协会 （Heart Rhythm Society HRS) SJM internal use ONLY ACC/AHA Guidelines for Pacemaker and ICD Implant Class I: conditions for which there is good eviden

7、ce and/or general agreement that the therapy is appropriate Class II: conflicting evidence or divergence of opinion IIa: favor of usefulness/efficacy IIb: less well established Class III: evidence and/ or general agreement that the therapy is not useful or effective SJM internal use ONLY ACC/AHA/HRS

8、指南指南 起搏器和起搏器和ICD植入植入 I类类: 证据和证据和/或一致意见均认为正在进行的医疗操作和治或一致意见均认为正在进行的医疗操作和治 疗是有益、有用和有效的疗是有益、有用和有效的 II类类:对于正在进行的医疗操作和治疗的有用性和有效性对于正在进行的医疗操作和治疗的有用性和有效性 存在不同的证据和存在不同的证据和/或相反的意见或相反的意见 IIa: 证据或意见更倾向于该医疗过程和治疗是有用和有效的证据或意见更倾向于该医疗过程和治疗是有用和有效的 IIb: 证据或意见更倾向于该医疗过程和治疗是无用和无效的证据或意见更倾向于该医疗过程和治疗是无用和无效的 III类类: 证据和证据和/或一致

9、意见均认为正在进行的医疗操作和治或一致意见均认为正在进行的医疗操作和治 疗是无用和无效的，在某种情况下甚至是有害的疗是无用和无效的，在某种情况下甚至是有害的 SJM internal use ONLY Level of Evidence (Cardiology) data derived from multicenter randomized trials data from limited or non-randomized studies or observational studies A.expert consensus but no formal studies ACC/AHA Gu

10、idelines for Pacemaker and ICD Implant SJM internal use ONLY ACC/AHA/HRS指南指南 起搏器和起搏器和ICD植入植入 证据分级证据分级 A级：数据来源于多中心随机临床试验级：数据来源于多中心随机临床试验 B级：数据来源于有限的或非随机临床研究或观察研级：数据来源于有限的或非随机临床研究或观察研 究究 1. C级：多数专家的意见，但没有正式的临床研究级：多数专家的意见，但没有正式的临床研究 SJM internal use ONLY Sick Sinus Syndrome Heart Block Carotid Sinus Hy

11、persensitivity and Neurocardiogenic Syncope HOCM, DCM Indications For Pacing SJM internal use ONLY 病窦综合征病窦综合征 房室传导阻滞房室传导阻滞 颈动脉窦过敏综合征和颈动脉窦过敏综合征和 血管迷走性晕厥血管迷走性晕厥 肥厚型梗阻性心肌病肥厚型梗阻性心肌病 起搏适应证起搏适应证 SJM internal use ONLY Sinus Bradycardia Sinus Arrest SA Exit Block Bradycardia-Tachycardia Syndrome Symptomatic

12、 chronotropic incompetence Sinus Node Dysfunction (Sick Sinus Syndrome) SJM internal use ONLY 窦性心动过缓窦性心动过缓 窦性停搏窦性停搏 窦房传出阻滞窦房传出阻滞 房颤伴慢心室率房颤伴慢心室率 慢快综合征慢快综合征 有症状的变时性功能不全有症状的变时性功能不全 窦房结功能障碍（病窦综合征）窦房结功能障碍（病窦综合征） SJM internal use ONLY Sinus Node Dysfunction Class I Symptomatic bradycardia, even drug induc

13、ed if medication cannot be discontinued (Level of evidence: C) Symptomatic chronotropic incompetence (Level of evidence: C) SJM internal use ONLY 窦房结功能障碍窦房结功能障碍 I类类 有症状的心动过缓，包括必需药物治疗所导致的有症状的心动过缓，包括必需药物治疗所导致的 (C) 有症状的变时性功能不全有症状的变时性功能不全 (C) SJM internal use ONLY Sinus Node Dysfunction Class II a SND o

14、ccurring spontaneously or as a consequence of Rx with heart rates below 40 with a clear association with symptoms (Level of evidence: C) Syncope of unexplained origin when SND is discovered on EP study ( C ) Class II b Minimally symptomatic patient, chronic heart rate 40 bpm while awake ( C ) SJM in

15、ternal use ONLY 窦房结功能障碍窦房结功能障碍 IIa类类 突发的或由必需药物治疗导致的窦房结功能障碍，其突发的或由必需药物治疗导致的窦房结功能障碍，其 心率心率40bpm，且与症状之间有明确的关联，且与症状之间有明确的关联 (C) 不能解释的晕厥，但在电生理检查时诱发出窦房结功不能解释的晕厥，但在电生理检查时诱发出窦房结功 能异常能异常 (C) IIb类类 对于有轻微症状的患者，清醒时长期心率对于有轻微症状的患者，清醒时长期心率40bpm (C) SJM internal use ONLY Sinus Node Dysfunction Class III Heart rate

16、3.0 seconds or escape rate 3.0s或逸搏心率或逸搏心率 40 bpm ( B, C ) “Asymptomatic” Type II 2nd Degree AV block ( B ) “Asymptomatic” Type I even infra-His ( B ) FIRST degree AV block with symptoms ( B ) Class II b First degree or second degree AV block with symptoms similar to those of pacemaker syndrome ( B )

17、 Previous guidelines required documentation of alleviation of symptoms with temporary pacing. This is no longer required First degree AV block (PR 300 ms) with LV dysfunction and CHF with documented hemodynamic improvement symptoms ( C ) Neuromuscular disease (myotonic muscular dystrophy, Erbs dystr

18、ophy, Kearns-Sayre syndrome, ) with any degree of AV block (even first degree) with or without symptoms as progression is unpredictable ( C ) SJM internal use ONLY 房室传导阻滞房室传导阻滞 IIa类类 无症状的完全性房室传导阻滞，心率无症状的完全性房室传导阻滞，心率 3 seconds of asystole in absence of vagomimetic meds ( C ) Class II a Recurrent sync

19、ope, + CSM, no other etiology ( C ) Class II b Recurrent syncope, + tilt table test with marked cardioinhibitory component ( C ) SJM internal use ONLY 神经介导综合征神经介导综合征 I类类 自发性颈动脉刺激和颈动脉按压诱导的心室停搏时自发性颈动脉刺激和颈动脉按压诱导的心室停搏时 间间3s导致的反复性晕厥导致的反复性晕厥 (C) IIa类类 反复性晕厥，没有确切的颈动脉刺激事件，高敏感反复性晕厥，没有确切的颈动脉刺激事件，高敏感 性心脏抑制反应心室

20、停搏时间性心脏抑制反应心室停搏时间3s者者 (C) IIb类类 有明显症状的神经心源性晕厥，伴有自发性或直立有明显症状的神经心源性晕厥，伴有自发性或直立 倾斜试验时出现明显的心动过缓倾斜试验时出现明显的心动过缓 (C) SJM internal use ONLY Neurally Mediated Syndromes Carotid Sinus Massage Check for bruits Always monitor ECG One side at a time Gentle SJM internal use ONLY 神经介导综合征神经介导综合征 颈动脉窦按摩颈动脉窦按摩(CSM) 检

21、查杂音检查杂音 监测监测ECG 每次仅按摩一侧每次仅按摩一侧 动作轻柔动作轻柔 SJM internal use ONLY Neurocardiogenic Syncop Type II Cardioinhibitory Tilt-test SJM internal use ONLY 神经介导性晕厥神经介导性晕厥 II型心脏抑制型型心脏抑制型 倾斜试验阳性倾斜试验阳性 SJM internal use ONLY Hypertrophic Obstructive Cardiomyopathy Class I Standard indications+ Class II b Medically r

22、efractory, symptomatic with significant gradient shown to respond to temporary pacing ( C ) SJM internal use ONLY 肥厚型梗阻性心肌病肥厚型梗阻性心肌病 I类类 标准适应证标准适应证 IIb类类 药物治疗无效，伴明显的流出道梗阻症状，对临床药物治疗无效，伴明显的流出道梗阻症状，对临床 起搏有反应起搏有反应 (C) SJM internal use ONLY Hypertrophic Obstructive Cardiomyopathy Fananapazir, CIRD 1992 S

23、JM internal use ONLY 肥厚型梗阻性心肌病肥厚型梗阻性心肌病 Fananapazir, CIRD 1992 SJM internal use ONLY Dilated Cardiomyopathy Class I Standard indications Class II b Symptomatic drug refractory with prolonged PR interval ( C ) Medically refractory NYHA class III or IV with wide QRS ( 130 ms), LVEDD 55 mm and EF 35% i

24、f use resynchronization therapy (biventricular pacing) (Level of Evidence A) in the 1998 guidelines, this had been Class II b with level of evidence C SJM internal use ONLY 扩张型心肌病扩张型心肌病 I类类 标准适应证标准适应证 IIb类类 有症状，药物治疗无效，伴有症状，药物治疗无效，伴PR间期延长间期延长 (C) 有症状，药物治疗无效，有症状，药物治疗无效，NYHA III/IV级级 ， QRS 130 ms，LV 舒张

25、末径舒张末径 55mm，LVEF 35%， 可考虑双心室起搏治疗可考虑双心室起搏治疗 (A) SJM internal use ONLY Dilated Cardiomyopathy - Biventricular Pacing Biventricular Pacing Ventricular Inhibition SJM internal use ONLY 扩张型心肌病双室起搏扩张型心肌病双室起搏 双室起搏双室起搏 心室抑制心室抑制 SJM internal use ONLY Non-Indications and Cautions Atrial bigeminy - conducted w

26、ith aberration SJM internal use ONLY 非适应证非适应证 房早二联律房早二联律 SJM internal use ONLY Non-Indications and Cautions Patient with weak spells and palpitations SJM internal use ONLY 非适应证非适应证 患者觉乏力和心悸患者觉乏力和心悸 SJM internal use ONLY Sinus arrest and AV block DURING sleep only! Evaluate for SLEEP APNEA Non-Indica

27、tions and Cautions SJM internal use ONLY 仅在睡眠中发生的窦性停搏和仅在睡眠中发生的窦性停搏和AVB! 检查是否存在睡眠呼吸暂停综合征检查是否存在睡眠呼吸暂停综合征 非适应证非适应证 SJM internal use ONLY Non-Indications and Cautions ? T wave End of T wave Patient in CCC post-PTCA MONITOR Lead fracture ! SJM internal use ONLY 非适应证非适应证 ? T wave End of T wave Patient in CCC post-PTCA MONITOR Lead fracture ! SJM internal use ONLY Non-Indications and Cautions Rx: Diltiazem Metoprolol Serum K 6.8 mEq/L Post - ATROPINE Insulin and Glucose SJM internal use ONLY 非适应证非适应证 口服地尔硫卓和美托洛尔口服地尔硫卓和美托洛尔 血血K+ 6.8 mEq/L 阿托品治疗后阿托品治疗后 胰岛素和葡萄糖胰岛素和葡萄糖 SJM internal u