急性心梗心律失常风暴.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,急性冠脉综合征室性心律失常风暴,The Ventricular Arrhythmia Storms of ACS,南京医科大学第一附属医院,江苏心血管病临床医学中心,曹克将,心律失常风暴,定 义,电风暴：,24h,内心律失常发作,三次,(,室性心律失常,风暴如室速或室颤,),在二级预防试验中显示电风暴发生率,10-20,Europace,2005:7:184-192,Heart Rhythm 2007:4:1395-1402,室性心律失常风暴可能原因,心律失常基质,(,缺血、通道病、低,K,+,、,结构异常等,),高交感活性,(,交感风暴,),高交感活性在电风暴中作用,不论何种心律失常基质，电风暴中都有高交感活性参与,高交感活性诱发,AMI,、,HF,高交感活性诱发通道疾病、低血钾、,类,AAD,所致电风暴,，因此电风暴又称交感风暴,高交感活性促发电风暴机制,加重病态心肌复极离散,加重细胞外钾转移，造成低钾反应，加重复极离散,增加,ICa,-L,和细胞内钙超载,诱发触发活性,交感激活的电生理作用,(,对正常心肌细胞,),增加,I,Ca,-L,电流,增加,I,kr,电流,I,ks,电流,增加,I,Cl,(Ca,),电流,产生电生理效应,增加,I,k,缩短,APD,，,增加,I,Ca,-L,延长,APD,综合效应,APD,缩短，不应期离散降低,对正常心肌为非致心律失常源性,交感激活的电生理作用,(,对,MI/,缺血性心肌细胞,),心肌缺血,I,ks,下调,(,分布外膜、内膜下,),、,Iks,电流,交感刺激逆转,I,ks,下调，使,I,ks,电流加大，,APD,90,缩短，,但对,M,细胞,I,kr,无影响，造成不应期离散加大,促心律,失常效应,交感刺激对,MI,促心律失常效应与,LQT,1,相似，,LQT,1,者先,天性,I,ks,下调，交感激活诱发,TdP,，,MI,者后天性,I,ks,下调，,交感也激发,TdP,，,二者,阻滞剂都有良好预防效应,交感活性促心律失常实验依据,正常心脏,(,狗,),应用,Chromanol,293 B,灌注,(,选择性,I,ks,阻,滞剂,),，所有心室肌,APD,90,都延长，,QT,间期延长，不表,现宽大,T,波，不诱发,TdP,在,Chromanol,293 B,灌注过程中滴加异丙肾素，内膜,外膜下心肌,ADP,90,缩短，中层,M,细胞,APD,90,不变，,造成宽大,T,波，复极离散加大,自发出现,TdP,高交感活性、异丙肾上素对病态 心肌可致心律失常,交感激活对,I,ks,阻滞反向调节,(1),交感激活对,LQT1,的,QT,间期反向调节，随,HR,增加，,QT,间期延长，复极离散加大,(2),交感激活对三种钾通道阻滞反应不同,Dofetilide,Ambasilide,Chromanol,293B,纯,I,kr,阻滞剂,非选择性,I,k,阻滞,选择性,I,ks,阻滞剂,QT(APD),延长,异丙肾素,APD,缩短,APD,缩短,APD,延长,复极离散,缩小,缩小,加大,ACS,所致电风暴,STEMI VT/VF,发生率,10,，,NSTEMI VT/VF,发生率,2,，,电风暴发生在,AMI 48h,内,STEMI,外膜下和周围存活心肌：,I,Ca,-L,峰流下降,I,Na,降低，,AP,振幅、上升速率下降,I,to,降低,肌细胞间裂隙传导障碍,ADP,延长，复极均质性，各异向传导紊乱,急性心梗合并室性心律失常风暴,20%,的急性心肌梗死患者可能有室性心律失常，其死亡率很高，如同时合并有心功能不全，则死亡率更高。但近,20,年急性心肌梗死患者住院和远期生存率明显改善，死亡率大大地降低：,大约,16%,(1970s,末,-1980s,初,),8%-10%,(1990s,初,),急性心梗合并心律失常,有研究表明,:,AMI,在,24,小时内,大约,90%,有心律失常,大约,25%,有传导障碍,AMI,在第一小时内,VF,发生率为,4.5%,Emerge Med,Clin,North Am.2005;23(4),急性心梗合并室性心律失常,AMI,患者室性心律失常,室性心律失常在急性心梗患者中最常见，包括：室早、,室速、室扑和室颤,，,后者最易发生电风暴现象,急性心梗合并室性心律失常风暴,非持续性室性心动过速,AMI,患者易发生,nSVT(6-40%),，,发病后,24-48h,内不增加猝死的死亡率，有报道,3,年的总死亡率在有,nSVT,患者和无,nSVT,患者中分别为,33%,和,15%,；前壁和下壁,AMI,的发生率相当,急性心梗合并室性心律失常风暴,持续性室性心动过速,AMI,后,48h,内发生率较低，多见于广泛前壁心梗,单形性,VT,在,AMI,中发生率为,0.3-2.8%,头,48h,内发生者在以后的随访中常有复发；在慢性,CHD,中十分常见，梗死后,1,年发生率可达,3-5%,伴心功能不全者,(,室壁瘤,),发生率更高,多形性,VT,多见于,ACS,和再灌注损伤，少数有报道可见于冠状动脉痉挛，有时可表现为,TDP,急性心梗合并室性心律失常风暴,心室扑动和心室颤动,(VF),CCU,监护中,4-8%,的,AMI,患者可出现,VF,，在,前壁和下壁,AMI,患者发生率相当，但在非,Q,波患者中罕见，,60%,发生在,AMI 4h,内，,80%,发生在发病,12h,内；继发性,VF,多伴发在左心衰和心源性休克患者中,A,：,心梗前心电图；,B,：,心梗后两天心电图；,C,：,心梗后第二天心电图显示,RBBB,；,D,：心梗后出现室性心律失常风暴,Sustained ventricular arrhythmias and mortality among patients with acute myocardial infarction:,Results from GUSTO-III trial,Background:,In many patients,ventricular arrhythmias will develop early after AMI.,To study the incidence,timing,and outcomes of the patients in the international,G,lobal,U,tilization of,S,treptokinase and,T,PA for,O,ccluded Coronary Arteries(,GUSTO,)-III trial,Methods,To identify independent predictors of,inhospital,VF and VT,To compare 30-day and 1-year mortality rates of patients with(n=1121:VT=519;VF=410;VT+VF=192)and without(n=13921),arrhymias,Al-,Khatib,et al.Am Heart J,2003;145:515-21,Sustained ventricular arrhythmias and mortality among patients with acute myocardial infarction:,Results from GUSTO-III trial,Results:,The 30-day mortality rate was,31%in patients with VF,The 30-day mortality rate was,24%in patients with VT,The 30-day mortality rate was,44%in patients with VT+VF,The 30-day mortality rate was,6%in patients with neither(p=.001),The 1-year mortality rates were,34%,29%,49%,and 9%(p=.001),The 30-day and 1-year mortality rates were,higher for patients,with late versus early arrhythmias,Conclusions:,Despite,thrombolysis,VT/VF are associated with higher 30-day and 1-year mortality rates after AMI,particularly when occurring later during the initial hospitalization,Al-,Khatib,et al.Am Heart J,2003;145:515-21,Reperfusion arrhythmias,Despite early,recanalization,of an occluded infarct-related artery,myocardial reperfusion may remain impaired due to,microvascu-lar,injury.Reperfusion arrhythmias may indicate successful mi-,crovascular,reperfusion in patients with AMI receiving PCI,Reperfusion arrhythmias include:,Accelerated,idioventricular,rhythm,Multifocal,ventricular premature beats,Ventricular,tachycardia(VT,),Ventricular,fibrillation(VF,),Reuben,Ilia,et al.,Coron,Aetery,Dis,2003;14;439-441,Reperfusion arrhythmias,Many trials of intravenous,thrombolytic,agents have not demons-,trated,any increase in life-threatening ventricular arrhythmias-,Arrhythmias do not appear to be valid marker of successful re-perfusion in patients with AMI receiving,thrombolysis,HD McKenna et al.,Int,J,Cardiol,1990;29:205-213,Multicenter,trails:European Cooperative trail,ISIS-2,and GISSI,reported,significant decreases,in the occurrence of ventricular fib-,rillation,during the hospital period in those patients receiving,thrombolytic,therapy,RA,Kloner,.J Am,Coll,Cardiol,1993;21:537-545,冠脉痉挛致室性心律失常风暴,发生在冠脉正常、轻度或重度狭窄的冠脉痉挛可致室性心律失常风暴：,室性心律失常多数为,VF,室性心律失常少数为多形性室速,或建立在,AV-B,基础上的,TdP,冠脉痉挛极少导致单形性室速,冠脉痉挛致室性心律失常风暴,长间歇依赖性,TDP,冠脉痉挛致室性心律失常风暴,16,例伴有心律失常的,CAS,患者,(,南医大一附院,),6,例有缓慢性心律失常,12,例有快速性室性心律失常,(4,例,VF,，,2,例,sVT,),5,例出现电风暴，其中,1,例死亡，其中,2,例,TdP,风暴是在,III,度,AV-B,基础上,王萌等，中华心律失常学杂志，,13,卷：,258-261,室性心律失常的风暴治疗,静注胺碘酮,用于不能应用,受体阻滞剂者,(,如低排、心衰,),受体阻滞剂不能控制者加用胺碘酮,胺碘酮,150mg,静注，可重复多次，直到,VT/VF,控制,电风暴远期治疗,无论,ICD,植入或未植入者，多数采用,阻滞剂与胺碘酮联合治疗,也有试用消融治疗,尽可能从病因着手,纠正低钾、低血镁,胸交感,N,截除,重建冠脉血运,室壁瘤切除,室性心律失常的风暴治疗,电风暴者都应补钾、补镁,血钾应维持在,4.5mM/L,血镁即使正常者，补镁也能获得好反应,应用,受体阻滞剂,只要没有,阻滞剂禁忌症，电风暴首选,阻滞剂治疗,急性期静注艾司洛尔,0.5mg/kg/1min,静注，,0.05-0.2mg/kg/min,静滴，或美托洛尔,2.5-5mg/2min,静注,“”,室性心律失常风暴的,风暴治疗,他汀强化治疗，阿托伐他汀,80mg/d,ICD,植入者降低,VT/VF,复发风险,40,从,38,降为,21,Curr,Proll,Cardiol,2007;32:501-46,室性心律失常风暴的治疗,缺血性心脏病室速推荐使用的药物：,胺碘酮,索他洛尔,-,blocker,联合治疗：,amiodaron,+,-,blocker,不推荐使用,Ic,类抗心律失常药,ICD,最为有效,冠脉痉挛致室性心律失常风暴治疗,主要治疗是针对冠状动脉痉挛本身,非二氢吡啶类钙拮抗剂：合心爽,-,最大耐受剂量,硝酸脂类药物,针对室性心律失常治疗,电复律或抗心律失常药物,针对管状动脉病变的治疗,不主张应用,-,blocker,AMI,时冠脉内注射,Verapamil,治疗再灌注性心律失常,Intracoronary,administration of,verapamil,can safely terminate reperfusion induced ventricular,tachyarrhythmias,in a rapid manner.However,this effect was not seen for reperfusion induced VF,Chest.2004;126,(3):702-708,冠心病室颤风暴的导管消融,德国,B,nsch,等报道,4,例急性心梗后,VT/VF,成功导管消融,：,Patients,Pat.1:,pVT,/VF at day 7 after AMI and emergency bypass,Pat.2:,pVT,/,inces.VF,3 days after AMI and 1 day after PTCA,Pat.3:,pVT,/,inces.VF,after AMI and after PTCA/CABG,Pat.4:VF day 5 after AMI and 1 day after PTCA,All Ventricular,pVT,/VF triggered by,VPBs,with RBBB morphology,LV mapping,Activation mapping(earliest activation,low-amplitude potentials and Purkinje potential)in 3 pats;pace mapping in 1 pat.,B,nsch,D et al.Circulation 2003;108:3011-3016,冠心病室颤风暴的导管消融,Radiofrequency ablation,RF ablation of the triggering,VPBs,was performed in left ventricle.,No episode of ventricular tachycardia/fibrillation for 33,14,6,and 5 months in patients 1,2,3,and 4,respectively,Conclusion,RF ablation of the triggering,VPBs,feasible and can prevent drug-resistant electrical storm,even after acute MI,B,nsch,D et al.Successful catheter ablation of electrical storm after myocardial infarction.Circulation 2003;108:3011-3016,AHA2008 CPR,强调持续胸外按压，不建议口对口呼吸,Circulation 2008;117;2162-2167,CC=chest compression;CPR=cardiopulmonary resuscitation;RB=rescue breathing.,多研究显示胸外按压提高生存率,与传统心肺复苏相比，心脑复苏后脑神经存活率,Ann,Emerg,Med 2008;52:244-52,JAMA 2008;229:1158-65,与传统心肺复苏相比，心脑复苏者存活率,急性,STEMI,发生院外心脏骤停者预后差,Am Heart J 2009;157:569-575,急性,STEMI,发生,心脏骤停被成功复苏后行急诊,PCI,，,6,个月后生存率达,54%,Circulation 2007;115:1354-1362,