室性心律失常的危险分层及评价方法.pptVIP

室性心律失常的危险分层及评价方法 浙江大学医学院附属第一医院 陶谦民 背景 对于个人和家庭而言，因恶性室性心律失常导致的心脏性猝死完全可以称之是一次“地震”！ 目前对于心脏性猝死的预测，虽然经过了四十多年的努力，仍然没有实质性的、确切有效的方法。 我们只是通过检出高危人群，预防性应用ICD，尽力去避免不幸的发生。 其实，在我们的身边，经常在出现…… 非侵入性检查评估方法 心电学及相关检查是对室性心律失常危险分层的常用方法。常规12导联心电图、心电图运动试验、动态心电图用以确定心律失常的诊断，QT间期的改变、ST改变、T波电交替等反映复极的影响，对某些状况下的危险分层具有重要意义。T波电交替是唯一能判断是否发展到致命性室性心律失常的危险分层指标（IIa类推荐、A级证据）；信号平均心电图、心率变异、压力反射敏感性及心率紊乱仅能作为不十分可靠的检测技术指标推荐（IIb类推荐、B级证据） Microvolt T-wave alternans testing for ventricular arrhythmia risk stratification T-wave alternans tests prognostic horizon exceeds two years in analysis The finding addresses a persisting question about the test used to screen candidates for primary-prevention ICDs: if its negative, how soon should it be repeated? (Chan PS et al. Am J Cardiol 2008; 102:280-284.) Could it be that easy? Clinical-risk score may further stratify low-LVEF ICD candidates A retrospective analysis of none other than the MADIT-2 trial identified five familiar markers that could potentially be used to screen out post-MI, low-LVEF patients unlikely to need the devices. (Goldenberg I et al. J Am Coll Cardiol 2008:51:288-296.) Markers of autonomic tone advance in post-MI risk assessments In two studies, long-term prognostic measures included baroreflex sensitivity, heart-rate variability, and heart-rate turbulence. One found that the risk assessment didnt predict CV events unless it was performed later than usual, 10 to 14 weeks after the MI. (De Ferrari GM et al. Exner DV et al. J Am Coll Cardiol 2007; 50:2285-2290, 2275-2284.) Trials mixed message challenges TWA tests image for predicting sudden-death risk A mountain of data supports a risk-stratification role for microvolt TWA testing in candidates for primary-prevention ICDs, so how could the MASTER 1 trial suggest that it doesnt predict life-threatening ventricular arrhythmias in post-MI patients with poor LV function? (American Heart Association 2007 Scientific Sessions.) MASTER I: Disappointment for T-wave alternans testing The test di