AMI合并心律失常的分析與處理

AMI合并心律失常的分析與處理屈百鳴急性心肌梗塞定義心肌梗塞是心肌由于嚴(yán)重缺血引起的不可逆損傷，又稱心肌梗死。合并心律失常早期晚期ST段抬高的心肌梗死院內(nèi)死亡率

CCUISIS-1,-2GUSTOIGISSI-1,-2ASSET溶栓治療ZWOLLEPAMIGUSTOIIbFRESCOPASTAprimaryPCI心律失常分類(lèi)緩慢型心律失常

房室傳導(dǎo)阻滯

竇房結(jié)病變快速型心律失常室性心律失常室上性心律失常AMI合并心律失常

的急診處理AMI合并心律失常

——房室傳導(dǎo)阻滯多見(jiàn)于下壁心肌梗死多數(shù)能恢復(fù)處理

臨時(shí)起搏器/永久起搏器藥物：阿托品、腎上腺素、異丙腎上腺素增加住院期間的死亡率，不影響增加住院期間死亡率，不影存活者的長(zhǎng)期死亡率心臟的起搏、傳導(dǎo)系統(tǒng)間隔支冠脈病變致AVBCase，男，73歲動(dòng)態(tài)心電圖：有間隙性２度２型房室傳導(dǎo)阻滯．AMI合并室上性心律失常房早、房速、房撲房顫AMI合并室性心律失常的急診處理室早、VT、VFJ波綜合癥(JWS)與ACS500-50-1000 100 200 300 400 500(1)(2)(3)(4)閾值閾值VNa+VK+Na+K+K+K+K+Na+Ca++Na+Cl-Ca++Na+Na+K+mhNa+門(mén)鈉泵401234外膜內(nèi)穿膜電位(mv)J波綜合癥(JWS)(CASE3)男性58歲陣發(fā)胸悶伴暈厥3天入院CAG:前降支中段30%狹窄，左室造影：心尖部運(yùn)動(dòng)減弱DCG記錄：間歇性ST-T改變，JWS伴短陣多形VT診斷：冠心病，自發(fā)性心絞痛(變異型心絞痛)，JWS，室性心律失常JWS(CASE3)JWS(CASE3)60M陣發(fā)胸痛1天，有高血壓史10年。發(fā)作前心電圖（7時(shí)58分）CASE2ISCDAMI合并室性心律失常

無(wú)脈室速/室撲/室顫缺血性心臟猝死AMI合并室性心律失常

非持續(xù)性室速&室性自主心律二者都不是VF早期的預(yù)示標(biāo)志

加速的室性自主心律與再灌注有關(guān)一般不需要處理右室流出道和左室間隔室早室早V1呈LBBB圖形，II、III、AVF主波向上，高大，來(lái)源于右室流出道。室早V1呈RBBB圖形，II、III、AVF和V5、V6呈rS型，，來(lái)源于左室間隔近心尖處。急性心肌缺血與心律失常CASE1AMI合并室性心律失常

不穩(wěn)定持續(xù)性室速反復(fù)VTAMI合并室性心律失常

多形室速Q(mào)T間期延長(zhǎng)強(qiáng)調(diào)糾正電解質(zhì)紊亂臨時(shí)起搏補(bǔ)鎂、異丙腎上腺素、苯妥英、利多卡因PCI和CABGAMI合并室性心律失常的治療血運(yùn)重建積極的血運(yùn)重建減少ACS事件早期VF（48小時(shí)內(nèi)）AMI合并室性心律失常的治療

血運(yùn)重建AMI合并室性心律失常的急診處理積極、及時(shí)血運(yùn)重建!

預(yù)防性應(yīng)用利多卡因可減少VF的發(fā)生，但似乎增加死亡率，很大程度上被淘汰，恰當(dāng)用B阻滯劑預(yù)防AMI減少VF發(fā)生被鼓勵(lì)，同樣鼓勵(lì)糾正低鎂和低鉀血癥，以減少電解質(zhì)紊亂而誘發(fā)的VF，AMI合并心律失常

后期評(píng)估與猝死預(yù)防心梗后死亡率與時(shí)間的關(guān)系

在β-受體阻滯劑時(shí)代，心梗后SCD的發(fā)生率1700位心梗后患者;其中約95%出院后2年內(nèi)長(zhǎng)期服用β-受體阻滯劑SCD的發(fā)生情況與以往的研究結(jié)果有所不同心律失常事件并未集中在心梗早期，大部分發(fā)生在心梗18個(gè)月以后1HuikuriHV.JAmCollCardiol.2003;42:652-658.Total

MortalityCardiac

MortalityNon-SCDSCDCumulativeEvents(%)181512963181512963204060204060Follow-Up(months)Follow-Up(months)心臟擴(kuò)大EF下降與SCD左室射血分?jǐn)?shù)（LVEF）已成為評(píng)估SCA非常重要的獨(dú)立危險(xiǎn)因素1LVEF<30%的患者發(fā)生SCA的危險(xiǎn)性極高

1MyerbergRJ,CastellanosA.Cardiacarrestandsuddencardiacdeath.BraunwaldE.HeartDisease,ATextbookofCardiovascularMedicine.5thed,Vol.Philadelphia:WBSaundersCo;1997:chapter24..不同程度心衰的死亡原因1MERIT-HFStudyGroup.EffectofMetoprololCR/XLinchronicheartfailure:MetoprololCR/XLrandomizedinterventiontrialincongestiveheartfailure(MERIT-HF).LANCET.1999;353:2001-2007.NYHAClassIIIn=103NYHAClassIIn=103NYHAClassIVn=2764%12%24%11%56%33%59%15%26%NYHAII/III級(jí)的患者的主要死因?yàn)镾CA，而NYHAIV級(jí)的患者大多死于心衰MI后心律失常的檢查

心超MI合并VA心功能評(píng)估T波電交替(TVA)，特別是微伏級(jí)的TWA平均信號(hào)心電圖(SAECG)、心率變異(HRV)、心率震蕩(IIbLevelofEvidence:B)心室晚電位“l(fā)atepotentials”QTc心率減速I(mǎi)IIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBMI后心律失常的

心臟電生理檢查診斷評(píng)估陳舊性MI患者癥狀提示室速，如心悸、暈厥先兆、暈厥冠心病VT患者消融指導(dǎo)和效果評(píng)估有助于診斷評(píng)價(jià)冠心病患者機(jī)制不明的寬QRS心動(dòng)過(guò)速陳舊性MI，非持續(xù)性室速，LVEF低于或接近40%的危險(xiǎn)分層IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB急性心肌梗塞后期

室性心律失常的治療ACC/AHA/ESC2006GuidelinesforManagementofPatientsWithVentricularArrhythmiasandthePreventionofSuddenCardiacDeathAMI后合并室性心律失常

心肌梗塞后左心功能障礙積極治療心衰積極治療心肌缺血血運(yùn)重建減少直接明確急性心肌缺血證據(jù)的VF存活患者SCD。不能或沒(méi)有完成血運(yùn)重建的MI后明顯左心功能低下，VF存活者長(zhǎng)期優(yōu)化藥物治療預(yù)計(jì)存活>1年，ICD為一線治療。推薦ICD一級(jí)預(yù)防，減少M(fèi)I（>40d）后左心功能低下（EF30~40%，NYHAII~III級(jí))接受長(zhǎng)期優(yōu)化藥物治療，預(yù)計(jì)存活>1年患者的猝死，降低死亡率MI后左心功能低下，血流動(dòng)力學(xué)不穩(wěn)定VT，接受長(zhǎng)期優(yōu)化藥物治療，預(yù)計(jì)存活>1年患者，ICD治療減少猝死，降低死亡率IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAACC/AHA/ESC2006GuidelinesforManagementofPatientsWithVentricularArrhythmiasandthePreventionofSuddenCardiacDeathAMI合并室性心律失常

心肌梗塞后左心功能障礙IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICACC/AHA/ESC2006GuidelinesforManagementofPatientsWithVentricularArrhythmiasandthePreventionofSuddenCardiacDeathAMI合并室性心律失常

心肌梗塞后左心功能障礙IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICACC/AHA/ESC2006GuidelinesforManagementofPatientsWithVentricularArrhythmiasandthePreventionofSuddenCardiacDeathAMI合并室性心律失常預(yù)防性治療無(wú)癥狀的非持續(xù)性室速?zèng)]有減少死亡率的證據(jù)IC類(lèi)抗心律失常藥不宜用于有心肌梗死史的患者IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIA盡管給予理想的藥物治療，心衰患者的猝死率仍非常高1,2,3,41MERIT-HFStudyGroup.EffectofmetroprololCR/XLinchronicheartfailure.Lancet.1999;353:2001-2007.2CIBISInvestigationsandCommittees.ThecardiacinsufficiencybisprololstudyII(CIBIS-II).Lancet.1999;353:9-13.3PackerM,BristowMR,CohnJN,etal.Theeffectofcarvedilolonmorbitityandnortalityinpatientswithchronicheartfailure.U.S.CarvedilolHeartFailureStudyGroup.NEnglJMed.1996;334:1349-1355.4TheRALEInvestigators.Effectivenessofspironolactoneaddedtoananiotensin-convertingenzymeinhibitorandaloopdiureticforseverechroniccongestiveheartfa