心脏性猝死的高危因素曹克将教授ppt课件

,心脏性猝死的高危因素,直击猝死！（残酷的事实）,2003年6月27日，在联合会杯的比赛中，喀麦隆国脚维维安福猝死赛场，震惊了整个足球界。最后经严格的尸检证实为心脏性猝死,54岁的爱立信（中国）有限公司总裁杨迈于2004年4月8日晚，由于心脏病突发在京猝死,直击猝死！（残酷的事实）,全球快餐业巨头麦当劳公司董事长兼首席执行官吉姆坎塔卢波于2004年4月19日凌晨猝死于家中,最终死因为心脏病突发，享年60岁,直击猝死！（残酷的事实）,直击猝死！（残酷的事实）,直击猝死！（残酷的事实）,他们的猝然离世为人们敲响了警钟：小心心脏性猝死！,现代SCD的定义,(1) 临床上有心脏骤停的证据 (2) 从突发症状到死亡的时间在1小时之内 或 (3) 不明原因的死亡，之前24小时内病人情况良好 注意: SCD (Sudden Cardiac Death) and SCA (Sudden Cardiac Arrest) 两者的定义有所不同,Kim SG. Standardized reporting of ICD patient outcome: the report of a North American Society of Pacing and Electrophysiology Policy Conference, February 9-10, 1993. PACE 1993;16:1358-1362.,美国SCA的发病情况,1 U.S. Census Bureau, Statistical Abstract of the United States: 2001. 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001. 3 2002 Heart and Stroke Statistical Update, American Heart Association. 4 Zheng Z. Circulation. 2001;104:2158-2163.,AIDS1,乳腺癌2,肺癌2,中风3,SCA4,在美国,每年SCA 的发病人数超过所有这些疾病的总和,450,000,167,366,157,400,40,600,42,156,每年450，000例 每天1200例 每小时50例 每80秒1例 大多数的SCA发生在临床确诊的心脏病患者中，特别是心梗后和心衰的患者,1Circulation. 2001;104:2158-2163. 2 Myerburg RJ, Castellanos A. Cardiac Arrest and Sudden Cardiac Death, in Braunwald E, Zipes DP, Libby P, Heart Disease, A textbook of Cardiovascular Medicine. 6th ed. 2001. W.B. Saunders, Co. 3 Every N, et al. Risk of Sudden versus Non Sudden Cardiac Death in Patient with Coronary Artery Disease. Am Heart J 2002; 144: 390-6.,美国SCA的发病情况,在美国，所有心脏原因引起的死亡中，SCA大约占63%1 在发达国家中，SCA是最常见的死亡原因之一,1 MMWR. Vol 51(6) Feb. 15, 2002. 2 Myerberg RJ, Catellanos A. Cardiac Arrest and Sudden Cardiac Death. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th Ed. New York: WB Saunders. 1997: 742-779. 3 Circulation. 2001;104:2158-2163. 4 Vreede-Swagemakers JJ et al. J Am Coll Cardiol 1997; 30: 1500-1505.,SCA的统计情况,SCA的病因,Huikuri HV. N Engl J Med. 2001;345:1473-1482. Myerburg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. W.B. Saunders, Co. 2001.,*ion-channel abnormalities, valvular or congenital heart disease, other causes,CAD已成为西方国家人群发生SCA的主要病因,不常见病因,心肌病,冠状动脉粥样硬化高危因素:老年,男性,高血脂,吸烟, 高血压,糖尿病,遗传因素,高血压,遗传因素,感染,其他,冠状动脉粥样硬化,肥厚型心肌病,扩张型心肌病,心梗后慢性心肌瘢痕,原发性电活动和遗传性离子通道异常,瓣膜病或先天性心脏疾患,其他原因,急性的瘢块不稳定:破裂,出血,血栓,SCA的触发机制: 短暂的缺血,血液动力学波动,神经心脏血管影响,环境因素,SCA的病因,Heikki HV,Castellanos A,Myerburg RJ.Sudden cardiac death due to cardiac arrhythmias.N Engl J Med.2001;20:1473-1482.,Bays de Luna A. Am Heart J. 1989;117:151-159.,心动过缓 17%,单形性VT 62%,原发性VF 8%,尖端扭转性VT 13%,SCA发生时的心律失常情况,中国人口基数大，每年SCA的发病人数超过100万,！,40% SCA发生在睡眠时或没有旁人在现场的情况下 1 80% SCA发生在家里 1 院外SCA的存活率仅5% 2,3 （美国）,SCA 存活率统计,即使在紧急救护系统非常完善/可早期给予除颤治疗的地区，SCA的存活率仍很低，因为大多数SCA发生时无旁人在场，或即便被发现，也很难在6-8分钟内给予有效的治疗,1 Swagemakers V. J Am Cardiol. 1997;30:1500-1505. 2 Ginsburg W. Am J Emer Med. 1998;16:315-319. 3 Cobb LA. Circulation. 1992;85:I98-102.,发现SCA的高危患者，给予有效预防措施,SCA干预的首要环节,SCA高危因素1,2,左室射血分数（LVEF）低下 冠心病（CAD）、心梗后 心梗后伴LVEF低下 曾经发生过SCA或VT事件 有SCA家族史 扩张型心肌病伴心衰（缺血性/非缺血性） 遗传异常：HCM、LQTS、Brugada综合征,1 Priori SG.et al.Task Force on Sudden Cardiac Death of the European Society of Cardiology.European Heart Journal.2001;22:1374-1450. 2 Maron BJ,et al.Efficacy of implantable cardioverter defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy.N Engl J Med.2004;342:363-373,不同危险人群猝死发生情况1,2,1 Adapted from: Myerburg RJ. Sudden Cardiac Death: Exploring the Limits of Our Knowledge. J Cardiovasc Electrophysiol Vol. 12, pp. 369-381, March 2001. 2 Bunch,JT.et al.Long-term outcomes of out-of-hospital cardiac arrest after successful defibrillation.N Engl J Med.2003;348:2626-2633.,300,000,200,000,100,000,0,猝死发生次数/年,有冠心病高危因素,冠心病,EF35%,心衰,院外SCA幸存者,心梗后,EF低下伴VT,总人群,30,25,20,10,5,0,猝死发生率(%),SCA的高危因素（一）,左室射血分数（LVEF）低下,左室射血分数（LVEF）已成为评估SCA非常重要的独立危险因素1,1 Myerberg RJ,Castellanos A.Cardiac arrest and sudden cardiac death.Braunwald E.Heart Disease,A Textbook of Cardiovascular Medicine.5th ed,Vol.Philadelphia:WB Saunders Co;1997:chapter 24,LVEF30%的患者发生SCA的危险性极高,LVEF与SCA,1 Gorgels, PMA Out-of-hospital cardiac arrest-the relevance of heart failure.The Maastricht Circulatory Arrest Registry.European Heart Journal.2003;24:1204-1209.,LVEF,% SCA Victims,7.5%,5.1%,2.8%,1.4%,LVEF与SCA的相关性1,1 Yap Y,Duong T,Blend M,et al.Heart.2000;83:85.,不同LVEF的死亡危险性1,冠心病、心梗后,SCA的高危因素（二）,1 Myerberg RJ,Castellanos A.Cardiac arrest and sudden cardiac death.Braunwald E.Heart Disease,A Textbook of Cardiovascular Medicine.5th ed,Vol.Philadelphia:WB Saunders Co;1997:chapter 24 2 Lombardi G,Gallagher J,Gennis P.Outcome of out-of hospital cardiac arrest in New York City.JAMA.1994;271:678-683. 3 Bigger JT,Fleiss JL,Kleiger R et al.The relationships among ventricular arrhythmias,left ventricular dysfunction,and mortality in the 2 years after myocardial infarction.Circulation. 1984;69:250-258,Post-MI占所有SCA病因的50-75%1,2,3,这些患者的SCA发生率比正常人高出4-6倍1,2,3,CAD,Post-MI与SCA,(n = 300),(n = 283),(n = 284),(n = 292),Hazard Ratio,.98 (p = 0.92),0.52 (p = 0.07),0.50 (p = 0.02),0.62 (p = 0.09),1 Wilber, D. Circulation. 2004;109:1082-1084.,MADIT-II 试验中心梗后患者在各时间段的死亡率1,在心梗后的15年时间里，ICD对这些患者生存率的影响将随着时间的推移而更加显著,心梗后死亡率与时间的关系 在-受体阻滞剂时代，心梗后SCD的发生率1,700 位心梗后患者; 其中约95%出院后2年内长期服用-受体阻滞剂 SCD的发生情况与以往的研究结果有所不同 心律失常事件并未集中在心梗早期，大部分发生在心梗18个月以后,1 Huikuri HV. J Am Coll Cardiol. 2003;42:652-658.,Total Mortality,Cardiac Mortality,Non-SCD,SCD,Cumulative Events (%),18,15,12,9,6,3,18,15,12,9,6,3,20,40,60,20,40,60,Follow-Up (months),Follow-Up (months),Post-MI伴LVEF低下,SCA的高危因素（三）,心肌梗死后LVEF30%的患者发生心脏骤停的风险更高(MADIT-II研究结果),心肌梗死 幸存者,低EF,心脏骤停的 高危人群,+ =,Post-MI伴LVEF低下,MUSTT和MADIT-II试验中， 非ICD组心律失常的死亡率1,2,1 Moss AJ,Wojciech Z,Hall WJ,et al.Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction.N Engl J Med. 2002;346:877-883. 2 Buxton,AE,Kerry KL,Fisher JD,et al.A randomized study of the prevention of sudden death in patients with coronary artery disease.N Engl J Med. 1999;341:1882-1890.,% Arrhythmic Death,18%,21%,32%,6%,14%,20%,NA,MI, LVEF 40%, NSVT, inducible VT at EPS,MI, LVEF 30%,10%,MI, LVEF 40%, NSVT, inducible VT at EPS,MI, LVEF 30%,32%,10%,6%,18%,14%,21%,20%,NA,SCA的高危因素（四）,曾经发生过SCA或VT事件,心梗后48h内曾发生VT/VF患者日后的死亡率1 (GUSTO-III Trial),1 Al-Khatib SM.Sustained ventricular arrhythmias and mortality among patients with acute myocardial infarction:Results from the GUSTO-III trial.Am Heart J. 2003;145:515-521.,% Mortality,31%,24%,44%,6%,34%,29%,49%,9%,AVID试验中非ICD治疗组VT/VF患者心律失常的死亡率,心律失常死亡（）,8%,11%,18%,1 Pratt CM,Greene L.,Anderson JL.et al.Cause of death in the AVID trial.Circ J Am Heart Assoc.1998;98(suppl I):1494-1495.,AVID试验结果分析,1 Wyse GD,love JC,Yao Q,et al.Atrial fibrillation:a risk factor for increased mortality in patients with ventricular tachyarrgythmias-an AVID registry analysis.Circ J Am Heart Assoc.1998;98(suppl I):1633.,VF/VT幸存者如同时伴有AF，其死亡率将增加1；尤其在VT患者中 在VF/VT幸存者中，有AF史已成为其死亡率增加的独立危险因素,SCA的高危因素（五）,有SCA家族史,有SCA家族史,近期的研究表明，SCA患者的一代亲属发生SCA的危险程度比一般人群高出50%1,1 Friedlander Y,Siscovick DS,Weinmann S,et al.Family history as a risk factor for primary cardiac arrest.Circulation.1998;97:155-160,SCA的高危因素（六）,扩张型心肌病伴心衰,心衰与SCD,1 Kanned WB,Wilson PWF,DAgostino RB,et al.Am Heart J.1998;136:205.,Framingham心脏研究中心的一项38年随访结果显示，心衰患者的猝死率和总死亡率明显增加1,Age-adjusted Annual Rate/1000,Women,Women,Men,Men,Sudden Death,Overall Mortality,不同程度心衰的死亡原因,1 MERIT-HFStudy Group. Effect of Metoprolol CR/XL in chronic heart failure:Metoprolol CR/XL randomized intervention trial in congestive heart failure(MERIT-HF).LANCET. 1999;353:2001-2007.,NYHA Class III n = 103,NYHA Class II n = 103,NYHA Class IV n = 27,64%,12%,24%,11%,56%,33%,59%,15%,26%,NYHA II/III级的患者的主要死因为SCA，而NYHA IV级的患者大多死于心衰,尽管给予理想的药物治疗， 心衰患者的猝死率仍非常高1,2,3,4,1 MERIT-HF Study Group.Effect of metroprolol CR/XL in chronic heart failure.Lancet.1999;353:2001-2007. 2 CIBIS Investigations and Committees.The cardiac insufficiency bisprolol study II (CIBIS-II).Lancet.1999;353:9-13. 3 Packer M,Bristow MR,Cohn JN,et al.The effect of carvedilol on morbitity and nortality in patients with chronic heart failure.U.S.Carvedilol Heart Failure Study Group.N Engl J Med.1996;334:1349-1355. 4 The RALE Investigators.Effectiveness of spironolactone added to an aniotensin-converting enzyme inhibitor and a loop diuretic for severe chronic congestive heart failure(the Randomized Aldactone Evaluation StudyRALES.Am J Cardiol.1997;78:902.,SCA的高危因素（七）,遗传异常,HCM （肥厚型心肌病） HCM是年轻人最常见的死因 SCD发生危险与左室肥厚存在直接相关性，无临床症状或症状轻微但左室肥厚严重的年轻患者长期存在SCD的危险。1,2,1 Spirito P. N Engl J Med. 1997;336:775-785. 2 Maron BJ. N Engl J Med. 2000;342:365-373.,遗传异常,左室壁厚度与猝死的关系1,1 Spirito P. N Engl J Med. 2000;342:1778-1785.,左室壁厚度最大值（mm）,猝死发生率 (每1,000人/年),0,2.6,7.4,11.0,18.2,遗传异常,LQTS（长QT综合征） - 曾经发生过晕厥和SCA事件的LQ