同济医院：《心律失常》威胁生命的室性心律失常治疗的循证基础

威胁生命的室性心律失常治疗的 循证基础 A satellite sympsoium XXth Congress of the EsC, vienna. Aug 1998

威胁生命的室性心律失常治疗的 循 证 基 础 A satellite sympsoium. XXth Congress of the ESC, Vienna. Aug.1998

室性心律失常 级预防( Secondary Prevention) 已有威胁生命的室性心律失常史 y一级预防( Primary Prevention) 有危险因素但尚未有快速室性心律失常发作

室性心律失常 v 二级预防 (Secondary Prevention) 已有威胁生命的室性心律失常史 v 一级预防（Primary Prevention） 有危险因素但尚未有快速室性心律失常发作

表抗心律失常治疗对猝死二级预防的研究汇总 Trials Therapy Study Size All-cause mortality Population (F-U duration) CASCADE Empirical amiodarone vsIF202 Including resuscitated VF and Cardiac arrest guided conventional (6 years) syncopal defibrillator shocks 47% survivors antiarrhythmic therapy vS 60%(guided therapy)P=0.007 Wever Implantable defibrillator n60 Including sudden circulatory Cardiac arrest as first choice (24 months) arrest and terminal pump failure survIvors 14% vs 35%(control) p=0.02 AVID Implantable defibrillator F1016 158%V24.0% Patients resuscitated vs class Ill drugs (18.2 months) from cardiac arrest or (mainly amiodarone) P<0.02 poorly tolerated VT CASH Groups: implantable m346 Propafenone limb nterrupted due Cardiac arrest defibrillator, amiodarone,(2 years) to excess mortality 12. 1% vS survIvorS metoprolol, Propafenone .6%(drug limb CIDS Implantable defibrillator=659 25%w30% Cardiac arrest vs amiodarone (3 years) (amiodarone) survivors and patients p=0.072 with poorly tolerated 月前支持用CDs进行二级预防,CDs已成为心脏猝死病 人复苏后首选的预防措施

Trials Therapy Study Size All-cause mortality Population (F-U duration) CASCADE Wever et al AVID CASH CIDS Empirical amiodarone vs guided conventional antiarrhythmic therapy Implantable defibrillator as first choice Implantable defibrillator vs class III drugs (mainly amiodarone) Groups:implantable defibrillator, amiodarone, metoprolol, Propafenone Implantable defibrillator vs amiodarone n=202 (6 years) n=60 (24 months) n=1016 (18.2 months) n=346 (2 years) n=659 (3 years) Including resuscitated VF and syncopal defibrillator shocks 47% vs 60% (guided therapy) P=0.007 Including sudden circulatory arrest and terminal pump failure 14% vs 35% (control) p=0.02 15.8% vs 24.0% (drugs) P<0.02 Propafenone limb interrupted due to excess mortality 12.1% vs 19.6% (drug limb) p=0.047 25% vs 30% (amiodarone) p=0.072 Cardiac arrest survivors Cardiac arrest survivors Patients resuscitated from cardiac arrest or poorly tolerated VT Cardiac arrest survivors Cardiac arrest survivors and patients with poorly tolerated VT 表 I 抗心律失常治疗对猝死二级预防的研究汇总 结 论: 目 前 支 持 用ICDs 进 行 二 级 预 防，ICDs 已 成 为 心 脏 猝 死 病 人 复 苏 后 首 选 的 预 防 措 施

级预防研究的主要对象 无威胁生命快速室性心律失常发作史 心肌梗塞后 y心力衰竭,EF↓ 频发室早伴晚电位阳性、HRV √电生理诱发+ 级预防以药物为主,CD?

v 无威胁生命快速室性心律失常发作史 v 心肌梗塞后 v 心力衰竭，EF↓↓ v 频发室早伴晚电位阳性、HRV↓ v 电生理诱发 + 一级预防以药物为主，ICD？ 一级预防研究的主要对象

表抗心律失常治疗对猝死一级预防的研究汇总 Trials Therapy Study Size(F-U duration! All-cause mortality Population CAST I Encainide/ n=1455(300days) 7,7%w3.0%(PL)p<0.001 Post-MI lowered LVEF complex VEA cAsT‖ n =1325(18 months) Early SD: 17 VS 3(PL)p<0.02 Post-MI LVEF <40% SWORD d-Sotalol n=3121(18 months) 50%31%(PLp<0.01 Post-MI LVEF≤40% EMIATAmiodarone n=1486(21 months) 13.9%Vs 13.7%(PL)=NSPost-MI LVEF<40% CAMIAT Amiodarone n=1202(1.79 years I 6.2% VS 8.3%(PL)p=NS Post-MI complex VEA GESICA Amiodarone n=516(24 months 33.5% Vs 41.4%(control) p<0.3 CHF LVEF $35% STAT-CHFI Amiodarone n=674(45 months) 39%s42%(PL)p=NS CHF10 VPCs/hour MADIT Implantable n=196(27 months) 15%vs 38%(control) p=0.009 Post-MI LVEF <% defibrillator NSVT Inducible. non- suppressible VT CABG Implantable n=900(32 months) 22.6%vs 20.9%(control) p=NS Coronary bypass Patch trial defibrillator surgery patients LVEF ≤35% Abnormal SA ECG 级预防以药物为主,IcD?

Trials Therapy Study Size (F-U duration) All-cause mortality Population CAST I CAST II SWORD EMIAT CAMIAT GESICA STAT-CHF MADIT CABG Patch trial n=1455 (300 days) n=1325 (18 months) n=3121 (18 months) n=1486 (21 months) n=1202 (1.79 years) n=516 (24 months) n=674 (45 months) n=196 (27 months) n=900 (32 months) Post-MI lowered LVEF complex VEA Post-MI LVEF≤40％ Post-MI LVEF≤40％ Post-MI LVEF≤40％ Post-MI complex VEA CHF LVEF ≤35% CHF10 VPCs/hour Post-MI LVEF ≤35% NSVT Inducible, non￾suppressible VT Coronary bypass surgery patients LVEF ≤35% Abnormal SA￾ECG Encainide/ Flecainide Moricizine d-Sotalol Amiodarone Amiodarone Amiodarone Amiodarone Implantable defibrillator Implantable defibrillator 7.7% vs 3.0% (PL) p<0.001 Early SD: 17 vs 3 (PL) p<0.02 5.0% vs 3.1% (PL) p<0.01 13.9% vs 13.7% (PL) p=NS 6.2% vs 8.3% (PL) p=NS 33.5% vs 41.4% (control) p<0.3 39% vs 42% (PL) p=NS 15% vs 38% (control) p=0.009 22.6% vs 20.9% (control) p=NS 表II 抗心律失常治疗对猝死一级预防的研究汇总 一级预防以药物为主，ICD？

胺碘酮适宜于一级预防 √广泛电生理作用 ∨有效的抗心律失常作用 ∨良好的血液动力学作用 最低的致心律失常作用

胺碘酮适宜于一级预防 v 广泛电生理作用 v 有效的抗心律失常作用 v 良好的血液动力学作用 v 最低的致心律失常作用

ATMA胺碘酮研究荟萃分析 Effect of prophylactic amiodarone on mortality after acute mycardial infarction and in congestive heart failure meta-analysis of individual data from 6500 patients in randomised trials Amiodarone Trials Meta-A nalysis Investigators > .350No.9089Nov.1997

ATMA 胺碘酮研究荟萃分析 Effect of prophylactic amiodarone on mortality after acute mycardial infarction and in congestive heart failure: meta-analysis of individual data from 6500 patients in randomised trials Amiodarone Trials Meta-Analysis Investigators > Vol.350 No. 9089 Nov. 1997

ATMA13个研究的结果综述 研究(索引) 总死亡率 EMIAT(8) CAMIAT(7) GEMICA(9) 相关性检验P=0.030 PAT(10) 异源性检验P=0.058 BASIS(12) HOCKING CAMIAT-P(14) CHFSTAT(15 EPAMSA(17) NICKLAS(18) R(19) 总括 087(95%c078-0.99) 118 比数比

ATMA13个研究的结果综述 研究(索引) 总死亡率 EMIAT(8) CAMIAT(7) GEMICA(9) PAT(10) SSSD(11) BASIS(12) HOCKINGS(13) CAMIAT-P(14) CHFSTAT(15) GESICA(16) EPAMSA(17) NICKLAS(18) HAMER(19) 总括 相关性检验P=0.030 异源性检验P=0.058 比数比 1/8 1/4 1/2 1 2 4 8 0.87(95% Cl 0.78~0.99)

ATMA13个研究的结果综述 心律失常猝死 研究(索引 EMIAT(8) GEMICA(9) 相关性检验P=0.00026 PAT(10) SSSD(11) 异源性检验P=0.24 BASIS(12) HOCKINGS(13) CAMIAT-P(14) CHFSTAT(15) EPAMSA(17) 4s(18) HAMER(19) 括 0.71(95%c|0.59-0.85) 118 比数比

ATMA13个研究的结果综述 心律失常/猝死 研究(索引) EMIAT(8) CAMIAT(7) GEMICA(9) PAT(10) SSSD(11) BASIS(12) HOCKINGS(13) CAMIAT-P(14) CHFSTAT(15) GESICA(16) EPAMSA(17) NICKLAS(18) HAMER(19) 总括 相关性检验P=0.00026 异源性检验P=0.24 比数比 1/8 1/4 1/2 1 2 4 8 0.71(95% Cl 0.59~0.85)

ATMA死亡的积累风险 25 胺碘酮 总死亡率 20 对照 15 心律失常死 10 0 6 12 24 随机分组时间(月)

ATMA死亡的积累风险 0 3 6 12 18 24 随机分组时间(月) 心律失常/猝死 总死亡率 胺碘酮 对照 累积风险(%) 25 20 15 10 5 0