1、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 2005:7:184-192Heart 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AM
2、I、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Iks阻 滞剂)，所有心室肌APD90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ADP90缩短，中层M细胞APD90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,
3、交感激活对Iks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,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：ICa-L峰流下降INa降低，AP振幅、上升速率下降Ito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，
4、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
5、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
6、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 wil
7、l develop early after AMI. To study the incidence, timing, and outcomes of the patients in the international Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries(GUSTO)-III trial Methods To identify independent predictors of inhospital VF and VT To compare 30-day and 1-year mor
8、tality rates of patients with(n=1121: VT=519; VF=410; VT+VF=192) and without (n=13921) arrhymiasAl-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 r
9、ate was 31% in patients with VFThe 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 mortalit
10、y 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 hospitalizationAl-Khatib et al. Am Heart J, 2003; 145: 515-21,Repe
11、rfusion 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 inclu
12、de: 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
13、life-threatening ventricular arrhythmias -Arrhythmias do not appear to be valid marker of successful re-perfusion in patients with AMI receiving thrombolysisHD McKenna et al. Int J Cardiol 1990; 29: 205-213 Multicenter trails: European Cooperative trail, ISIS-2, and GISSIreported significant decreas
14、es 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,16例伴有心律失常的
15、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
16、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21Curr 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
17、 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. Howev
18、er, this effect was not seen for reperfusion induced VFChest. 2004; 126(3): 702-708,冠心病室颤风暴的导管消融,德国Bnsch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/C
19、ABG 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. Bnsch D et al. Circulation 2003; 108: 3011-3016,冠心病室
20、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-res
21、istant electrical storm, even after acute MIBnsch 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,
