室性心律失常的药物治疗

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1、室性心律失常的药物治疗目前的困惑与挑战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SuddenCardiacDeathAMajorPublicHealthProblem1/2ofallcardiacdeaths1/7ofalldeathsLeadingCausesofDeathintheUSSCDisaleadingcauseofdeathintheU.S.,secondtoallcancerscombinedSuddenCardiacDeath(SCD)SepticemiaNephritisAlzheimer’sDiseaseInfluenza/PneumoniaDiabet

2、esAccidents/InjuriesChronicLowerRespiratoryDiseasesCerebrovascularDiseaseOtherCardiacCausesAllCancers20%25%NationalVitalStatisticsReport,Vol49(11),Oct.12,2001State-specificmortalityfromsuddencardiacdeath–UnitedStates1999.MMWR.2002,51:123-12615%10%5%0%Atleast335,000SCDintheU.S.eachyearOnly5to10%su

3、rviveafterfirstepisodeofSCDRoughlytwo-thirdsofSCDout-of-hospitalSCDSurvival&MortalityDataSeidlK,SengesJ.CardElectrophysiolRev.2003;7:5-13HeartDiseaseandStrokeStatistics—2005Update.AHA.www.americanheart.orgCrespoEM,KimJ,SelzmanKA.AmJMedSci.2005;329:238-246ZhengZJ,etal.Circulation.2001;104:2158-216

4、3Zipes,DP,etal.2006ACC/AHA/ESCPracticeGuidelines5.Circulation.2006;114;385-484ArrhythmicCauseofSCDAlbertCM.Circulation2003,107:2096-210112%OtherCardiacCause88%ArrhythmicCauseBradycardia17%PrimaryVF8%VT62%BayésdeLunaA.AmHeartJ1989,117:151-159TorsadesdePointes13%UnderlyingArrhythmiasofSudd

5、enCardiacArrest室性心律失常的治疗措施药物治疗电复律和电除颤心律转复除颤器(ICD)射频导管消融外科手术治疗基因治疗室性心律失常的药物治疗药物选择依据基础心脏病变心功能状态药物副作用总体死亡率室性心律失常药物治疗的副作用I类奎尼丁，普鲁卡因酰胺：毒副作用较大恩卡尼，氟卡尼：CAST-I研究发现该药虽可控制心肌梗死患者的心律失常，但服药组的死亡率却明显高于安慰剂组普罗帕酮：消化道不良反应、传导阻滞；致心律失常作用如多形性室速、室颤等；在心肌缺血和心功能不全时耐受性下降；CASH研究中普罗帕酮组死亡率明显高于安慰剂组CAST-IPrognosisofPost-MIPatient

6、sTreatedwithPlacebovs.Encainide/Flecainide80859095100091182273364455DaysafterRandomizationPatientswithoutEvent(%)Placebo(n=743)EncainideorFlecainide(n=755)P=0.001EchtDS.,etal.NEnglJMed1991;324:781-788TheCardiacArrestStudyHamburg(CASH)AssignmenttopropafenonewasdiscontinuedontherequestoftheSafetyM

7、onitoringBoardinMarch1992,afteraninterimanalysisconductedon58patientsshoweda61%higherall-causemortalityratethanin61ICDpatientsduringafollow-upof11.3monthsKuck.etal.Circulation2000;102:748-754室性心律失常药物治疗的副作用II类ß受体阻滞剂：心动过