室性心律失常的临床处理,贵州省人民医院 杨 龙,内容,特发性室性早搏 特发性室性心动过速 获得性尖端扭转型室速 急性心肌梗死相关室速 慢性心力衰竭相关室速,一、特发性室性早搏,治疗与否？ 药物？消融？,（一）选择治疗的理由,症状。 心脏重构：导致心脏扩大、心功能减退。,In patients with frequent PVCs and no organic heart disease, who are at low risk of sudden cardiac death, a decrease in QOL(Quality Of Life) and severity of symptoms are the main indications for treatment with antiarrhythmic agents .,Zipes DP, et al. J Am Coll Cardiol, 2006. Aliot EM, et al. Heart Rhythm, 2009.,Two hundred and thirty-nine consecutive patients presenting with frequent PVCs (1000 beats/day) originating from the RVOT or LVOT without any detectable heart disease were enrolled in the study. During an observation period of 5.6 (1.7) years, there was a significant negative correlation between the PVC prevalence and Delta LVEF (p0.001) and positive correlation between the PVC prevalence and Delta LVDd (p 20,000 beats/day) or baseline decreased LVEF exhibit a significant decrease in LVEF during long-term follow-up.,Niwano S, et al. Heart,2009. Bogun F, et al. Heart Rhythm, 2007.,The use of metoprolol, propafenone and verapamil is recommended in patients with PVCs of RVOT origin.,Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Am Coll Cardiol, 2006.,（二）药物治疗,Beta-blockers have been tested in patients with idiopathic PVCs. Their efficacy was modest (25% for metoprolol) or not superior to a placebo (atenolol) .,Capucci A, et al. Clin Cardiol, 1989. Saikawa T, et al. Jpn Heart J, 2001. Krittayaphong R, et al.Am Heart J, 2002.,Patients were included in the study if they had: (1) symptomatic ( 4 weeks) monomorphic PVCs 2,500/24 h; or (2) persistent ( 3 months) monomorphic PVCs 2,500/24 h with similar PVCs (65岁 心脏病：各种基础心脏病 QT间期：原有QT/QTc延长 电解质：低钾、低镁 室性心律失常：室早、短长短现象 警告性心电图：QT延长、TU波变形、T波电交替 药物：服用一种或一种以上延长QT药物 其他：缓慢性心律失常,一旦发生TdP及室颤，迅速采取有效措施（12字方针） 停药 除颤 补镁 （2-4g） 补钾 （4.5mmol/L） 起搏 提高心率（90ppm） 药物 提高心率（异丙肾等）,TdP抢救及治疗措施,四、急性心肌梗死相关室性心律失常,2012 Ventricular arrhythmias,（一）Ventricular premature beats,心梗首日几乎皆发生PVC，表现形式多样，如多形态、RonT，并非VF预兆，无需特殊治疗。,（二）Ventricular tachycardia,非持续性室速（NSVT ；lasting 30 s）并非预测VF发作的可靠因子，通常可耐受。 没有证据支持抑制无症状NSVT能改善存活率；不提倡特别针对NSVT抗心律失常治疗，除非伴随血流动力学不稳定。,如果持续存在的心肌缺血导致的VT引起血流动力学不稳定，可静脉推注amiodarone, sotalol 或lidocaine以期终止，但成功率低。 对心梗合并左室功能减退者，amiodarone是唯一一种无严重致心律失常作用的抗心律失常药，因此对此类患者优先选择。,（三）Ventricular fibrillation,lidocaine可减少AMI者VF的发生率，但有增加心脏停搏的危险。 对于持续VT或VF反复发作3小时以上AMI患者，amiodarone增加死亡率, 而lidocaine不增加。,