心源性猝死的预防和治疗 共38页PPT资料
合集下载
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
CHF Other Sudden Death
MERIT-HFStudy Group. LANCET. 2019;353:2019-2019.
NYHA Class IV n = 27
• Myocardial infarction and SCD
– Acute phase: ischemia-provoked VF; or mechanical dysfunctions (e.g. ventricular or papillary rupture)
Sensitivity Specificity PPV
NPV
PA
Microvolt -TWA 83%
83%
9%
99.6%
83%
Nonsustained 44%
83%
7%
98.8%
88%
VT
Ventricular late 35%
91%
7%
98.6%
90%
potentials
So what we do?
• ICD vs placebo • Median follow-up of 45
months
SCD- HeFT
Bardy et al. N Eng J Med 2019; 352 (3): 225
All patients 30
25
Nonischemic patients
27
23
Ischemic patients
MADIT II
– Randomized trial evaluating the effect of an implantable defibrillator on survival
– Patients: prior MI (> 4 weeks); left ventricular EF <30%; >21 years
• The most important criterion is reduced left ventricular function
– LVEF<35% and 40 days after MI
Prevention of SCD
– Anti-arrhythmic drugs
• Amiodarone is probably the most effective drug for secondary prevention of VT – Marginally reduce SCD and mortality
– Patients randomly assigned in a 3:2 ratio to receive ICD or conventional medical therapy
MADIT-II
• Trial started July 8, 2019 • Trial stopped prematurely in November 20,
0.1
0
0
1
2
3
4
5
Time after Enrollment (Years)
Buxton AE. N Engl J Med. 2019;341:1882-90.
MUSTT Results
• Therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease
– Chronic phase: structural remodelling of the LV, leading to re-entry or heart failure
Risk stratification of SCD
• Risk assessment – Clinical data
• Aetiology; family history; LVEF
Sudden Cardiac Death: Prevention and Treatment
Lexin Wang, M.D., Ph.D. Professor of Clinical Pharmacology
Head, Cardiovascular Research
Incidence of SCD
• Half of these early survivors die before discharge
Risk Factors of SCD
• Left ventricular failure
– CHD, cardiomyopathy
• Sudden cardiac death syndromes
MUST: Arrhythmic Death or Cardiac Arrest
0.5
EP-Guided Rx, No ICD No EP-Guided AA Rx EP-Guided Rx, ICD
0.4 p < 0.001
0.3
Event Rate
0.2
0.1
0
0
1
2
3
4
5
Time after Enrollment (Years)
*ion-channel abnormalities, valvular or congenital heart disease, other causes
Prevalence of arrhythmia at SCD
TdP 13%
Monomorphic VT 62%
Bradycardia 17% Primary VF 8%
2019 because ICD saved lives • 1,232 patients enrolled from 76 centers in
U.S. and Europe
MADITT II- Mortality
•
CONV
•
(n=490)
DEFIB
(n=742)
• Deaths
97 [19.8%]
0.9
Defibrillator 0.8
0.7
Conventional
P = 0.007 0.6
0.0
0
1
2
3
4
No. At Risk
Year
Defibrillator 742
502 (0.91) 274 (0.94) 110 (0.78)
9
Conventional 490
329 (0.90) 170 (0.78)
– ICD
• Most effective when LVEF<30%
– Other
• Surgery
– Long QT () – Ventricular aneurysm, heart transplant
• Catheter ablation
Prevention of SCD
105 [14.2%]
•
---------------------------------
• Hazard Ratio (ICD:CONV) • (95% CI) • P-value
•
0.69 (31% mortality) (0.51, 0.93) 0.016
1.0
MADIT-II
Probability of Survival
AVID MADIT
MUSTT
MADIT-II
DEFINITE
SCD-HeFT
90’
95’
2000’
MUSTT
– Multicenter Unsustained Tachycardia Trial (MUSTT), a randomized controlled trial
– Can electrophysiologically guided antiarrhythmic therapy reduce the risk of sudden death?
– Looked at coronary artery disease patients with a left ventricular ejection fraction <40% and asymptomatic unsustained ventricular tachycardia
Buxton AE. Prog in Cardiovasc Dis 1993;3:215-226
65 (0.69)
3
Moss AJ. N Engl J Med. 2019;346:877-83.
SCD-HeFT
– Sudden Cardiac Death in Heart Failure Trial (SCDHeFT)
• NYHA class 2-3 HF and LVEF <35%
• Largest internalcardioverter-defibrillator (ICD) trial ever conducted
Buxton AE. N Engl J Med. 2019;341:1882-90.
MUSTT: Total Mortality
0.6
EP-Guided Rx, No ICD
No EP-Guided Rx
0.5
EP-Guided Rx, ICD
p < 0.001 0.4
Event Rate
0.3
0.2
• SCD (caused by sudden cardiac arrest) is the most common cause of death in Western societies
• Incidence: 300,000 to 400,000 each year (U.S.) only 2% – 15% reach the hospital
15% cardiomyopathy
80% CAD
Huikuri HV. N Engl J Med. 2019;345:1473-1482.
Myerburg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. W.B. Saunders, Co. 2019.
21
End point (%)
20
• Secondary
Prevention in those who had a history of SCA
• Primary
Prevention in those with a high risk but no history of SCA
Second二ar级y
Primary
80’
85’
CIDS CASH
– EPS
• T wave alternans • QT dispersion • Arrhythmia during Holter monitoring or
stress test
Ideka T, et al JACC 2019; 48:2268
Predictive values of positive TWA, nonsustained VT and ventricular Late potentials
1.4%
>50%
Causes of deaths in HF: mainly SCD in NYHA II-III, heart failure in NYHA IV
12%
64%
2Hale Waihona Puke %59%26% 15%
NYHA Class II n = 103
33% 11%
56%
NYHA Class III n = 103
– Long QT syndromes – Brugada syndrome – Polymorphic catecholaminergic VT – Isolated ventricular fibrillation
CAD has become a main cause of SCD
5% other*
– A total of 15% of CHF patients die of SCD
% SCD Victims
8
7.5%
7
6
5
4
3
2•
1
0
0-30%
LVEF and SCD
5.1%
2.8%
31-40%
41-50%
LVEF
Gorgels, PMA. Eur Heart J .2019;24:1204-1209.
Bayés de Luna A. Am Heart J. 1989;117:151-159.
Heart Failure and SCD
• More than one million new heart failure patients every year in the USA – 25% mortality in 2.5 years in moderate to severe CHF
MERIT-HFStudy Group. LANCET. 2019;353:2019-2019.
NYHA Class IV n = 27
• Myocardial infarction and SCD
– Acute phase: ischemia-provoked VF; or mechanical dysfunctions (e.g. ventricular or papillary rupture)
Sensitivity Specificity PPV
NPV
PA
Microvolt -TWA 83%
83%
9%
99.6%
83%
Nonsustained 44%
83%
7%
98.8%
88%
VT
Ventricular late 35%
91%
7%
98.6%
90%
potentials
So what we do?
• ICD vs placebo • Median follow-up of 45
months
SCD- HeFT
Bardy et al. N Eng J Med 2019; 352 (3): 225
All patients 30
25
Nonischemic patients
27
23
Ischemic patients
MADIT II
– Randomized trial evaluating the effect of an implantable defibrillator on survival
– Patients: prior MI (> 4 weeks); left ventricular EF <30%; >21 years
• The most important criterion is reduced left ventricular function
– LVEF<35% and 40 days after MI
Prevention of SCD
– Anti-arrhythmic drugs
• Amiodarone is probably the most effective drug for secondary prevention of VT – Marginally reduce SCD and mortality
– Patients randomly assigned in a 3:2 ratio to receive ICD or conventional medical therapy
MADIT-II
• Trial started July 8, 2019 • Trial stopped prematurely in November 20,
0.1
0
0
1
2
3
4
5
Time after Enrollment (Years)
Buxton AE. N Engl J Med. 2019;341:1882-90.
MUSTT Results
• Therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease
– Chronic phase: structural remodelling of the LV, leading to re-entry or heart failure
Risk stratification of SCD
• Risk assessment – Clinical data
• Aetiology; family history; LVEF
Sudden Cardiac Death: Prevention and Treatment
Lexin Wang, M.D., Ph.D. Professor of Clinical Pharmacology
Head, Cardiovascular Research
Incidence of SCD
• Half of these early survivors die before discharge
Risk Factors of SCD
• Left ventricular failure
– CHD, cardiomyopathy
• Sudden cardiac death syndromes
MUST: Arrhythmic Death or Cardiac Arrest
0.5
EP-Guided Rx, No ICD No EP-Guided AA Rx EP-Guided Rx, ICD
0.4 p < 0.001
0.3
Event Rate
0.2
0.1
0
0
1
2
3
4
5
Time after Enrollment (Years)
*ion-channel abnormalities, valvular or congenital heart disease, other causes
Prevalence of arrhythmia at SCD
TdP 13%
Monomorphic VT 62%
Bradycardia 17% Primary VF 8%
2019 because ICD saved lives • 1,232 patients enrolled from 76 centers in
U.S. and Europe
MADITT II- Mortality
•
CONV
•
(n=490)
DEFIB
(n=742)
• Deaths
97 [19.8%]
0.9
Defibrillator 0.8
0.7
Conventional
P = 0.007 0.6
0.0
0
1
2
3
4
No. At Risk
Year
Defibrillator 742
502 (0.91) 274 (0.94) 110 (0.78)
9
Conventional 490
329 (0.90) 170 (0.78)
– ICD
• Most effective when LVEF<30%
– Other
• Surgery
– Long QT () – Ventricular aneurysm, heart transplant
• Catheter ablation
Prevention of SCD
105 [14.2%]
•
---------------------------------
• Hazard Ratio (ICD:CONV) • (95% CI) • P-value
•
0.69 (31% mortality) (0.51, 0.93) 0.016
1.0
MADIT-II
Probability of Survival
AVID MADIT
MUSTT
MADIT-II
DEFINITE
SCD-HeFT
90’
95’
2000’
MUSTT
– Multicenter Unsustained Tachycardia Trial (MUSTT), a randomized controlled trial
– Can electrophysiologically guided antiarrhythmic therapy reduce the risk of sudden death?
– Looked at coronary artery disease patients with a left ventricular ejection fraction <40% and asymptomatic unsustained ventricular tachycardia
Buxton AE. Prog in Cardiovasc Dis 1993;3:215-226
65 (0.69)
3
Moss AJ. N Engl J Med. 2019;346:877-83.
SCD-HeFT
– Sudden Cardiac Death in Heart Failure Trial (SCDHeFT)
• NYHA class 2-3 HF and LVEF <35%
• Largest internalcardioverter-defibrillator (ICD) trial ever conducted
Buxton AE. N Engl J Med. 2019;341:1882-90.
MUSTT: Total Mortality
0.6
EP-Guided Rx, No ICD
No EP-Guided Rx
0.5
EP-Guided Rx, ICD
p < 0.001 0.4
Event Rate
0.3
0.2
• SCD (caused by sudden cardiac arrest) is the most common cause of death in Western societies
• Incidence: 300,000 to 400,000 each year (U.S.) only 2% – 15% reach the hospital
15% cardiomyopathy
80% CAD
Huikuri HV. N Engl J Med. 2019;345:1473-1482.
Myerburg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. W.B. Saunders, Co. 2019.
21
End point (%)
20
• Secondary
Prevention in those who had a history of SCA
• Primary
Prevention in those with a high risk but no history of SCA
Second二ar级y
Primary
80’
85’
CIDS CASH
– EPS
• T wave alternans • QT dispersion • Arrhythmia during Holter monitoring or
stress test
Ideka T, et al JACC 2019; 48:2268
Predictive values of positive TWA, nonsustained VT and ventricular Late potentials
1.4%
>50%
Causes of deaths in HF: mainly SCD in NYHA II-III, heart failure in NYHA IV
12%
64%
2Hale Waihona Puke %59%26% 15%
NYHA Class II n = 103
33% 11%
56%
NYHA Class III n = 103
– Long QT syndromes – Brugada syndrome – Polymorphic catecholaminergic VT – Isolated ventricular fibrillation
CAD has become a main cause of SCD
5% other*
– A total of 15% of CHF patients die of SCD
% SCD Victims
8
7.5%
7
6
5
4
3
2•
1
0
0-30%
LVEF and SCD
5.1%
2.8%
31-40%
41-50%
LVEF
Gorgels, PMA. Eur Heart J .2019;24:1204-1209.
Bayés de Luna A. Am Heart J. 1989;117:151-159.
Heart Failure and SCD
• More than one million new heart failure patients every year in the USA – 25% mortality in 2.5 years in moderate to severe CHF