威脅生命的室性心律失常治療的循證基礎(chǔ)

Asatellitesympsoium.XXthCongressoftheESC,Vienna.Aug.1998室性心律失常二級預(yù)防(SecondaryPrevention)

已有威脅生命的室性心律失常史一級預(yù)防（PrimaryPrevention）

有危險(xiǎn)因素但尚未有快速室性心律失常發(fā)作TrialsTherapyStudySizeAll-causemortalityPopulation

(F-Uduration)

CASCADEWeveretalAVIDCASHCIDSEmpiricalamiodaronevsguidedconventionalantiarrhythmictherapyImplantabledefibrillatorasfirstchoiceImplantabledefibrillatorvsclassIIIdrugs(mainlyamiodarone)Groups:implantabledefibrillator,amiodarone,metoprolol,PropafenoneImplantabledefibrillatorvsamiodaronen=202(6years)n=60(24months)n=1016(18.2months)n=346(2years)n=659(3years)IncludingresuscitatedVFandsyncopaldefibrillatorshocks47%vs60%(guidedtherapy)P=0.007Includingsuddencirculatoryarrestandterminalpumpfailure14%vs35%(control)p=0.0215.8%vs24.0%(drugs)P<0.02Propafenonelimbinterruptedduetoexcessmortality12.1%vs19.6%(druglimb)p=0.04725%vs30%(amiodarone)p=0.072CardiacarrestsurvivorsCardiacarrestsurvivorsPatientsresuscitatedfromcardiacarrestorpoorlytoleratedVTCardiacarrestsurvivorsCardiacarrestsurvivorsandpatientswithpoorlytoleratedVT

表I抗心律失常治療對猝死二級預(yù)防的研究匯總結(jié)論:目前支持用ICDs進(jìn)行二級預(yù)防，ICDs已成為心臟猝死病人復(fù)蘇后首選的預(yù)防措施無威脅生命快速室性心律失常發(fā)作史心肌梗塞后心力衰竭，EF↓↓

頻發(fā)室早伴晚電位陽性、HRV↓

電生理誘發(fā)+

一級預(yù)防以藥物為主，ICD？

一級預(yù)防研究的主要對象TrialsTherapyStudySize(F-Uduration)

All-causemortalityPopulation

CASTICASTIISWORDEMIATCAMIATGESICASTAT-CHFMADITCABGPatchtrialn=1455(300days)n=1325(18months)n=3121(18months)n=1486(21months)n=1202(1.79years)n=516(24months)n=674(45months)n=196(27months)n=900(32months)Post-MIloweredLVEFcomplexVEAPost-MILVEF≤40％

Post-MILVEF≤40％

Post-MILVEF≤40％

Post-MIcomplexVEACHFLVEF≤35%CHF10VPCs/hourPost-MILVEF≤35%NSVTInducible,non-suppressibleVTCoronarybypasssurgerypatientsLVEF≤35%AbnormalSA-ECGEncainide/FlecainideMoricizined-SotalolAmiodaroneAmiodaroneAmiodaroneAmiodaroneImplantabledefibrillatorImplantabledefibrillator7.7%vs3.0%(PL)p<0.001EarlySD:17vs3(PL)p<0.025.0%vs3.1%(PL)p<0.0113.9%vs13.7%(PL)p=NS6.2%vs8.3%(PL)p=NS33.5%vs41.4%(control)p<0.339%vs42%(PL)p=NS15%vs38%(control)p=0.00922.6%vs20.9%(control)p=NS表II抗心律失常治療對猝死一級預(yù)防的研究匯總一級預(yù)防以藥物為主，ICD？胺碘酮適宜于一級預(yù)防

廣泛電生理作用有效的抗心律失常作用良好的血液動(dòng)力學(xué)作用最低的致心律失常作用ATMA

胺碘酮研究薈萃分析

Effectofprophylacticamiodaroneonmortalityafteracutemycardialinfarctionandincongestiveheartfailure:meta-analysisofindividualdatafrom6500patientsinrandomisedtrials

Amiodarone

TrialsMeta-Analysis

Investigators

<<THELANCET>>

Vol.350No.9089Nov.1997ATMA13個(gè)研究的結(jié)果綜述總死亡率研究(索引)EMIAT(8)CAMIAT(7)GEMICA(9)PAT(10)SSSD(11)BASIS(12)HOCKINGS(13)CAMIAT-P(14)CHFSTAT(15)GESICA(16)EPAMSA(17)NICKLAS(18)HAMER(19)總括相關(guān)性檢驗(yàn)P=0.030異源性檢驗(yàn)P=0.058比數(shù)比1/8 1/4 1/2 1 2 4 80.87(95%Cl0.78~0.99)ATMA13個(gè)研究的結(jié)果綜述心律失常/猝死研究(索引)EMIAT(8)CAMIAT(7)GEMICA(9)PAT(10)SSSD(11)BASIS(12)HOCKINGS(13)CAMIAT-P(14)CHFSTAT(15)GESICA(16)EPAMSA(17)NICKLAS(18)HAMER(19)總括相關(guān)性檢驗(yàn)P=0.00026異源性檢驗(yàn)P=0.24比數(shù)比1/8 1/4 1/2 1 2 4 80.71(95%Cl0.59~0.85)ATMA死亡的積累風(fēng)險(xiǎn)0 3 6 12 18 24隨機(jī)分組時(shí)間(月)心律失常/猝死總死亡率胺碘酮對照累積風(fēng)險(xiǎn)(%)2520151050ATMA不良反應(yīng)導(dǎo)致早期永久性停藥的主要不良反應(yīng)

Amiodarone(%) Placebo(%) OR甲減 181/2580(7.0) 27/2545(1.1) 7.3甲亢 37/2580(1.4) 13/2545(1.1) 2.5周圍神經(jīng)病 12/2580