心源性猝死的预防和治疗ppt课件

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,*,*,心源性猝死的预防和治疗,Incidence of SCD,?,SCD(caused by sudden cardiac arrest)is,the most common cause of death in,Western societies,?,Incidence:300,000 to 400,000 each year,(U.S.)only 2%,15%reach the hospital,?,Half of these early survivors die before,discharge,Risk Factors of SCD,?,Left ventricular failure,CHD,cardiomyopathy,?,Sudden cardiac death syndromes,Long QT syndromes,Brugada syndrome,Polymorphic catecholaminergic VT,Isolated ventricular fibrillation,CAD has become a main cause of SCD,80%,CAD,15%,cardiomyopathy,5%other,*,Huikuri HV.,N Engl J Med,.2001;345:1473-1482.,Myerburg RJ.Heart Disease,A Textbook of Cardiovascular,Medicine,.6,th,ed.W.B.Saunders,Co.2001.,*,ion-channel abnormalities,valvular or,congenital heart disease,other causes,Bay,s de Luna A.,Am Heart J.,1989;117:151-159.,Bradycardia 17%,Monomorphic VT,62%,Primary VF 8%,TdP 13%,Prevalence of arrhythmia at SCD,Heart Failure and SCD,?,More than one million new heart failure,patients every year in the USA,25%mortality in 2.5 years in moderate,to severe CHF,A total of 15%of CHF patients die of SCD,?,0,1,2,3,4,5,6,7,8,0-30%,31-40%,41-50%,50%,Gorgels,PMA.,Eur Heart J,.2003;24:1204-1209.,LVEF,%,S,C,D,V,i,c,t,i,m,s,7.5%,5.1%,2.8%,1.4%,LVEF and SCD,Causes of deaths in HF:mainly SCD in NYHA II-III,heart failure in,NYHA IV,MERIT-HFStudy Group.,LANCET.,1999;353:2001-2007.,CHF,Other,Sudden Death,NYHA Class III n=103,NYHA Class II n=103,NYHA Class IV n=27,64%,12%,24%,11%,56%,33%,59%,15%,26%,?,Myocardial infarction and SCD,Acute phase:ischemia-provoked VF;or,mechanical dysfunctions(e.g.ventricular or,papillary rupture),Chronic phase:structural remodelling of the,LV,leading to re-entry or heart failure,Risk stratification of SCD,?,Risk assessment,Clinical data,?,Aetiology;family history;LVEF,EPS,?,T wave alternans,?,QT dispersion,?,Arrhythmia during Holter monitoring or,stress test,Ideka T,et al JACC 2006;48:2268,S,ensitivity,Specificity,PPV,NPV PA,Microvolt-TWA,83%,83%,9%,99.6%,83%,Nonsustained,VT,44%,83%,7%,98.8%,88%,Ventricular late,potentials,35%,91%,7%,98.6%,90%,Predictive values of positive TWA,nonsustained VT and,ventricular Late potentials,So what we do?,?,The most important criterion is reduced,left ventricular function,LVEF35%and 40 days after MI,Prevention of SCD,Anti-arrhythmic drugs,?,Amiodarone is probably the most effective drug for,secondary prevention of VT,Marginally reduce SCD and mortality,ICD,?,Most effective when LVEF30%,Other,?,Surgery,Long QT(http:/www.scd-symposium.org),Ventricular aneurysm,heart transplant,?,Catheter ablation,Prevention of SCD,?,Secondary,Prevention in those who had a history of SCA,?,Primary,Prevention in those with a high risk but no,history of SCA,80,85,2000,90,95,A,VID,CASH,CIDS,SCD-HeFT,MADIT-II,MUSTT,MADIT,二级,Secondary,Primary,DEFINITE,MUSTT,Multicenter Unsustained Tachycardia Trial,(MUSTT),a randomized controlled trial,Can electrophysiologically guided,antiarrhythmic therapy reduce the risk of,sudden death?,Looked at coronary artery disease patients,with a left ventricular ejection fraction 40%,and asymptomatic unsustained ventricular,tachycardia,Buxton AE.Prog in Cardiovasc Dis 1993;3:215-226,MUST:Arrhythmic Death or Cardiac Arrest,EP-Guided Rx,No ICD,No EP-Guided AA Rx,EP-Guided Rx,ICD,p 0.001,Time after Enrollment(Years),0,1,2,3,4,5,0,0.1,0.2,0.3,0.4,0.5,E,v,e,n,t,R,a,t,e,Buxton AE.,N Engl J Med,.1999;341:1882-90.,MUSTT:Total Mortality,EP-Guided Rx,No ICD,No EP-Guided Rx,EP-Guided Rx,ICD,p 4 weeks);left ventricular,EF 21 years,Patients randomly assigned in a 3:2 ratio to,receive ICD or conventional medical therapy,MADIT-II,?,Trial started July 8,1997,?,Trial stopped prematurely in November 20,2001 because ICD saved lives,?,1,232 patients enrolled from 76 centers in,U.S.and Europe,MADITT II-Mortality,?,CONV,DEFIB,?,(n=490),(n=742),?,Deaths,97 19.8%,105 14.2%,?,-,?,Hazard Ratio(,ICD:CONV),0.69,(31%,?,mortality),?,(95%CI),(0.51,0.93),?,P-value,0.016,?,MADIT-II,Moss AJ.,N Engl J Med,.2002;346:877-83.,Defibrillator,Conventional,P=0.007,1.0,0.9,0.8,0.7,0.6,0.0,P,r,o,b,a,b,i,l,i,t,y,o,f,S,u,r,v,i,v,a,l,0,1,2,3,4,Year,No.At Risk,Defibrillator,742,502(0.91),274(0.94),110(0.78),9,Conventional 490,329(0.90),170(0.78),65(0.69),3,SCD-HeFT,S,udden,C,ardiac,D,eath in,H,eart,F,ailure,T,rial(SCD-,HeFT),?,NYHA class 2-3 HF and,LVEF 35%,?,Largest internal-,cardioverter-defibrillator,(ICD)trial ever,conducted,?,ICD vs placebo,?,Median follow-up of 45,months,SCD-HeFT,Bardy et al.N Eng J Med 2005;352(3):225,23,27,21,0,5,10,15,20,25,30,E,n,d,p,o,i,n,t,(,%,),Decrease in mortality risk,All patients,Nonischemic patients,Ischemic patients,SCD-HeFT:All-cause mortality,All-cause,mortality,ICD,Amiodarone,Placebo,3 years,17.1%,24.0%,22.3%,5 years,28.9%,34.1%,35.8%,Jared Bunch T,et al.Circulation 2007;115:2451-57,Jared Bunch T,et al.Circulation 2007;115:2451-57,Summary,Most SCD are due to coronary artery,disease and heart failure,?,LVEF is the most reliable non-invasive predictor for,SCD,SCD under 3