心源性猝死的预防和治疗课件

1、Sudden Cardiac Death: Prevention and Treatment Lexin Wang, M.D., Ph.D.Professor of Clinical PharmacologyHead, Cardiovascular Research Incidence of SCDSCD (caused by sudden cardiac arrest) is the most common cause of death in Western societiesIncidence: 300,000 to 400,000 each year (U.S.) only 2% 15%

2、 reach the hospitalHalf of these early survivors die before dischargeRisk Factors of SCDLeft ventricular failureCHD, cardiomyopathy Sudden cardiac death syndromesLong QT syndromes Brugada syndromePolymorphic catecholaminergic VTIsolated ventricular fibrillation CAD has become a main cause of SCD80%C

3、AD15% cardiomyopathy5% other*Huikuri HV. N Engl J Med. 2001;345:1473-1482.Myerburg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. W.B. Saunders, Co. 2001.*ion-channel abnormalities, valvular or congenital heart disease, other causesBays de Luna A. Am Heart J. 1989;117:151-159.Brad

4、ycardia 17%Monomorphic VT62%Primary VF 8%TdP 13%Prevalence of arrhythmia at SCDHeart Failure and SCDMore than one million new heart failure patients every year in the USA25% mortality in 2.5 years in moderate to severe CHFA total of 15% of CHF patients die of SCD Gorgels, PMA. Eur Heart J .2003;24:1

5、204-1209.LVEF% SCD Victims7.5%5.1%2.8%1.4%LVEF and SCDRisk stratification of SCDRisk assessmentClinical dataAetiology; family history; LVEFEPST wave alternansQT dispersionArrhythmia during Holter monitoring or stress testIdeka T, et al JACC 2006; 48:2268 SensitivitySpecificityPPV NPV PAMicrovolt -TW

6、A83%83%9%99.6%83%Nonsustained VT44%83%7%98.8%88%Ventricular late potentials35%91%7%98.6%90%Predictive values of positive TWA, nonsustained VT and ventricular Late potentials808520009095AVIDCASHCIDSSCD-HeFTMADIT-IIMUSTTMADIT二级SecondaryPrimaryDEFINITEMUSTTMulticenter Unsustained Tachycardia Trial (MUS

7、TT), a randomized controlled trialCan electrophysiologically guided antiarrhythmic therapy reduce the risk of sudden death?Looked at coronary artery disease patients with a left ventricular ejection fraction 40% and asymptomatic unsustained ventricular tachycardiaBuxton AE. Prog in Cardiovasc Dis 19

8、93;3:215-226MUST: Arrhythmic Death or Cardiac ArrestEP-Guided Rx, No ICD No EP-Guided AA RxEP-Guided Rx, ICDp 4 weeks); left ventricular EF 21 yearsPatients randomly assigned in a 3:2 ratio to receive ICD or conventional medical therapyMADIT-II Trial started July 8, 1997Trial stopped prematurely in

9、November 20, 2001 because ICD saved lives1,232 patients enrolled from 76 centers in U.S. and EuropeMADITT II- MortalityCONV DEFIB (n=490) (n=742) Deaths 97 19.8% 105 14.2% -Hazard Ratio (ICD:CONV)0.69 (31% mortality)(95% CI) (0.51, 0.93)P-value 0.016 MADIT-IIMoss AJ. N Engl J Med. 2002;346:877-83.De

10、fibrillatorConventionalP = 0.0071.00.60.0Probability of Survival01234YearNo. At RiskDefibrillator742502 (0.91)274 (0.94)110 (0.78)9Conventional 490329 (0.90)170 (0.78) 65 (0.69)3SCD-HeFTSudden Cardiac Death in Heart Failure Trial (SCD-HeFT) NYHA class 2-3 HF and LVEF 35%Largest internal-car

11、dioverter-defibrillator (ICD) trial ever conductedICD vs placebo Median follow-up of 45 months SCD- HeFTBardy et al. N Eng J Med 2005; 352 (3): 225SCD-HeFT: All-cause mortalityAll-cause mortality ICD Amiodarone Placebo 3 years 17.1% 24.0% 22.3%5 years 28.9% 34.1% 35.8% Jared Bunch T, et al. Circulat

12、ion 2007;115:2451-57Jared Bunch T, et al. Circulation 2007;115:2451-57SummaryMost SCD are due to coronary artery disease and heart failureLVEF is the most reliable non-invasive predictor for SCDSCD under 30 years of age is usually due to inherited heart diseaseSummaryAnti-arrhythmic drugs to prevent sudden death are not as important as once thought-blockers are more effective than amiodarone or sotalol in pts with CHF or CHDSummaryICD is the most effective prevention for SCDProphylactic ICD therapy is ready for prime-time use in patients with CHD and CHFICDs prolong lif