应进一步加强对心脏性猝死的一、二级预防

现代心脏性猝死(sudden cardiac death,SCD)的定义为(1)临床上有心脏骤停(sudden cardiac arrest,SCA)的证据;(2)从突发症状到死亡的时间在1 h之内;(3)不明原因的死亡,此前24 h内病人情况良好.     

Indications for implantable cardioverter defibrillator use for primary prevention of sudden cardiac death

The implantable cardioverter defibrillator (ICD) is used for primary and secondary prophylaxis of sudden cardiac death in high-risk patients. Although several trials have demonstrated the superiority of ICD over standard medical therapy or antiarrhythmic medication in this population, a few trials have not shown survival benefit. This review examines the major ICD trials that provide the basis for current therapy in this rapidly changing and very important area of cardiology.     

Effectiveness of implantable defibrillators in octogenarians and nonagenarians for primary prevention of sudden cardiac death

Given their advanced age and frequent co-morbidities, it is unclear whether octogenarians and nonagenarians with decreased left ventricular ejection fraction (LVEF) derive a survival benefit from implantable cardioverter-defibrillators (ICDs) in the primary prevention setting. The purpose of this study was to examine the effect of ICDs, age, and multiple co-morbidities on survival in elderly patients who otherwise meet implantation criteria for primary prevention of sudden cardiac death. Patients ≥80 years of age who received an ICD for LVEF ≤35% at our institution from 2001 through 2008 (n = 99) were compared to a cohort of patients ≥80 years of age with similarly low LVEF who did not receive an ICD (n = 53). Co-morbid conditions were assessed using the Charlson co-morbidity index (CCI). The overall cohort (n = 152, 84 ± 4 years old, 72% men, 87% with ischemic cardiomyopathy, LVEF 25 ± 7%, CCI 5.9 ± 3.2) was followed for 2.3 ± 2.0 years. Patients with ICDs were younger (82 ± 3 vs 86 ± 4 years, p <0.001) and had fewer co-morbidities reflected in a lower CCI (5.3 ± 3.1 vs 6.7 ± 3.1, p = 0.021). Patients with ICDs also had a trend toward lower LVEF (24 ± 6% vs 27 ± 7%, p = 0.06). During follow-up 93 (61%) patients died, 58 (59%) in the ICD group and 35 (66%) in the no-ICD group. ICD recipients had better 1-year survival compared to patients with no ICD (72% vs 52%, p = 0.014). However, after adjusting for age, LVEF, glomerular filtration rate (GFR), and CCI using multivariate Cox models, an ICD did not confer any survival benefit (hazard ratio 0.71, 95% confidence interval 0.42 to 1.20, p = 0.20), whereas age (p = 0.043) and GFR (p = 0.006) were the only independent predictors of survival. In conclusion, age and GFR are the main determinant of survival in octogenarians and nonagenarians with LV dysfunction. After correcting for these parameters, an ICD does not appear to confer a survival benefit.     

植入型心律转复除颤器对心脏性猝死一级预防临床研究

目的 分析植入型心律转复除颤器(ICD)及心脏再同步治疗除颤器(CRT-D)一级预防患者的室性心律失常发生情况.方法 统计分析2007年1月至2012年6月在浙江医院因一级预防而植入ICD或CRT-D的所有患者.结果 140例患者中,植入ICD的患者51例,CRT-D患者89例,平均随访(26.8±12.6)个月.结果显示在ICD一级预防中启动ICD正确治疗的室性心律失常发生率为19.3％,误治疗率为12.9％,其中误治疗中85.3％发生在单腔ICD一级预防中.ICD一级预防中主要死亡原因为心力衰竭(52.2％),非心脏原因死亡(39.1％).ICD正确治疗组与未治疗组相比,宽QRS时限、低左心室射血分数(LVEF)及高B型脑钠肽(NT-proBNP)容易导致室性心律失常发生.结论 在ICD或CRT-D一级预防患者中,宽QRS时限、低LVEF及高NT-proBNP容易导致室性心律失常发生;ICD误治疗主要发生在单腔ICD患者.     

植入型心律转复除颤器在心脏性猝死一级和二级预防中的应用

目的比较植入型心律转复除颤器（ICD）在心脏性猝死一级及二级预防中的治疗作用。方法对2005年1月至2009年6月符合ICD一级预防及二级预防标准并在我院植入ICD的患者进行随访。ICD的诊断设置室性心动过速（VT）、快速室性心动过速（FVT）及心室颤动（VF）3个工作区,治疗设置抗心动过速起搏（ATP）、低能量同步转复（CV）和高能量除颤（DF）。术后每3—6个月随访1次,利用程控仪获取ICD储存资料,了解患者心律失常发作情况以及ICD的诊断和治疗情况。结果共随访了40例患者,一级预防及二级预防各20例,平均随访时间一级预防组（12．2±7．6）个月,二级预防组（14．6±9．6）个月。随访过程中共13例患者发生了VF事件,其中一级预防组4例,二级预防组9例,21例患者发生了VT事件,其中一级预防组9例,二级预防组12例,统计学分析显示两组患者间VF及VT事件发生率差异无统计学意义。VT发生频率（VTfrenquency）在一级预防组为4．465次／月,二级预防组为26．16次／月（P〈0．001）。VT发作时间（VTduration）在一级预防组为（25．6±15．6）s,二级预防组为（78．1±58．7）s（P〈0．001）。一级预防组中9例患者ICD记录有持久性VT事件,其中由ATP终止6例,CV终止3例。4例患者有VF事件,均DF成功,二级预防组中12例患者ICD记录有持久性VT事件,其中由ATP终止7例,CV终止5例。9例患者有VF事件,均DF成功。结论二级预防的患者室性心律失常发作频率及发作时间均明显高于一级预防的患者,但因样本量较小,两组患者间因VT或VF接受ICD治疗的比例差异无统计学意义。     

The role of the implantable cardioverter-defibrillator for prevention of sudden cardiac death

Sudden cardiac death, which accounts for approximately 350,000 deaths each year, is a major health care problem. Antiarrhythmic drugs have not been reliable in preventing sudden cardiac death. Although beta-blockers, angiotensin-converting enzyme inhibitors, and revascularization play a role in prevention of sudden cardiac death, the development and subsequent refinement of the implantable cardioverter-defibrillator has made the most important contribution to its management. Several randomized, controlled trials have demonstrated improved survival in patients resuscitated from cardiac arrest. Two recent trials also suggest a role for primary prevention in selected patients with coronary artery disease, ventricular dysfunction, and nonsustained ventricular tachycardia in whom sustained ventricular tachycardia is induced. Further technological refinements and development of new, more sensitive risk stratifiers with a higher positive predictive value for sudden cardiac death will expand the indications for this life-saving therapy.     

加强心脏性猝死的一级预防

心脏性猝死(SCD)是严重威胁人类生命的疾病,美国每年SCD的发生率为0.1%～0.2%,每年约有45万人死于SCD[1].由阜外心血管病医院牵头完成的国家十五攻关课题结果显示,我国SCD的年发生率为0.04%,每年死于SCD人数高达54.4万.SCD由于发病突然、进展迅速,具有无法预测的特点,发生心脏骤停的患者经心肺复苏生存的机会极低.具有完善急救体系的发达国家成功复苏的几率不到15%,大多数国家包括中国在内仅为0～5%.因此SCD的预防显得尤为重要.     

Influence of gender on ICD implantation for primary and secondary prevention of sudden cardiac death.

AIMS: This study sought to investigate the influence of gender on access to ICD therapy and examine the influence of gender on subsequent ICD shock experience. METHODS AND RESULTS: The records of 353 consecutive patients (140 and 213 secondary prevention, respectively) who received their first ICD between January 2000 and March 2004 were reviewed. All patients fulfilled criteria for primary or secondary prevention ICD implantation. Baseline characteristics and ICD shock experiences were compared. Female patients were younger and less likely to have a history of ischaemic heart disease or atrial arrhythmias (P<0.01). In contrast, female patients were more likely to have heart failure and diabetes (P<0.01). Markedly fewer females received an ICD for either primary (M:F ratio 8.5:1, P<0.01) or secondary (M:F ratio 4.5:1, P<0.01) prevention. Further, significantly fewer female patients received an ICD for MADIT II indications (M:F 11.2:1, P<0.01). Over the mean follow-up of 1.8+/-1.1 years, gender had no influence upon the likelihood of receiving either an appropriate or an inappropriate shock (P=ns). CONCLUSION: Although male patients accounted for the great majority (85%) of all ICD recipients, there was no evidence of influence of gender on the likelihood of receiving an appropriate or inappropriate shock.     

Beta-blockers and amiodarone for the primary prevention of sudden cardiac death

Sudden cardiac death remains a major public health care problem, generally occurring in patients with ventricular dysfunction. Beta-blockers, already of proven benefit for patients after myocardial infarction, have recently been shown to improve functional status and mortality outcomes in patients with heart failure. Amiodarone, a potent antiarrhythmic drug, was recently studied in a number of randomized clinical trials involving patients with heart failure and patients after myocardial infarction. Routine use of amiodarone cannot be recommended in these patient groups, but serious adverse outcomes were not observed. When antiarrhythmic drug therapy is required, amiodarone is the drug of choice for patients with structural heart disease.     

心脏性猝死一级与二级预防植入型心律转复除颤器患者临床特征单中心分析

目的 了解植入型心律转复除颤器(ICD)植入数量与心脏性猝死(SCD)一级与二级预防患者临床资料特征,为ICD患者筛选提供实践依据.方法 连续入选2006年1月至2011年12月于我院行ICD或心脏再同步治疗除颤器(CRT-D)植入术的患者,收集患者术前资料与患者植入ICD类型,分析历年ICD植入数量与一级、二级预防患者资料的特征与差异.结果 入选214例患者,一级预防108例,二级预防106例.ICD植入数量与一级预防患者比例逐年增加.与二级预防患者相比,一级预防患者术前心功能(NYHA分级)更差(P＜0.01),术前左心室射血分数更低[(0.34±0.01)对(0.50±0.16),P＜0.01],QRS时限更长[(135.83±35.08)ms对(111.68±34.15)ms,P＜0.01],log (NT-proBNP)水平更高[(3.32±0.62)pg/ml对(2.83±0.83) pg/ml,P＜0.01],肾小球滤过率更低[(75.15±24.23) ml/min对(90.25±70.30) ml/min,P=0.037];一级预防患者冠状动脉疾病与扩张型心肌病占90％,与二级预防患者疾病组成差异有统计学意义(P＜0.01),两组内冠状动脉疾病比例均较低(13.1％与22.6％);二级预防患者主要植入单腔ICD(84.0％),而一级预防患者植入CRT-D比例最高(74.1％),组间植入ICD类型差异有统计学意义(P＜0.01).结论 ICD植入数量与一级预防患者比例逐年增加,一级预防患者的识别与植入工作有待改进,特别是心肌梗死后左心室功能不良患者与未符合心脏再同步治疗适应证的慢性心功能不良患者的识别.     

无痛治疗在植入型心律转复除颤器患者心脏性猝死一级和二级预防中的应用

目的 随访植入型心律转复除颤器(ICD)患者,了解抗心动过速起搏(antitachycardia pacing,ATP)作为室性心动过速(VT)无痛治疗手段在心脏性猝死一级和二级预防中的应用.方法 对2005年1月至2009年6月符合ICD一级和二级预防标准并在我院植入ICD的患者进行随访.将ICD的诊断程序设置为VT...     

A critical appraisal of implantable cardioverter-defibrillator therapy for the prevention of sudden cardiac death

The indications for implantable cardioverter-defibrillators (ICDs) for the prevention of sudden cardiac death have rapidly expanded over the past 10 years. Clinical trial data have quickly been implemented into guidelines without critical reassessment of the strengths and limitations of the evidence. ICD therapy has inherent risks including infection, unnecessary shocks, potential for proarrhythmia, device malfunction, highly publicized manufacturer advisories, and procedural complications, which can adversely affect morbidity and quality of life. A reappraisal of the benefits and potential hazards of ICD therapy will enable physicians to a have a more mutually informed and balanced dialogue with their patients.     

The impact of gender on survival amongst patients with implantable cardioverter defibrillators for primary prevention against sudden cardiac death

BACKGROUND: Implantable cardioverter defibrillators (ICDs) are a life-saving therapy for many patients with cardiovascular disease at increased risk of fatal dysrhythmias. As men comprise the majority of the study population (67-92%) in clinical trials, the benefit to women is unknown. We performed a meta-analysis of primary prevention trials to evaluate the impact of ICDs in men and women on death from any cause. METHODS: Included trials met the following criteria: (i) randomized controlled trials versus standard of care, (ii) ICD used as primary prevention in a well-described protocol and (iii) data provided on risk of death from any cause for both male and female patients. RESULTS: Five clinical trials were included in this meta-analysis. The risk of death from any cause was significantly reduced by 26% in male patients who received ICD therapy compared to control, hazard ratio (HR) 0.74 (95% CI 0.60-0.91) but not amongst female patients, HR 0.81 (95% CI 0.60-1.09). As the COMPANION trial evaluated the combination of biventricular pacemaker with ICD therapy we conducted a separate analysis without the inclusion of this study. Male patients receiving ICD therapy demonstrated a similar 24% reduction in risk of death from any cause, HR 0.76 (95% CI 0.58-0.99) whilst female patients demonstrated a reduction of only 12%, HR 0.88 (95% CI 0.63-1.22). CONCLUSIONS: Unlike their male counterparts, females did not significantly benefit from ICD therapy and without concurrent biventricular pacing, appear only to achieve a nonsignificant 12% reduction in risk of death.