心源性猝死高危病人的识别信栓力邯郸市第一医院心内科邯郸

1、 心源性猝死高危病人的识别信栓力 邯郸市第一医院心内科邯郸市心血管病研究所6个故事揭示猝死的残酷现实：马xx造影后拒绝PCI后8个月猝死，抢救成功李x军PCI术后10天从CCU转至普通病房后1小时猝死宋x亮42岁晚一次胸疼，次日驾车上班途中猝死抢救成功苏x山凌晨4点早八点十点下午3点三次就诊2家医院，均告知没事的情况下在医生面前发生猝死抢救成功 赵x义本院ICD后10月陪人看病时自己猝死；荆x文ICD后4个月早晨被发现猝死于床上。胡xx教师左主干猝死 马某某LAD狭窄猝死 宋xxLCX狭窄猝死后两个抢救成功李xx下午前手术回家邯郸大学老师：救护车都到了，最终放走了上午看病中午就猝死了马xx、绿

2、化路老太太 风险管理的为难处境 医生因此而饱受诟病是医学无能？还是医生无能？是管理问题？还是责任问题？是个体问题？还是社会问题？难道灾难不能预测？不能预防？不能防止吗？发作一次心绞痛就猝死了1疼了许屡次，终于猝死了(1.。)装了ICD还是猝死了(2)不放支架猝死了 vs 放了支架也猝死了上午看病下午就猝死了(2)微结院内患者的SCD预防-Livewest理想的SCD危险分层工具应该：_能够识别出大多数发生VT/VF并且能够除外那些不会发生的患者。筛选出的异常患者接受干预 (medical, surgical, ICD) 能够比一般人群大幅度改善生存状况。Circulation on line

3、8/25/2021现有的SCD主要危险分层工具具有局限性:大多数此类危险分层工具同时对SCD和非SCD提供预后信息，不能区别开来。Circulation on line 8/25/2021由此我们要思考：我们是要预测死亡呢？我们还是要预测死亡方式？猝死不过是一种死亡方式！狭义的猝死应该只指恶性心律失常死亡！而不包括肺栓塞、主动脉瓣狭窄等等Relationshipbetween cardiac mortalityand LVEFN Engl J Med 1983;309:331Value of LVEF for risk stratification after MI: The Multicen

4、ter Postinfarction Research GroupWhy decreased LVEF outperforms all available surrogate EP measurements for the risk of SCD? LVEF降低和左室重构关联，导致复极离散度加大。收缩功能降低和交感迷走张力平衡有关，导致复极离散度加大和循环崩溃。收缩功能降低的室速的快速发生和持续能够导致血流动力学快速恶化，引起本已受损心肌进一步低灌注。无论如何，LVEF降低和心脏性死亡相关性很好，但是预测心源性猝死敏感性低。Limitations of LVEF as the main ind

5、ication of primary ICD prophylaxis降低的LVEF是心脏原因总死亡率的良好标志物，但对SCD而言确实不是特异的。将LVEF降低和其他SCD危险标志结合起来，可能对更好的选择何时得患者植入 ICD 一级预防SCD有益处。Cardiac Defibrillators:Are we implanting too many? 在MADIT II研究, 在四年随访期内针对VT/VF恰当的ICD治疗累积概率为40% (1)在SCD-HeFT研究中, 21% 的ICD植入者在平均45个月的随访期内因为VT/VF接受了恰当的ICD治疗 (2)1 N Engl J Med 200

6、2;346:8772 N Engl J Med 2005;352:225Risk stratification for sudden cardiac death:Beyond LVEFA) 动态心律监测: Holter ECGB)传导延迟: Signal averaged ECG EPSC) 复极异常indices of abnormal repolarization: T wave alternans QT prolongation and dispersionD) 自主神经功能紊乱: Heart rate variability Heart rate turbulence Barorefl

7、ex sensitivityF) ?othersPrevalence of several risk markers in patients with LV dysfunction and /or MI Study Population Risk factor PrevalenceATRAMI,1998AMISDNN70 ms15%BRS3ms/mmHg15%EMIAT,2000AMI, EF40%HRV index10/h38%Abnormal SAECG39%Abnormal TWA48%MUSTT, 2001CAD,NSVT, EF40%Abnormal SAECG44%ABCD,200

8、6“MUSTT-likeAbnormal TWA71%ALPHA,2007Dilated CMAbnormal TWA65%MASTER,2007 “MADIT-II eligibleAbnormal TWA63%Low mortality and SCD in MI survivors with EF 1 risk factors (10 VPCs/h, SDNN 120 ms的患者比之QRS 120 msec是最有价值的预测参数。 多参数分析(包括临床资料、Holter数据，LVEF和SAECG, QRS时限延长 是心律失常事件的最重要预测因素 (p0.0002)。Time-domain

9、SAECG: prognostic value in post-infarction patients (CAST Substudy) El-Sherif et al, JACC 1995Arrhythmic death/ Cardiac deathCardiac arrest_ c p value c p value_DichotomousVariables28.9 0.001 35.5 0.001ContinuousVariables18.5 0.001 20.3 0.001Adjusted multivariate analysis for event prediction by SAE

10、CG variables in the Multicenter Unsustained Tachycardia Trial (MUSTT) Gomes JA et al, Circulation 2001 Gomes JA et al, Circulation 2001Kaplan-Meier estimates of arrhythmic death or cardiac arrest by SAECG results in the Multicenter Unsustained Tachycardia Trial (MUSTT)P0.001 Gomes JA et al, Circulat

11、ion 2001Kaplan-Meier estimates of cardiac death by SAECG results in the Multicenter Unsustained Tachycardia Trial (MUSTT)P114 ms, RMS4020 mv at 40-250 Hz) 是心律失常死亡和总的心源性死亡率强预测因素。 “无创的检查SAECG异常和LVEF降低在选择高危病人接受有创评估方面具有应用价值。 Gomes JA et al, Circulation 2001Role of the SAECG in MUSTT80例非缺血性心脏病患者2年无心律失常生存

12、期Survival (%)(months)p=NSTuritto et al, JACC 1994MADIT II PatientsQRS duration 120 ms (37%) Mortality= 33%SAECG- (31%) SAECG+ (32%)Mortality: 7% Mortality: 20% Presented by W. Zareba on behalf of MADIT II Investigators at Heart Rhythm Sessions, May 2004Does the combination of QRSD and SAECG provide

13、additional value for risk stratification?T-Wave Alternans“微伏级T波电交替能很好的区别ICD疗法可能收益和不可能收益的患者群。 A Solution to the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II ConundrumBloomfield et al, Circulation 2004T-Wave AlternansBloomfield et al, Circulation 2004;110:1885Kaplan-Meier mortalit

14、y curves, stratified by MTWA test results and by QRS durationTHE ALTERNANS BEFORE CARDIOVERTER DEFIBRILLATOR (ABCD) TRIALUsing T wave alternans in a strategy to improve efficacy of sudden cardiac death prevention Constantini O et al, AHA 2006ABCD Trial Protocol“MUSTT-like population:566 pts with CAD

15、, LVEF40%, non-sustained VTTWA, EPS Pts (%) Arrhythmicresults events (VTE)TWA-,EPS- 99 (17%) 2.3%TWA+,EPS-245 (43%) 5.0%TWA-,EPS+ 66 (12%) 7.5%TWA+,EPS+156 (28%)12.6%*TWA+: TWA present or indeterminate*p=0.016 vs both tests negativeConstantini O et al, AHA 2006ABCD Trial Results (The study was power

16、ed to test the hypothesis that TWA was non-inferior to EPS in predicting events at 1 year)Kaplan-Meier Event Rates VTE RATE6121824EPS -HAZARD RATIO6121824MONTHS*0123456 *P 0.05ABCD Trial: Conclusions对于CAD, NSVT, and LVEF 40%的患者而言, TWA在预测一年心律失常事件方面和EPS同样有效。联合应用 MTWA 和 EPS 在预后评估方面具有协同作用。 MTWA的预测价值在随访的

17、第二年发生分化，提示可能需要周期性的危险分层。MASTER TRIALMicrovolt T-Wave Alternans Testing for Risk Stratification of post-MI patientswith LV dysfunction (EF30%)Chow T et al, AHA 2007* All patients*Survival curves for total mortalitySurvival curves for LTVTE*Primary endpoint: * Life-threatening ventricular tachyarrhythm

18、ic events arrhythmic death, appropriate ICD discharge (LVTE)Additional endpoints: total and cause-specific mortalityP=0.37P=0.02MASTER Trial Results MASTER Trial: ConclusionsIn patients with CAD, prior MI, and LVEF 30%, life-threatening ventricular tachyarrhythmic events (arrhythmic death/appropriat

19、e ICD shocks) did not differ according to TWA classificationOn the other hand, total mortality was higher in patients with a non-negative TWAGrimm, W. et al. Circulation 2003;108:2883Kaplan-Meier estimates for arrhythmia-free and transplant- free survival of 263 patients with dilated cardiomyopathyN

20、oninvasive risk stratification in idiopathic dilated cardiomyopathy:Results of the Marburg Cardiomyopathy Study (MACAS)Predictors of Transplant-Free Survival in 263 Patients With IDC and Sinus Rhythm Transplantation-Free Survival Univariate and Multivariate Cox Analysis Yes (n=220) No (n=43) P, Uni

21、P, Multivariate RR (95% CI) Age, y 471251130.07NSSex, M/F 158/6235/80.22NSNYHA I or II 174 (79)22 (51)NYHAIII 46 (21)21 (49)0.0001NS-Blockers 116 (53)16 (37)0.460.0850.51 (0.241.11)Echo LV EDD, mm 6677080.003NSLVEF, % 3110 2380.00010.00012.51 (1.653.85)Signal-averaged ECG, n (%)Normal 91 (41) 9 (21)

22、0.03NSAbnormal 52 (24)12 (28)0.61NSBBB 77 (35)22 (51)0.08NSNS VT on Holter 69 (31)19 (44)0.09NSHRV (SDNN) 1104599450.04NSBRS, ms/mm Hg 8.1 5.55.63.90.030.0831.42 (0.952.13)Microvolt T-wave alternans, n (%)Positive 112 (51)25 (58)0.26NSNegative 64 (29) 8 (19)0.14NSIndeterminate 44 (20)10 (23)0.79NSFr

23、eedom From Cardiac Death + Life-Threatening ArrhythmiasThe ALPHA Study. Salerno et al, J Am Coll Cardiol 2007;50:1896TWA 在心衰和非缺血性心肌病患者的预后价值Is TWA an accurate predictor for SCD?Explanations for conflicting results事件发生率和随访间期不同可能影响了不同研究的效能。ICD放电次数作为替代终点可能不可靠技术因素的干扰不确定结果的原因未知可能需要周期性评估检测?缺乏长期可重复的检测数据A) L

24、VEF (the “gold standard)B) Clinical variablesD) Non-invasive risk stratifiers F) Clinical risk “models or “scoresSudden Cardiac Death:Prevention and Detection of High-Risk PatientsMulticenter Automatic Defibrillator Implantation Trial (MADIT II)Moss AJ et al, N Engl J Med 2002;346:877High-risk popul

25、ation: CAD, previous MI, LV ejection fraction 30%EPS not requiredRandomization (3:2 ratio): “conventional therapy (n =490) vs ICD (n= 742)Follow-up: 20 monthsTotal mortality: 97 cases with “conventional therapy, 105 with ICD (19.8% vs 14.2%, hazard ratio= 0.69, p=0.016) Multicenter Automatic Defibri

26、llator Implantation Trial (MADIT II)Moss AJ et al, N Engl J Med 2002;346:877p=0.01619.8%14.2%Goldenberg et al, JACC 2021;51:288U-shaped curve for ICD efficacy in the MADIT-II TrialCan current non-invasive markers improve the redundancy of LVEF? There is no accepted risk stratification strategy for s

27、udden cardiac deathIt is still not established if a non-invasive screening algorithm may improve cost-effectiveness and risk/benefit ratio of ICD therapy尽管有局限性，但探索仍在进行：BNPCMRLDE：借助于DE技术，CMR成为影像评估不可逆损伤心肌的金标准. 10% -26% 的没有堵塞证据的 DCM患者 可见和冠脉分布区域无关的室壁中部DEA:缺血心肌病OMI跨壁瘢痕下壁100%、下侧壁50%B：心肌炎的下壁室壁中部的延迟显像C：扩张性心

28、肌病之室间隔中部的延迟显像瘢痕的多少和跨壁程度可以预测PCI后功能的恢复近期心肌堵塞患者，在DE显像区域有微血管阻塞的证据。侧壁的黑色区域完全被增强区域包围。实际上就是无复流区In patients with ICM and severely reduced LVEF, myocardial scar has predictive significance CMR监测心肌瘢痕特征是最新预测指标？Myocardial Fibrosis Predicts Appropriate Device Therapy in Patients With Implantable Cardioverter-Def

29、ibrillators for Primary Prevention of Sudden Cardiac DeathConclusions: Patients with advanced cardiomyopathy and myocardial fibrosis demonstrated by LGE on cardiac magnetic resonance imaging have a high likelihood of appropriate ICD therapy. Correspondingly, absence of LGE may indicate a lower risk

30、for malignant ventricular arrhythmias.NO scar no ICD TherapyScar in the ventricular base=VT观点和事实预防: 比什么都重要的是猝死生活方式和猝死的工作方式的改变：吸烟 增肥 饮酒 彻夜不休息 OSA 压力药物疗法远比非药物方法预防心衰更根底更有效!ICD CRT等确实能够预防猝死的发生，降低SCD死亡率。防范范围加大：医院 写字楼 火车上 影院既然任何SCD高危患者不能一直生活在医院，那么家庭成为预防猝死的重要场所，那么培训就成了一项重要课题。药物可以预防猝死也可以增加猝死发生率致心律失常作用。政策面：提

31、高政府和职能部门健康促进的组织能力和关注程度。为预防猝死发生，单靠包括医学在内的任一方面绝对不能解决问题。不靠系统管理和全社会参与绝对不能很好的解决问题！猝死预防：技术派临床派管理派合纵连横-联防派TWAHRVQTJ波Brugada波ERPVVTVFelectrolyteThank you%#Gl+c0q%GrYuJIqd-JChdw2+f4)F6)g+viP70MA(z161a-PRmSHVF!I9TV0fL0PHdOsHg2fiibQh-2rtmew9*Rgw!(nt1Gy0r+PWW20G9Ba4LM4h6ATmRStBOl7W%n5y+DeJ0EO431Duz%9S#Vh6Sm56$D

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