心電學(xué)預(yù)警心衰猝死的風(fēng)險(xiǎn)-wenkub
2022-11-04 15:54:12 本頁(yè)面
【正文】 g RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. P. 895. 一、心臟猝死的概況 Albert CM. Circulation. 2020。18:12691275. 10 20 30 40 50 60 70 80 90 100 0 1 2 3 4 5 6 7 8 9 % Success *Nonlinear Time (minutes) 成功減少的幾率 7 10% 每分鐘！ 一、心臟猝死的概況 （四） SCD 的克星 — ICD ? 對(duì)猝死的征服中， ICD已邁出了第一步 MICHEL MIROWSKI, Oct 14 1924 Mar 26 1990 conceived of ICD in the 1960s The first human implant in 1980 ICD 放電 一、心臟猝死的概況 二、影響 SCD 危險(xiǎn)因素及 相關(guān)檢測(cè)方法 自主神經(jīng)系統(tǒng) HRV BRS HRT 運(yùn)動(dòng)后心率恢復(fù) 心肌基質(zhì) SAECG LVEF QRS時(shí)限 QTc QT d TWA 心肌易損性 二、影響 SCD 危險(xiǎn)因素 三、常用的 SCD危險(xiǎn)分層檢測(cè)方法 1）心率變異性 （ HRV） 2）壓力反射敏感性試驗(yàn) （ BRS ） 3）心室晚電位（ SAECG ） 4） QT 離散度（ QTd ） 5） T 波電交替 （ TWA ） 6）竇性心律震蕩 （ HRT ） 7） LVEF值 (30%) 8） EP（誘發(fā)出惡性室性心律失常） 9）常規(guī) 12導(dǎo) ECG （多種異常：各種離子通道病，傳導(dǎo)阻滯等） 10） Holter （檢出嚴(yán)重室性心律失常） 11）平板運(yùn)動(dòng)試驗(yàn)（誘發(fā)嚴(yán)重室性心律失常） 三、 SCD危險(xiǎn)分層方法 2020年 AHA/ACC/HRS 無(wú)創(chuàng)技術(shù)對(duì)心臟性猝死危險(xiǎn)分層 專家共識(shí) 五、有關(guān)指南的評(píng)價(jià) （一） QRS寬度 ? QRS duration is a simple measure of the duration of ventricular activation measured on the 12lead ECG and is a manifestation of intraventricular or interventricular conduction delay or block ? Estimates of the prevalence of QRS prolongation in the population with chronic congestive heart failure range between 20% and 50% [1] ? Observational studies suggest that QRS prolongation is a significant marker for poor oute in pts with depressed LVEF, especially due to coronary artery disease [2] [1] Nichol G, et al . Ann Intern Med. 2020。10:73– 80. [4] Iuliano S, et al. Am Heart J. 2020。94: 3198–3203. ? In pts with nonischemic cardiomyopathy and congestive heart failure, LVEF 35%, and ventricular arrhythmias (NSVT or an average of 10 or more VPBs per hour), DEFINITE demonstrated a trend toward improvement in overall survival (hazard ratio , 95% CI to , P ) and a reduction in arrhythmic events (hazard ratio , 95% CI to ,P ) with ICD therapy. The mortality rate of the nonICD group was 7% per year, but no parison group of pts without ventricular arrhythmias was reported. （三）心率恢復(fù)和恢復(fù)性室性異位搏動(dòng) ? Immediately after graded exercise,heart rate normally falls in a biphasic manner, with an initial rapid decline occurring during the first 30 seconds to 1 minute of recovery. ? Imai K,et al. demonstrated that this initial steep descent is marked in athletes and attenuated in pts with heart failure and that it can be eliminated by administration of atropine. [1] ? The ideal recovery protocol and abnormal cutoff value are unclear。104:1911–1916. ? A phenomenon related to heart rate recovery is ventricular ectopy during recovery, which has also been hypothesized to reflect parasympathetic activity. Occurrence of frequent or severe ventricular ectopy during the first 5 minutes of recovery after exercise has been linked to risk of death in pts without and with heart failure and/or coronary artery disease.[1,2] JP, et al. N Engl J Med. 2020。 87: 814 ? 檢測(cè)對(duì)象 : 自主神經(jīng)功能變化 ? 檢測(cè)方法 : 時(shí)域法 ,頻域法 ,非線性分析法 長(zhǎng)時(shí)程（ 24h）分析 , 短時(shí)程（ 5min）分析 ? 正常值 : ① SDNN： 100 ms，② SDANN： 127177。但目前的數(shù)據(jù)表明 HRV可能是預(yù)測(cè)非心律失常死亡的更好指標(biāo)。 however, low HRV did not predict arrhythmic mortality. ? Abundant data show that depressed HRV is a predictor of total mortality. Despite the theoretical pathophysiol
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