双腔ICD并非一级预防的最佳选择

双腔ICD并非一级预防的最正确选择南京大学医学院附属鼓楼医院

徐伟循证医学的证据

MADIT,MUST,MADIT-II,SCD-HFT,COMPANION等一系列有关SCD一级预防临床试验证明：ICD是心脏性猝死的唯一有效的治疗手段证明单腔ICD在一级预防中有效降低死亡率的研究SuddenCardiacDeathinHeartFailureTrial心衰患者心脏猝死临床研究SCD-HeFT入选方案入选标准安慰剂n=847ICDn=829平均随访40个月优化：B、ACE-I、利尿剂BardyGH.ChapterExcerptfromArrhythmiaTreatmentandTherapy.WoosleyRL,SinghSN,editors.MarcelDekker,1stedition.2000;323-42.SCD-HeFTInvestigatorsMeeting,August2001,datafrommostrecentfollow-up胺碘酮n=845ICD植入设置VVI-ICD〔Medtronic7223〕仅翻开VF治疗功能FDI=320毫秒，NID=18/12滞后功能设为34次/分〔VVI=50次/分〕VT/VF发生前的存储记录SCD-HeFT结论NYHAII-III级，EF35%且有良好药物治疗的患者，5年内抚慰剂组的总死亡率到达7.2%/年〔单腔〕ICD有效减少23%的总死亡率胺碘酮作为主要预防药物，不增加生存率DifferencesinOutcomesBetweenPatientsTreatedwith

Single-versusDual-ChamberImplantableCardioverter

Defibrillators:ASubstudyoftheMulticenterAutomatic

DefibrillatorImplantationTrial-IIMADIT-II心脏性猝死预防研究中，ICD治疗组ICD植入构成比单腔ICD404例双腔ICD313例MADIT-II研究中双腔ICD较单腔ICD相比在全因死亡率和心力衰竭上有增加的趋势单腔ICD一级预防结论在有关心脏性猝死的一级预防临床试验中大局部是单腔ICD在一级预防中，单腔ICD降低死亡率的证据充分双腔ICD的优点更好识别快速室上性心律失常〔分析P波和R波之间关系〕提供更符合生理的起搏治疗引起误放电的室上性心律失常类型窦性心动过速房性心动过速心房扑动心房颤抖阵发性室上速单腔ICD也能识别以上心律失常自动波形鉴别〔wavelet〕EGM宽度〔width〕稳定性(stability)——心房颤抖猝发性(onset)——窦速、局部房速可识别绝大多数室上性心律失常双腔ICDvs.单腔ICD：误电击

双腔ICD在误电击方面并不优于单腔ICD新型单腔ICD具有心房感知功能双腔ICD的优点更好识别快速室上性心律失常〔分析P波和R波之间关系〕提供更符合生理的起搏治疗美国心血管注册数据库中ICD注册数据

〔JAmCollCardiol,2021,58:1007-13〕美国植入双腔ICD的患者仅不到50%具有起搏治疗适应证双腔ICDvs.单腔ICD：无起搏适应证者

〔PACE,2006,29:946-952〕植入单腔ICD者的全因死亡率、心源性死亡率似乎更低双腔ICDvs.单腔ICD：无起搏适应证者

〔PACE,2006,29:946-952〕植入双腔ICD者遭受电击的比例似乎更高双腔ICD的缺点增加电极故障升高医疗花费ICD电极故障逐年增加Circulation.2007,15;115(19):2474-80.单腔ICD电极故障少Circulation.2007,15;115(19):2474-80.美国心血管注册数据库中ICD注册数据

〔JAmCollCardiol,2021,58:1007-13〕与单腔ICD相比，双腔ICD围术期并发症更多，住院期间死亡率更高双腔ICD的缺点增加电极故障升高医疗花费双腔ICDvs.单腔ICD：

一级预防的效价比MADITII研究人群随访到8年发现每植入8例，可挽救1例患者生命单腔ICD9万x2x8=144万双腔ICD16万x2x8=256万中国有大城市也有贫困地区小结在一级预防中，单腔ICD降低死亡率的证据充分双腔ICD在误放电方面无优势对于无起搏适应证者，双腔ICD不额外改善预后双腔ICD电极故障更高，围术期死亡率更高双腔ICD明显加重经济负担因此，在一级预防中不应该常规选择双腔ICD

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