宋尚明缓慢性心律失常诊治.pptVIP

31 Danish 研究：慢性房颤 32 Danish 研究结论 ? 对于 SND 患者而言， AAI 起搏比 VVI 起搏 : ? 降低总死亡率 ? 降低心血管死亡率 ? 减少心衰发生 ? 减少房颤发生 ? 减少血栓事件 33 SND 患者随访期间 AVB 发生率 Study Mean Follow-Up Time Incidence of AVB Annualized Incidence Rosenqvist 1989 (literature review) 3 years Median 2.1% Range: 0-11.9% Median: 0.6% Range: 0-4.5% Andersen 1997 8 years 3.6% 0.6% Brandt 1992 5 years 8.5% 1.8% Sutton 1986 3 years 8.4% 2.8% Rosenqvist 1986 2 years 4.0% 2.0% Rosenqvist 1985 5 years 3.3% 0.7% Hayes 1984 3 years 3.4% 1.1% 34 SND 患者 AAI 起搏条件 ? PR 间期正常 ? 无束支或分支阻滞 ? 文氏点 120 次 / 分 35 SND 患者双腔起搏更符合生理要求？ ? AV 同步 ? 房颤减少 ? 心衰降低 ? 生活质量提高 36 DDD 或 DDDR 起搏问题：心室不同步 ? 心房灌注压升高 ? 心室充盈降低 ? 心室舒张末压增高 ? 心室不对称肥厚 房颤发生率上升 诱发心室 诱发室性心律失常 增加死亡率 37 0.55 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 0 12 24 36 48 Months P r o p o r t i o n e v e n t - f r e e Cum%VP ≤ 40% Cum%VP 40-70% Cum%VP 70-90% MOST 研究： DDDR 起搏机会与房颤发生 Randomized to DDDR mode, baseline QRSd 120 ms Sweeney MO, et al. Circulation 2003;23:2932-2937 38 MOST 研究：心室起搏比例与心衰住院 ? 1339 Normal QRS duration patients from MOST ? Association between Cum Vp and risk for HF 0 2 4 6 8 10 12 14 16 R a t e o f H e a r t F a i l u r e H o s p i t a l i z a t i o n 10% Cum VP 90% Cum VP DDDR VVIR Sweeney MO, et al. Circulation 2003 39 Notable Changes in 2008 ACC/AHA/HRS Guidelines 1. ICD recommendations are combined into a single list because of overlap between primary and secondary indications. 2. Primary prevention ICD indications in nonischemic cardiomyopathy are clarified using data from SCD-HeFT (i.e., ischemic and nonischemic cardiomyopathies and LVEF ≤35%, NYHA II -III) for support. 3. Indications for ICD therapy in inherited arrhythmia syndromes and selected nonischemic cardiomyopathies are listed. 4. MADIT II indication (i.e., ischemic cardiomypathy and LVEF ≤30%, NYHA I) is now Class I, elevated from Class IIa. 5. EF criteria for primary prevention ICD indications are based on entry criteria for trials on which the recommendations are based. 6. Emphasized pri