老年人心源性猝死的先兆和预防

老年人心源性猝死的先兆和预防济南军区总医院（２５００３１）任国铨心源性猝死的先兆心源性猝死是由于潜在心脏疾病发生意料不到的呼吸和循环停止。定义既是“意料不到”，目前肯定什么是心源性猝死先兆，还比较困难。对猝死先兆，都来自回顾性研究，包括尸检病例的临床...     

1 294例心源性猝死的回顾性分析

目的 探讨心源性猝死的诱因、病因、发生规律及发病机制。方法 利用Excel统计软件回顾性分析1294例心源性猝死案例资料。结果1294例中792例诱因明确，心源性猝死的诱因以精神刺激、活动及劳累、便秘或排便、饱餐、睡眠、饮酒等多见，占93．55％：对1169例病因分析结果为冠心病（65．53％）、风湿性心脏病（8.90％）、心肌炎（6．16％）、心肌病（4.87％）、肺心病（3．51％）、高血压性心脏病（1．80％）为心源性猝死的6大死因，占90．77％。对800例死亡时间段明确的病例分析显示06：00～12：00时粹死的发生率为44．50％，高于其他时段。结论心源性猝死的法医学鉴定除要进行详细的尸体解剖外，还要对死者的相关资料如基础疾病、诱因、年龄、死亡时间等进行分析，这样不仅有助于得出正确的鉴定结论，还可为以后的科研工作积累资料。     

老年心源性猝死病因学及易患因素

老年心源性猝死病因学及易患因素南京军区南京总医院（２１０００２）林修功老年心源性猝死的病因尽管各种心脏病均可引起老年心源性猝死，但老年心源性猝死的病因学主要是缺血性心脏病，包括心绞痛、心肌梗塞和无症状性的冠心病，以及心肌病（含各种心肌炎）、主动脉瘤与...     

前言─加强对老年心源性猝死的认识与救治

前言─加强对老年心源性猝死的认识与救治南京军区南京总医院（２１０００２）林修功老年心源性猝死尚无准确的定义，目前国内外学者多认为老年人自然发生，出乎意料的突然心源性死亡；ＷＨＯ规定发病后６小时内死亡者为猝死，但多数学者主张为１小时之内，也有的主张发病...     

老年冠心病人再发心脏事件的临床危险因素

随访曾住院的２６５例老年冠心病人２～８．５年，观察增龄、男性、高血压、糖尿病、吸烟、血清总胆固醇（ＴＣ）与高密度脂蛋白胆固醇（ＨＤＬ－ｃ）比值≥４．５、复杂室性心律失常、无痛性心肌缺血和左室肥厚等临床危险因素对再发心脏事件（包括急性心肌梗塞和心源性猝死）的影响。由Ｋａｐｌａｎ－Ｍｅｉｅｒ生存曲线得到８年累积再发心脏事件率为２３．９％。单因素分析提示，除增龄外的每个危险因素都使再发心脏事件明显增加。Ｃｏｘ多因素分析提示，冠心病合并高血压、ＴＣ与ＨＤＬ－Ｃ比值≥４．５，无痛性心肌缺血和复杂室性心律失常是再发心脏事件的重要的独立预报因素。     

肠道病毒感染与云南省不明原因心源性猝死的关系

目的 探讨肠道病毒感染与云南省不明原因心源性猝死的关系。方法 根据流行病学现场调查和临床检查资料在病区设立病例组和病区对照组，在非病区设立非病区对照组，采用巢式反转录聚合酶链反应检测观察对象静脉血中肠道病毒核糖核酸（RNA）。结果 肠道病毒RNA阳性率，病区[56．3％（58／103）]与非病区[41．7％（10／24）]相比有增高趋势，但二者之间差异无统计学意义（χ^2=1．68，P〉0．05）；病例组、病区对照组、非病区对照组肠道病毒RNA阳性率分别为56．0％（14／25）、56．4％（44／78）、41．7％（10／24），组间比较差异无统计学意义（χ^2=1．68，P〉0．05），但是各组感染率水平均较高。结论 云南省不明原因心源性猝死病区肠道病毒感染水平较高，两者之间的关系需进一步研究。     

推动AED任重而道远

猝死是本世纪人类与医学面临的最大挑战之一。Framingham心脏中心一项前瞻性研究表明，75％的猝死为心源性。心源性猝死（SCD）见于各个年龄段，多发生于院外，常没有任何先兆，绝大多数SCA为致命性心律失常（约90％），其中80％为心室颤动（VF），20％为心脏停搏。研究显示，发生VF后抢救时间窗为10min，最佳抢救时间是最初的3～5min，每延迟1minCPR和除颤，心脏性猝死的生存率以7％-10％递减。早期电除颤是治疗VF唯一有效的方法。     

心内科老年患者院内心源性猝死的临床探讨

目的分析心内科老年患者院内心源性猝死的临床原因。方法选取2014年6月~2015年6月我院收治的心脏病猝死患者60例作为研究对象,回顾性分析心内科老年患者院内心源性猝死的临床原因和过程。对在住院期间患者的主要病因予以记录分析。结果冠心病、高血压、心脏病等是导致老年患者发生院内心源性猝死的主要病因;饮酒、抽烟和情绪激动用力等是导致老年患者发生院内心源性猝死的常见危险因素。结论心内科老年患者院内心源性猝死的原因比较复杂,因此应详细的了解患者的相关病史,预防导致患者发生心源性猝死的相关危险因素,减少心源性猝死的发生率。     

老年结核性脑膜炎的临床特点

１９８４－１９９５上出院６０岁以以上老年结核性脑膜炎（ＴＢＭ）患者，占同期ＴＭＢ病人的１３．３％，与青年对照相比有以下特点；１．老年ＴＢＭ首发症状头芍吐占３２．３％，明显低于青年组（Ｐ〈０．０１）；２．合并非结核性疾病者多，占７７．４％，以心血管疾病占首位３８．７％；３．４８．４％的患者首次脑脊液化验改变不典型，仅１９．４％的患者脑压升高。４．误诊率及死亡率高，４８．４％的病例入院时已属晚期，５．     

遗传因素与老年心源性猝死的相关性研究进展

老年人心源性猝死(SCD)定义为年龄65岁及以上患者, 在出现症状后1 h内或无症状24 h内突然发生意外死亡, 可能是由于心律失常或血流动力学突变所致。有发病急、进展快、死亡率高的特点。老年人心源性猝死是老年心脏疾病最严重的临床综合征, 心源性猝死占整个猝死病例的80%以上, 多数的老年猝死患者由于心源性猝死引起。临床对心源性猝死的检测手段主要是对家族史、个人史进行筛查, 同时进行体格检查、心电图分析及超声心动图等检查, 但存在针对性不强、检出率低、应用范围相对比较局限等缺点。心源性猝死也具有遗传易感性, 遗传因素在心源性猝死的发生、发展中起着不可忽视的作用。现综述不同心血管疾病基础上猝死与遗传因素间的相关性, 包括基因多态性在老年心源性猝死发生中的作用。     

Usefulness of an abnormal signal-averaged electrocardiogram for predicting cardiac death in elderly persons without heart disease

We found an abnormal signal-averaged ECG in 7 of 51 elderly patiente (14%) (mean age 83 years) without clinical evidence of heart disease, and in 1 of 25 volunteers (4%) (mean age 31 years [range 17 to 47]) without clinical evidence of heart disease.¹ The data from bur prospective study indicate that at 43-month mean follow-up, elderly patients with an abnormal signal-averaged ECG but no clinical evidence of heart disease do not have an increased incidence of sudden cardiac death, total cardiac death, or total death.     

Prediction of sudden cardiac death by fractal analysis of heart rate variability in elderly subjects

OBJECTIVES: The aim of this study was to test the hypothesis that abnormal scaling characteristics of heart rate (HR) predict sudden cardiac death in a random population of elderly subjects. BACKGROUND: An abnormality in the short-term fractal scaling properties of HR has been observed to be related to a risk of life-threatening arrhythmias among patients with advanced heart diseases. The predictive power of altered short-term scaling properties of HR in general populations is unknown. METHODS: A random sample of 325 subjects, age 65 years or older, who had a comprehensive risk profiling from clinical evaluation, laboratory tests and 24-h Holter recordings were followed up for 10 years. Heart rate dynamics, including conventional and fractal scaling measures of HR variability, were analyzed. RESULTS: At 10 years of follow-up, 164 subjects had died. Seventy-one subjects had died of a cardiac cause, and 29 deaths were defined as sudden cardiac deaths. By univariate analysis, a reduced short-term fractal scaling exponent predicted the occurrence of cardiac death (relative risk [RR] 2.5, 95% confidence interval [CI], 1.9 to 3.2, p < 0.001) and provided even stronger prediction of sudden cardiac death (RR 4.1, 95% CI, 2.5 to 6.6, p < 0.001). After adjusting for other predictive variables in a multivariate analysis, reduced exponent value remained as an independent predictor of sudden cardiac death (RR 4.3, 95% CI, 2.0 to 9.2, p < 0.001). CONCLUSIONS: Altered short-term fractal scaling properties of HR indicate an increased risk for cardiac mortality, particularly sudden cardiac death, in the random population of elderly subjects.     

Effect of quinidine or procainamide versus no antiarrhythmic drug on sudden cardiac death, total cardiac death, and total death in elderly patients with heart disease and complex ventricular arrhythmias

A prospective study correlated the effect of quinidine or procainamide versus no antiarrhythmic drug on sudden cardiac death, total cardiac death and total death in 406 elderly patients with heart disease and asymptomatic complex ventricular arrhythmias detected by 24-hour ambulatory electrocardiograms. Of 397 patients treated with quinidine, 184 (46%) developed adverse effects during the first 2 weeks of therapy and were given no further antiarrhythmic therapy. Of 9 patients treated with procainamide, 2 (22%) developed adverse effects during the first 2 weeks of therapy and were given no further antiarrhythmic therapy. Adverse effects developed during long-term therapy in 6 patients (2%) receiving quinidine and in 3 patients (33%) receiving procainamide. Mean follow-up was 24 +/- 15 months in both groups. Sudden cardiac death, total cardiac death and total death occurred in 21, 43 and 65% of patients receiving quinidine or procainamide, respectively, and in 23, 44 and 63% of patients receiving no antiarrhythmic drug, respectively (difference not significant). Survival by Kaplan-Meier analysis showed no significant difference between the 2 groups for sudden cardiac death, total cardiac death or total death through 4 years. Patients with abnormal left ventricular ejection fraction had a 3.4 times higher incidence of sudden cardiac death, a 2.4 times higher incidence of total cardiac death and a 1.4 times higher incidence of total death than patients with normal left ventricular ejection fraction. These data showed no significant difference in sudden cardiac death, total cardiac death or total death between patients treated with quinidine or procainamide or with no antiarrhythmic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

老年急性心肌梗塞晚发心原性猝死的临床及病理分析

为了分析老年急性心肌梗塞（ＡＭＩ）２周后发生心原性猝死的原因，本文总结了１２例心原性猝死患者，其中６例进行了尸检。认为无论是持续心肌电不稳定所致的原发性室颤，还是梗塞早期的全并症，如休克、心功能不全，梗塞后心绞痛引起的继发性室颤均为晚发心原性猝死的常见原因。尸检结果表明，老年ＡＭＩ晚发心原性猝死多发生于冠脉病变严重者。对于室颤高危患者应采取积极预防措施，如抗心律失常药物的合理应用、改善冠脉循环及改     

Clinical and pathological analysis of sudden coronary death in hospitalized elderly patients]

Forty-five hospitalized elderly patients with coronary heart disease who died suddenly within 6 hours after the onset of symptoms were analyzed clinically and pathologically and summarized as following. (1) All the cases showed abnormal ST segments or T waves on ECG. (2) Various degrees of cardiac dysfunction were found clinically in all the patients. (3) Pathological examination of 31 cases revealed serious coronary atherosclerosis. New myocardial necrosis and/or multiple myocardial scars existed in about two-thirds of the patients. Based on these findings and characteristics, it is speculated that sudden coronary death in the elderly patients is caused by imbalance between oxygen supply and demand in the myocardium or deterioration of the cardiac function, which may result in fatal ventricular arrhythmia. Therefore, the prevention of sudden coronary death in the elderly patients should be focusing on reduction of myocardial ischemia, improvement of myocardial metabolism and protection of cardiac function.     

91例猝死患者尸体解剖病理和临床的回顾性分析

目的探讨猝死的病因、病理基础及防治措施。方法回顾性分析我院91例猝死患者的临床病理资料。结果91例猝死患者中,老年人62例,占681%,非老年人29例,占319%。心源性猝死68例,占747%,其中冠心病43例,患者主要有冠状动脉多支严重病变;非心源性猝死23例,其中以急性出血坏死型胰腺炎所占比例最高,有10例。结论猝死以老年男性多见,有广泛严重冠状动脉病变的冠心病患者猝死发生率高。防治冠心病、改善心肌缺血等综合治疗对预防猝死十分必要。胰源性猝死主要为急性出血坏死型胰腺炎所致,误诊率较高。     

高龄老年人心率变异性减低与心脏性猝死的关系

目的　研究高龄老年人心率变异性 (Heart Rate Variability,HRV)减低与心脏性猝死的关系。方法　回顾性分析 36例 75岁以上心脏性猝死患者的临床资料及其死亡前 6个月之内 2 4小时动态心电图 HRV资料 ,HRV分析包括时域分析和频域分析。比较猝死组与对照组各时域与频域参数有无差别。结果　高龄老年人心脏性猝死组HRV各参数均明显降低 (P<0 .0 1)。结论　 HRV减低是预测高龄老年人心脏性猝死的有价值的指标。多种因素导致心脏性猝死患者 HRV减低     

Can the mode of death be predicted in patients with angiographically documented coronary artery disease?

To determine whether sudden versus non-sudden cardiac death could be predicted in high risk patients, 1157 medical patients were followed for an average of 46 months after a diagnostic coronary angiogram and 18 clinical, hemodynamic, and angiographic variables known to be associated with a high risk of mortality were analyzed. The total group of 141 deaths was classified into 3 subgroups: (1) 82 sudden deaths (less than 1 hour after onset of symptoms); (2) 46 deaths due to acute myocardial infarction with or without heart failure, and (3) 13 deaths unrelated to cardiac symptoms. In a subset of 64 patients, the duration of electrical systole (QTc) was calculated before angiography and before death. A comparison was made of QTc measurements at entry with QTc values of subjects with normal coronary arteries and normal left ventricular function. Deaths from cardiac causes could often be predicted from older age, male sex, history of myocardial infarction, unstable angina, congestive heart failure, abnormal cardiothoracic ratio, multivessel disease, abnormal left ventricular contraction, and abnormal ejection fraction. However, these variables did not discriminate between sudden and nonsudden cardiac deaths and both modes of death were characterized by depressed left ventricular function and multivessel coronary disease. During follow-up the incidence of acute myocardial infarction was not different in patients with cardiac and noncardiac deaths and in long-term survivors. However, patients dying from cardiac causes had a higher incidence of heart failure. Patients dying suddenly did not present new infarctions during follow-up whereas patients dying from acute myocardial infarction had a 13% incidence of prior infarction and a higher incidence of heart failure. In addition, QTc at entry was longer in nonsurvivors than in normal subjects (p less than 0.0001) and patients experiencing sudden death exhibited the highest incidence of QTc prolongation (greater than or equal to 440 ms) during follow-up (p less than 0.05). We conclude that: (1) although the severity of coronary disease and left ventricular dysfunction are closely related to cardiac mortality, they do not discriminate between sudden and nonsudden cardiac deaths; (2) patients experiencing sudden death are characterized by a low incidence of new myocardial infarction or congestive heart failure and prolongation of the QTc interval during follow-up.     

A survey of sudden death among school children in Osaka Prefecture

For 2 years, from January 1985 to December 1986, we carried out a thorough investigation of sudden death or apparent sudden death in a population between 5 and 19 years of age in Osaka Prefecture. Sudden death (unexpected death caused by intrinsic factors within 24 h after the onset of symptoms) occurred in 62 boys and 30 girls, with an annual sudden death rate of 3.0 per 100,000 for boys and 1.5 per 100,000 for girls. Of these 92 deaths, 64 occurred among school children (elementary or high school students), and it was these that were subjected to further analyses. Of the school children deaths, 29.7% seemed to be apparent sudden cardiac death (based on circumstances immediately before death, although there was no definite evidence for sudden cardiac death), and 29.7% were sudden death clearly attributable to underlying heart diseases (hence, sudden cardiac death in the usual meaning of this term accounted for about 60% of the 64 sudden deaths). In addition, 17.2% of the 64 cases were sudden death from bronchial asthma. Analysis of seasonal variation in the incidence of sudden death showed that apparent sudden cardiac death frequently occurred in summer, while sudden death clearly attributable to underlying cardiac diseases often took place in winter, sudden death from bronchial asthma occurred chiefly in summer and fall. Of the total number of sudden deaths, death occurred during exercise in 29.7%, and during sleep in 18.8% of individuals. The percentage of sudden deaths occurring during school hours was as low as 23.4% (15/64). Analysis of the physical condition of the 64 sudden death cases immediately before death disclosed the presence of respiratory infection in 10.9%, fatigue in 21.9%, lack of sleep in 4.7% and other conditions in 4.7%. Thus, the percentage of sudden deaths which occurred under ordinary physical conditions was 57.8% (37/64), of which 14 deaths (21.9% of the total) were associated with exercise.     

Magnetocardiography in the evaluation of fetuses at risk for sudden cardiac death before birth

Background

We hypothesized that fetuses at risk for sudden death may have abnormal conduction or depolarization, ischemia, or abnormal heart rate variability (HRV) detectable by magnetocardiography.

Methods

Using a 37-channel biomagnetometer, we evaluated 3 groups of fetuses at risk for sudden death: group 1, critical aortic stenosis (AS); group 2, arrhythmias; and group 3, heart failure and in utero demise. Five to 10 recordings of 10-minute duration were recorded, and signal was averaged to determine rhythm, conduction intervals, HRV, and T-wave morphology.

Results

In group 1, 2 of 3 had atrial and ventricular strain patterns. In (n = 53) group 2, 15% had prolonged QTc and 17% had T-wave alternans (TWA). Of 23 group 2 fetuses with atrioventricular block, 74% had ventricular ectopy, 21% had junctional ectopic tachycardia, and 29% had ventricular tachycardia. Group 3 (n = 2) had abnormal HRV and TWA.

Conclusion

Repolarization abnormalities, unexpected arrhythmias, and abnormal HRV suggest an arrhythmogenic mechanism for “sudden cardiac death before birth.”