(宋尚明)缓慢性心律失常的诊治.ppt

Danish 研究：慢性房颤 Danish 研究结论 对于SND患者而言，AAI起搏比VVI起搏 : 降低总死亡率 降低心血管死亡率 减少心衰发生 减少房颤发生 减少血栓事件 SND患者随访期间AVB发生率 Study Mean Follow-Up Time Incidence of AVB Annualized Incidence Rosenqvist 1989 (literature review) 3 years Median 2.1% Range: 0-11.9% Median: 0.6% Range: 0-4.5% Andersen 1997 8 years 3.6% 0.6% Brandt 1992 5 years 8.5% 1.8% Sutton 1986 3 years 8.4% 2.8% Rosenqvist 1986 2 years 4.0% 2.0% Rosenqvist 1985 5 years 3.3% 0.7% Hayes 1984 3 years 3.4% 1.1% SND患者AAI起搏条件 PR间期正常 无束支或分支阻滞 文氏点120次/分 SND患者双腔起搏更符合生理要求？ AV同步 房颤减少 心衰降低 生活质量提高 DDD或DDDR起搏问题：心室不同步 心房灌注压升高 心室充盈降低 心室舒张末压增高 心室不对称肥厚 房颤发生率上升 诱发心室 诱发室性心律失常 增加死亡率 MOST 研究：DDDR起搏机会与房颤发生 Randomized to DDDR mode, baseline QRSd 120 ms Sweeney MO, et al. Circulation 2003;23:2932-2937 MOST 研究：心室起搏比例与心衰住院 1339 Normal QRS duration patients from MOST Association between Cum Vp and risk for HF Sweeney MO, et al. Circulation 2003 Notable Changes in 2008 ACC/AHA/HRS Guidelines ICD recommendations are combined into a single list because of overlap between primary and secondary indications. Primary prevention ICD indications in nonischemic cardiomyopathy are clarified using data from SCD-HeFT (i.e., ischemic and nonischemic cardiomyopathies and LVEF ≤35%, NYHA II-III) for support. Indications for ICD therapy in inherited arrhythmia syndromes and selected nonischemic cardiomyopathies are listed. MADIT II indication (i.e., ischemic cardiomypathy and LVEF ≤30%, NYHA I) is now Class I, elevated from Class IIa. EF criteria for primary prevention ICD indications are based on entry criteria for trials on which the recommendations are based. Emphasized primary SCD prevention ICD recommendations apply only to patients receiving optimal medical therapy and reasonable expectation of survival with good functional capacity for 1 year. Independent risk assessment preceding ICD implantation is emphasized, including consideration of patient preference. Optimization of pacemaker programming to minimize unneeded RV pacing is encouraged. Pacemaker in