老年人心臟性猝死是指急性癥狀發作后1小時內發生的以意識突然喪失為特征的由心臟原因引起的自然死(si)亡(wang)(wang)。1979年國(guo)際(ji)心(xin)臟(zang)病(bing)學(xue)會、美國(guo)心(xin)臟(zang)學(xue)會以(yi)及1970年世(shi)界衛生(sheng)組織定義的猝(cu)(cu)死(si)為(wei):急性癥狀發生(sheng)后即刻(ke)或(huo)者情況24小時內發生(sheng)的意外死(si)亡(wang)(wang)。目(mu)前大多數學(xue)者傾(qing)向于將猝(cu)(cu)死(si)的時間限定在(zai)發病(bing)1小時內。其特點有三,①死(si)亡(wang)(wang)急驟,②死(si)亡(wang)(wang)出(chu)人意料(liao),③自然死(si)亡(wang)(wang)或(huo)非暴力死(si)亡(wang)(wang)。
(1)冠心病
冠心病(急性缺血事(shi)件,慢性缺血性心臟病)是心臟性猝(cu)(cu)死的最常(chang)(chang)見(jian)的原因(yin)。對心臟性猝(cu)(cu)死的尸檢(jian)發現,大約80%的患(huan)者(zhe)具有不(bu)同程度的冠狀動(dong)脈(mo)病變,大約2/3以上(shang)的患(huan)者(zhe)為2支或3支以上(shang)的病變。心肌梗(geng)死后伴有左心功能下(xia)降或嚴(yan)重室性心律(lv)失常(chang)(chang)的患(huan)者(zhe),心臟性猝(cu)(cu)死的發生率(lv)顯著(zhu)增(zeng)加。
(2)心肌病
擴張(zhang)型心(xin)(xin)肌(ji)(ji)病(bing)(bing)的心(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)猝(cu)(cu)(cu)死(si)(si)率(lv)為(wei)(wei)2%,在(zai)伴有室(shi)性(xing)(xing)(xing)心(xin)(xin)律失常(chang)時(shi)心(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)猝(cu)(cu)(cu)死(si)(si)率(lv)可明顯增加。而肥厚(hou)性(xing)(xing)(xing)心(xin)(xin)肌(ji)(ji)病(bing)(bing)患者中(zhong)心(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)猝(cu)(cu)(cu)死(si)(si)更常(chang)見。大多(duo)數(shu)學者報(bao)道,肥厚(hou)性(xing)(xing)(xing)心(xin)(xin)肌(ji)(ji)病(bing)(bing)的年病(bing)(bing)死(si)(si)率(lv)為(wei)(wei)3%~4%,其中(zhong)大多(duo)數(shu)為(wei)(wei)心(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)猝(cu)(cu)(cu)死(si)(si)。在(zai)肥厚(hou)性(xing)(xing)(xing)心(xin)(xin)肌(ji)(ji)病(bing)(bing)患者,下(xia)列情形(xing)為(wei)(wei)發生心(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)猝(cu)(cu)(cu)死(si)(si)的高危因(yin)素:①年齡(ling)較輕,在(zai)30歲以下(xia)。②曾有暈厥病(bing)(bing)史。③既往有心(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)猝(cu)(cu)(cu)死(si)(si)的家(jia)族史。此外(wai),各種原因(yin)產生的心(xin)(xin)肌(ji)(ji)病(bing)(bing)和致(zhi)心(xin)(xin)律失常(chang)性(xing)(xing)(xing)心(xin)(xin)肌(ji)(ji)病(bing)(bing)也容(rong)易發生心(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)猝(cu)(cu)(cu)死(si)(si)。
(3)心臟(zang)瓣膜炎(yan)癥浸潤
現已公認(ren),二(er)尖瓣(ban)脫垂(chui)綜合征可發(fa)生心臟性(xing)(xing)(xing)猝(cu)死,但發(fa)生率不高(gao)。據Jersaty報道,二(er)尖瓣(ban)脫垂(chui)患(huan)者伴(ban)有(you)下(xia)列情形者易發(fa)生心臟性(xing)(xing)(xing)猝(cu)死:①40歲左右的(de)女性(xing)(xing)(xing)患(huan)者。②有(you)暈厥(jue)病史。③心電圖(tu)上有(you)ST段(duan)改(gai)變或有(you)頻發(fa)室(shi)性(xing)(xing)(xing)期前收縮等室(shi)性(xing)(xing)(xing)心律(lv)失(shi)常。④有(you)“喀啦”音和(he)收縮晚期或全收縮期雜音。
(4)心律失常
一般(ban)不易發(fa)生(sheng)心(xin)臟(zang)性(xing)(xing)猝死(si)(si),但在(zai)老年(nian)患者,常可并發(fa)嚴重的冠狀動脈狹窄或高血壓致(zhi)嚴重左心(xin)室肥厚(hou)型心(xin)肌病(bing)的左心(xin)室流出(chu)道梗阻時,快(kuai)速性(xing)(xing)室上性(xing)(xing)心(xin)律失常發(fa)作時也易發(fa)生(sheng)心(xin)臟(zang)性(xing)(xing)猝死(si)(si)。
多(duo)數學(xue)(xue)者(zhe)認為(wei)(wei)(wei)(wei)(wei),嚴(yan)(yan)重的(de)(de)(de)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)可(ke)發(fa)(fa)(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si),尤其(qi)(qi)在(zai)患有(you)(you)嚴(yan)(yan)重器(qi)(qi)質性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)病(bing)的(de)(de)(de)老年患者(zhe)。目前(qian)(qian)(qian),室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)在(zai)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)中的(de)(de)(de)意(yi)(yi)義尚存爭(zheng)議。有(you)(you)些(xie)學(xue)(xue)者(zhe)發(fa)(fa)(fa)現(xian),室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)并不(bu)能增(zeng)加(jia)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)發(fa)(fa)(fa)生(sheng)(sheng)率(lv)(lv),尤其(qi)(qi)是無明顯(xian)器(qi)(qi)質性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)病(bing)基(ji)礎的(de)(de)(de)單純性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)。但也有(you)(you)一些(xie)研究提(ti)示,室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)本(ben)身即(ji)是心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)危險因素,特別是嚴(yan)(yan)重的(de)(de)(de)冠狀動(dong)(dong)(dong)脈(mo)病(bing)變(bian)或(huo)(huo)心(xin)(xin)(xin)(xin)(xin)肌梗死(si)(si)(si)后(hou)的(de)(de)(de)患者(zhe),頻發(fa)(fa)(fa)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)對心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)發(fa)(fa)(fa)生(sheng)(sheng)具(ju)有(you)(you)一定的(de)(de)(de)意(yi)(yi)義,特別是合并有(you)(you)左(zuo)心(xin)(xin)(xin)(xin)(xin)室(shi)(shi)(shi)(shi)(shi)(shi)肥厚、室(shi)(shi)(shi)(shi)(shi)(shi)內傳導阻滯(zhi)和(he)(he)(he)(he)ST-T改變(bian)者(zhe)。而室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)動(dong)(dong)(dong)過速(su)(su)(su)(su)在(zai)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)中的(de)(de)(de)意(yi)(yi)義比室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)為(wei)(wei)(wei)(wei)(wei)大(da)。在(zai)臨(lin)床中,我(wo)們(men)常(chang)(chang)(chang)把室(shi)(shi)(shi)(shi)(shi)(shi)速(su)(su)(su)(su)或(huo)(huo)成對、多(duo)源及頻發(fa)(fa)(fa)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)稱(cheng)為(wei)(wei)(wei)(wei)(wei)復(fu)(fu)雜(za)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)。Morganroth根據復(fu)(fu)雜(za)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)引起心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)危險程度,將(jiang)復(fu)(fu)雜(za)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)分為(wei)(wei)(wei)(wei)(wei)良性(xing)(xing)(xing)(xing)(xing)(xing)(xing)占(zhan)30%,其(qi)(qi)左(zuo)心(xin)(xin)(xin)(xin)(xin)功能和(he)(he)(he)(he)血(xue)(xue)流動(dong)(dong)(dong)力(li)(li)學(xue)(xue)均正常(chang)(chang)(chang),發(fa)(fa)(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)危險性(xing)(xing)(xing)(xing)(xing)(xing)(xing)極小;潛在(zai)惡性(xing)(xing)(xing)(xing)(xing)(xing)(xing)占(zhan)65%,心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)結構輕度異常(chang)(chang)(chang),有(you)(you)心(xin)(xin)(xin)(xin)(xin)功能不(bu)全和(he)(he)(he)(he)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)異位(wei)激(ji)動(dong)(dong)(dong),如室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)期(qi)(qi)(qi)(qi)前(qian)(qian)(qian)收(shou)(shou)(shou)縮(suo)(suo)和(he)(he)(he)(he)(或(huo)(huo))非(fei)持續(xu)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)速(su)(su)(su)(su),無血(xue)(xue)流動(dong)(dong)(dong)力(li)(li)學(xue)(xue)障礙,但心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)危險性(xing)(xing)(xing)(xing)(xing)(xing)(xing)增(zeng)加(jia);惡性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)占(zhan)5%,幾乎都有(you)(you)血(xue)(xue)流動(dong)(dong)(dong)力(li)(li)學(xue)(xue)表(biao)現(xian)和(he)(he)(he)(he)體征(zheng)(暈厥,心(xin)(xin)(xin)(xin)(xin)功能不(bu)全,心(xin)(xin)(xin)(xin)(xin)肌缺血(xue)(xue)或(huo)(huo)低(di)血(xue)(xue)壓)其(qi)(qi)發(fa)(fa)(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)危險性(xing)(xing)(xing)(xing)(xing)(xing)(xing)最大(da)。臨(lin)床上常(chang)(chang)(chang)見5種類型:①心(xin)(xin)(xin)(xin)(xin)室(shi)(shi)(shi)(shi)(shi)(shi)率(lv)(lv)≥230bpm的(de)(de)(de)持續(xu)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)單形(xing)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)速(su)(su)(su)(su)。②心(xin)(xin)(xin)(xin)(xin)室(shi)(shi)(shi)(shi)(shi)(shi)率(lv)(lv)逐(zhu)漸加(jia)速(su)(su)(su)(su)的(de)(de)(de)室(shi)(shi)(shi)(shi)(shi)(shi)速(su)(su)(su)(su)或(huo)(huo)可(ke)蛻變(bian)為(wei)(wei)(wei)(wei)(wei)室(shi)(shi)(shi)(shi)(shi)(shi)撲和(he)(he)(he)(he)(或(huo)(huo))室(shi)(shi)(shi)(shi)(shi)(shi)顫(zhan)(zhan)趨(qu)勢者(zhe)。③室(shi)(shi)(shi)(shi)(shi)(shi)速(su)(su)(su)(su)伴嚴(yan)(yan)重血(xue)(xue)流動(dong)(dong)(dong)力(li)(li)學(xue)(xue)障礙如暈厥,左(zuo)心(xin)(xin)(xin)(xin)(xin)功能不(bu)全和(he)(he)(he)(he)低(di)血(xue)(xue)壓。④多(duo)形(xing)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(包括(kuo)長(chang)Q-T綜合征(zheng)合并的(de)(de)(de)尖端(duan)扭轉型)室(shi)(shi)(shi)(shi)(shi)(shi)速(su)(su)(su)(su)。⑤室(shi)(shi)(shi)(shi)(shi)(shi)撲和(he)(he)(he)(he)(或(huo)(huo))室(shi)(shi)(shi)(shi)(shi)(shi)顫(zhan)(zhan)起始心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)即(ji)為(wei)(wei)(wei)(wei)(wei)室(shi)(shi)(shi)(shi)(shi)(shi)撲和(he)(he)(he)(he)(或(huo)(huo))室(shi)(shi)(shi)(shi)(shi)(shi)顫(zhan)(zhan)(如特發(fa)(fa)(fa)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)顫(zhan)(zhan),Brugada綜合征(zheng))。臨(lin)床表(biao)現(xian)為(wei)(wei)(wei)(wei)(wei)阿-斯綜合征(zheng)發(fa)(fa)(fa)作。而由(you)心(xin)(xin)(xin)(xin)(xin)電圖證實的(de)(de)(de)大(da)多(duo)數心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)發(fa)(fa)(fa)作(65%~85%)是由(you)心(xin)(xin)(xin)(xin)(xin)室(shi)(shi)(shi)(shi)(shi)(shi)顫(zhan)(zhan)動(dong)(dong)(dong)之類的(de)(de)(de)惡性(xing)(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)(shi)(shi)(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)所致。但緩慢(man)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)也可(ke)能是心(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)(zang)(zang)(zang)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)猝(cu)(cu)(cu)(cu)死(si)(si)(si)的(de)(de)(de)潛在(zai)原因,并可(ke)能在(zai)記錄到緩慢(man)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)之前(qian)(qian)(qian)就已轉變(bian)為(wei)(wei)(wei)(wei)(wei)心(xin)(xin)(xin)(xin)(xin)室(shi)(shi)(shi)(shi)(shi)(shi)顫(zhan)(zhan)動(dong)(dong)(dong)。
預激綜合(he)征(zheng)患者并發(fa)房室折返(fan)性(xing)心動(dong)過速(su)、心房顫動(dong)等(deng)快速(su)性(xing)心律失常者占40%~80%。但發(fa)生心臟(zang)性(xing)猝死(si)的危險性(xing)較低,有調查在4%以下,老年患者也(ye)未見心臟(zang)性(xing)猝死(si)增加的報道。
(5)其他
糖(tang)(tang)尿病除了增加(jia)冠(guan)心(xin)病的發生(sheng)率外,本身也可損(sun)傷心(xin)肌而(er)增加(jia)心(xin)臟(zang)(zang)性(xing)猝(cu)死(si)的發生(sheng)率。尤其(qi)女性(xing)患(huan)(huan)者的心(xin)臟(zang)(zang)性(xing)猝(cu)死(si)發生(sheng)率增加(jia)更(geng)明顯,較同年齡組而(er)無糖(tang)(tang)尿病的患(huan)(huan)者增加(jia)3倍。
目(mu)前已知,發(fa)生心臟性猝死的(de)機制主(zhu)要為嚴重(zhong)的(de)室性心律失(shi)常,包括室性心動過速,心室顫動等(deng)。也有一部分人為突然(ran)發(fa)生的(de)嚴重(zhong)血流動力學障礙,心臟破裂等(deng)。
一般(ban)認(ren)為,心(xin)室(shi)(shi)顫動是多發(fa)(fa)的(de)(de)折(zhe)返(fan)小波引起的(de)(de)持續性(xing)快而不(bu)規(gui)則的(de)(de)心(xin)室(shi)(shi)激動。心(xin)室(shi)(shi)顫動的(de)(de)發(fa)(fa)生(sheng)必需(xu)包括以下幾個(ge)基(ji)本條件(jian),即異步和分(fen)離的(de)(de)局部波前興奮,傳導延緩(huan)和心(xin)室(shi)(shi)不(bu)應期縮短。這些變(bian)化,在缺血的(de)(de)心(xin)肌(ji)中均可出現。
(1)缺(que)(que)血(xue)(xue)性(xing)(xing)(xing)室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang):包括(kuo)急性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)缺(que)(que)血(xue)(xue)所致的(de)(de)(de)室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)和心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)梗(geng)死(si)后陳舊性(xing)(xing)(xing)病變并發的(de)(de)(de)室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)。如(ru)果急性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)缺(que)(que)血(xue)(xue)發生在(zai)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)梗(geng)死(si)后瘢痕(hen)愈合的(de)(de)(de)邊(bian)緣心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji),則(ze)室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)的(de)(de)(de)發生率(lv)(lv)更高。在(zai)急性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)缺(que)(que)血(xue)(xue)時,局部(bu)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)組織灌注不足,導致缺(que)(que)血(xue)(xue)部(bu)位(wei)(wei)的(de)(de)(de)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)能(neng)量(liang)代謝(xie)較(jiao)正常(chang)(chang)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)組織明(ming)顯降低,大量(liang)游離脂肪(fang)酸(suan)(FFA)堆積(ji),細(xi)胞內(nei)乳酸(suan)含量(liang)增加,細(xi)胞內(nei)鉀、鎂(mei)離子外流,則(ze)靜息電位(wei)(wei)的(de)(de)(de)負值進(jin)一(yi)步增加,形成舒張(zhang)期電位(wei)(wei)。同時,動(dong)(dong)作(zuo)電位(wei)(wei)的(de)(de)(de)振幅下降,去極化的(de)(de)(de)速(su)度減(jian)慢,興奮(fen)傳導速(su)度減(jian)慢,則(ze)心(xin)(xin)(xin)(xin)肌(ji)(ji)(ji)自律(lv)(lv)性(xing)(xing)(xing)增強(qiang),并易于形成折返的(de)(de)(de)條件而發生室(shi)性(xing)(xing)(xing)折返性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)及心(xin)(xin)(xin)(xin)室(shi)顫動(dong)(dong)。而同時存在(zai)左心(xin)(xin)(xin)(xin)功(gong)能(neng)不全的(de)(de)(de)患者,心(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝死(si)的(de)(de)(de)發生率(lv)(lv)則(ze)更高,尤其左室(shi)射血(xue)(xue)分(fen)數低于30%是心(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝死(si)的(de)(de)(de)最強(qiang)的(de)(de)(de)預測(ce)因素。
現(xian)已知再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)是(shi)發(fa)生(sheng)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)(xing)(xing)(xing)猝死的(de)(de)(de)(de)(de)(de)重(zhong)要(yao)(yao)機(ji)制。再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)可見于(yu)冠(guan)(guan)(guan)狀動(dong)(dong)(dong)脈痙攣緩解(jie)以后(hou),也(ye)(ye)(ye)可見于(yu)急性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)肌梗死溶栓治療(liao)或(huo)機(ji)械性(xing)(xing)(xing)(xing)(xing)(xing)粉(fen)碎斑(ban)塊后(hou)使(shi)完(wan)全閉塞的(de)(de)(de)(de)(de)(de)血(xue)(xue)管(guan)再(zai)(zai)(zai)(zai)(zai)通(tong)等情況。常(chang)(chang)(chang)在冠(guan)(guan)(guan)狀動(dong)(dong)(dong)脈再(zai)(zai)(zai)(zai)(zai)通(tong)后(hou)幾秒鐘而出現(xian)再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)。許多(duo)研究表(biao)明,冠(guan)(guan)(guan)狀動(dong)(dong)(dong)脈再(zai)(zai)(zai)(zai)(zai)通(tong)時,再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)的(de)(de)(de)(de)(de)(de)發(fa)生(sheng)率高(gao)達82%。在再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)的(de)(de)(de)(de)(de)(de)不(bu)同類型中60%~80%為(wei)加(jia)速性(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)自主心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)和(he)室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)期前收(shou)縮,可引(yin)(yin)起(qi)(qi)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)(xing)(xing)(xing)猝死的(de)(de)(de)(de)(de)(de)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)為(wei)室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)動(dong)(dong)(dong)過速和(he)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)室(shi)(shi)顫動(dong)(dong)(dong),嚴重(zhong)的(de)(de)(de)(de)(de)(de)緩慢性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)也(ye)(ye)(ye)可引(yin)(yin)起(qi)(qi)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)(xing)(xing)(xing)猝死。而再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)的(de)(de)(de)(de)(de)(de)類型和(he)冠(guan)(guan)(guan)狀動(dong)(dong)(dong)脈的(de)(de)(de)(de)(de)(de)再(zai)(zai)(zai)(zai)(zai)通(tong)部(bu)位(wei)有(you)一定的(de)(de)(de)(de)(de)(de)關系。左前降(jiang)支(zhi)和(he)左旋支(zhi)再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)時易(yi)(yi)發(fa)生(sheng)加(jia)速性(xing)(xing)(xing)(xing)(xing)(xing)室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)自主心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv),室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)動(dong)(dong)(dong)過速和(he)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)室(shi)(shi)顫動(dong)(dong)(dong)。右冠(guan)(guan)(guan)狀動(dong)(dong)(dong)脈阻塞再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)時易(yi)(yi)發(fa)生(sheng)竇(dou)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)動(dong)(dong)(dong)過緩,房(fang)室(shi)(shi)傳導阻滯。實(shi)驗研究提示(shi),再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)的(de)(de)(de)(de)(de)(de)發(fa)生(sheng)機(ji)制包括觸(chu)發(fa)激動(dong)(dong)(dong)、折返激動(dong)(dong)(dong)和(he)異位(wei)自律(lv)(lv)(lv)(lv)性(xing)(xing)(xing)(xing)(xing)(xing)增高(gao)。目前多(duo)數學者認為(wei),觸(chu)發(fa)激動(dong)(dong)(dong)在再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)的(de)(de)(de)(de)(de)(de)發(fa)生(sheng)中占據重(zhong)要(yao)(yao)位(wei)置。而折返機(ji)制的(de)(de)(de)(de)(de)(de)產生(sheng)可能與再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)后(hou)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)肌細胞(bao)電生(sheng)理恢(hui)復不(bu)均(jun)(jun)勻有(you)關。心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)肌缺血(xue)(xue)性(xing)(xing)(xing)(xing)(xing)(xing)損傷使(shi)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)肌細胞(bao)的(de)(de)(de)(de)(de)(de)電生(sheng)理改變(bian)不(bu)均(jun)(jun)勻,血(xue)(xue)管(guan)再(zai)(zai)(zai)(zai)(zai)通(tong)后(hou)的(de)(de)(de)(de)(de)(de)再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)使(shi)血(xue)(xue)流恢(hui)復,但恢(hui)復血(xue)(xue)流后(hou)的(de)(de)(de)(de)(de)(de)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)肌細胞(bao)血(xue)(xue)液供應和(he)代(dai)謝(xie)恢(hui)復也(ye)(ye)(ye)不(bu)均(jun)(jun)勻,結果導致缺血(xue)(xue)區內(nei)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)肌應激性(xing)(xing)(xing)(xing)(xing)(xing)的(de)(de)(de)(de)(de)(de)恢(hui)復程(cheng)度不(bu)一致,則易(yi)(yi)于(yu)形成折返而引(yin)(yin)起(qi)(qi)室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)動(dong)(dong)(dong)過速和(he)(或(huo))心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)室(shi)(shi)顫動(dong)(dong)(dong)。此外,心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)肌缺血(xue)(xue)-再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)損傷也(ye)(ye)(ye)可引(yin)(yin)起(qi)(qi)異位(wei)興奮灶(zao)的(de)(de)(de)(de)(de)(de)自律(lv)(lv)(lv)(lv)性(xing)(xing)(xing)(xing)(xing)(xing)增加(jia),引(yin)(yin)起(qi)(qi)室(shi)(shi)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)。Pogwizd等用心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)臟三維標測技術(shu)研究表(biao)明,75%的(de)(de)(de)(de)(de)(de)再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)是(shi)由(you)觸(chu)發(fa)激動(dong)(dong)(dong)引(yin)(yin)起(qi)(qi)的(de)(de)(de)(de)(de)(de),25%的(de)(de)(de)(de)(de)(de)再(zai)(zai)(zai)(zai)(zai)灌(guan)(guan)(guan)注(zhu)(zhu)性(xing)(xing)(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)(lv)失(shi)(shi)常(chang)(chang)(chang)是(shi)由(you)折返機(ji)制引(yin)(yin)起(qi)(qi)。
病(bing)因(yin)不明(ming)(ming),無(wu)明(ming)(ming)顯冠狀動脈或心(xin)(xin)肌本(ben)身的(de)病(bing)變(bian),常常突(tu)然(ran)或在某(mou)些誘因(yin)的(de)作用下發(fa)(fa)(fa)(fa)生(sheng)(sheng)嚴重的(de)室(shi)(shi)性(xing)心(xin)(xin)律(lv)失(shi)(shi)常和(或)心(xin)(xin)室(shi)(shi)顫(zhan)動,而發(fa)(fa)(fa)(fa)生(sheng)(sheng)心(xin)(xin)臟性(xing)猝死。研究表(biao)明(ming)(ming),原發(fa)(fa)(fa)(fa)性(xing)室(shi)(shi)性(xing)心(xin)(xin)律(lv)失(shi)(shi)常的(de)發(fa)(fa)(fa)(fa)生(sheng)(sheng)機制多(duo)為觸發(fa)(fa)(fa)(fa)激動,也有的(de)為折返機制。
Raizes等研究表(biao)明,非心(xin)(xin)(xin)(xin)(xin)律失常(chang)引起(qi)的心(xin)(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝(cu)死只占0.56%,包括心(xin)(xin)(xin)(xin)(xin)臟或主動脈破裂,心(xin)(xin)(xin)(xin)(xin)肌(ji)梗死擴展,交(jiao)感神(shen)經(jing)反(fan)射(she)性(xing)(xing)(xing)抑制,以及(ji)各種(zhong)原因引起(qi)的心(xin)(xin)(xin)(xin)(xin)臟嚴重(zhong)的機(ji)械(xie)性(xing)(xing)(xing)梗阻等。尤其伴有左心(xin)(xin)(xin)(xin)(xin)功(gong)(gong)能(neng)不(bu)(bu)全(quan)的患者心(xin)(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝(cu)死的發生(sheng)率(lv)最高。左心(xin)(xin)(xin)(xin)(xin)功(gong)(gong)能(neng)不(bu)(bu)全(quan)又(you)常(chang)有冠狀動脈病變和(he)彌(mi)漫的心(xin)(xin)(xin)(xin)(xin)肌(ji)病變,因而可伴有急性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)肌(ji)缺血(xue)或心(xin)(xin)(xin)(xin)(xin)肌(ji)瘢(ban)痕組(zu)織(zhi)所(suo)誘發的惡性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律失常(chang),從而導致心(xin)(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝(cu)死。在冠心(xin)(xin)(xin)(xin)(xin)病合并左心(xin)(xin)(xin)(xin)(xin)室功(gong)(gong)能(neng)不(bu)(bu)全(quan)致心(xin)(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝(cu)死事件中,36%表(biao)現為嚴重(zhong)心(xin)(xin)(xin)(xin)(xin)動過緩(huan)或電-機(ji)械(xie)分離。心(xin)(xin)(xin)(xin)(xin)臟驟停前并未伴心(xin)(xin)(xin)(xin)(xin)力(li)衰竭癥狀的惡化。緩(huan)慢(man)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)律失常(chang)或電-機(ji)械(xie)分離可能(neng)因左室收縮(suo)(suo)功(gong)(gong)能(neng)衰竭終末(mo)期心(xin)(xin)(xin)(xin)(xin)室壁應激時使心(xin)(xin)(xin)(xin)(xin)室內壓(ya)力(li)和(he)容量(liang)突(tu)然增(zeng)加,而周圍(wei)血(xue)管收縮(suo)(suo)同時出現障礙,不(bu)(bu)能(neng)維持(chi)體循環血(xue)壓(ya),以至虛脫和(he)暈厥。猝(cu)死則為血(xue)流動力(li)學障礙所(suo)致,并非心(xin)(xin)(xin)(xin)(xin)電不(bu)(bu)穩(wen)定事件。另一(yi)部分左心(xin)(xin)(xin)(xin)(xin)功(gong)(gong)能(neng)不(bu)(bu)全(quan)的患者伴有室性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)動過速,則可能(neng)為心(xin)(xin)(xin)(xin)(xin)律失常(chang)所(suo)致。
(2)心(xin)臟(zang)性猝死后的病生理變化
原發(fa)性改(gai)(gai)變(bian):心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)性猝(cu)死(si)(si)(si)的(de)(de)(de)(de)(de)心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)病(bing)(bing)理改(gai)(gai)變(bian)資料(liao)主要(yao)來自尸體解剖。但(dan)不(bu)同學者(zhe)(zhe)所(suo)報(bao)道的(de)(de)(de)(de)(de)尸體解剖病(bing)(bing)理結(jie)(jie)果有(you)很大的(de)(de)(de)(de)(de)不(bu)一(yi)致(zhi),且多數(shu)學者(zhe)(zhe)研究為(wei)(wei)冠心(xin)(xin)(xin)(xin)(xin)(xin)病(bing)(bing)猝(cu)死(si)(si)(si)。從冠心(xin)(xin)(xin)(xin)(xin)(xin)病(bing)(bing)猝(cu)死(si)(si)(si)的(de)(de)(de)(de)(de)病(bing)(bing)理資料(liao)來看,主要(yao)病(bing)(bing)理結(jie)(jie)果為(wei)(wei)冠狀(zhuang)動(dong)(dong)脈狹窄程(cheng)度重,冠狀(zhuang)動(dong)(dong)脈內并發(fa)血栓形成(cheng),心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)出現嚴重的(de)(de)(de)(de)(de)缺血或梗(geng)死(si)(si)(si)。Schwartz等發(fa)現,1/3以上的(de)(de)(de)(de)(de)冠心(xin)(xin)(xin)(xin)(xin)(xin)病(bing)(bing)猝(cu)死(si)(si)(si)患(huan)(huan)者(zhe)(zhe)的(de)(de)(de)(de)(de)冠狀(zhuang)動(dong)(dong)脈內有(you)血栓形成(cheng)。國(guo)內外(wai)的(de)(de)(de)(de)(de)一(yi)些資料(liao)提示:冠心(xin)(xin)(xin)(xin)(xin)(xin)病(bing)(bing)猝(cu)死(si)(si)(si)患(huan)(huan)者(zhe)(zhe)中急性心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)梗(geng)死(si)(si)(si)的(de)(de)(de)(de)(de)發(fa)生(sheng)(sheng)率(lv)約為(wei)(wei)40%,并且冠心(xin)(xin)(xin)(xin)(xin)(xin)病(bing)(bing)猝(cu)死(si)(si)(si)患(huan)(huan)者(zhe)(zhe)的(de)(de)(de)(de)(de)竇(dou)房結(jie)(jie)和傳導(dao)系(xi)統并無明顯的(de)(de)(de)(de)(de)急性病(bing)(bing)變(bian),亦證實了冠心(xin)(xin)(xin)(xin)(xin)(xin)病(bing)(bing)猝(cu)死(si)(si)(si)的(de)(de)(de)(de)(de)發(fa)生(sheng)(sheng)機制為(wei)(wei)心(xin)(xin)(xin)(xin)(xin)(xin)電(dian)不(bu)穩定所(suo)致(zhi)。心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)性猝(cu)死(si)(si)(si)很少(shao)發(fa)生(sheng)(sheng)在(zai)沒(mei)有(you)器質性心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)病(bing)(bing)的(de)(de)(de)(de)(de)患(huan)(huan)者(zhe)(zhe)。有(you)些患(huan)(huan)者(zhe)(zhe)發(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)性猝(cu)死(si)(si)(si)后,即使心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)的(de)(de)(de)(de)(de)大體檢查(cha)無明顯肉眼病(bing)(bing)變(bian),但(dan)可能(neng)其(qi)心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)的(de)(de)(de)(de)(de)分子(zi)結(jie)(jie)構(gou)和功能(neng)也存在(zai)著明顯的(de)(de)(de)(de)(de)異常(chang)。如離子(zi)通(tong)道、蛋白質結(jie)(jie)構(gou)異常(chang)等。
繼(ji)發性(xing)改變:正常心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)做功所需能量首先來自脂肪,約占(zhan)心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)(ji)總耗氧量的(de)67%,其次來自葡萄糖(tang)和(he)乳(ru)酸(suan)(suan),分別占(zhan)17.9%和(he)16.46%,極少數(shu)來自醋酸(suan)(suan)、氨基酸(suan)(suan)、丙酮酸(suan)(suan)等(deng)。同(tong)時(shi)心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)必須依賴ATP來維持其心(xin)(xin)(xin)(xin)(xin)(xin)室壁的(de)張(zhang)力和(he)收縮狀態。研究(jiu)表(biao)明,心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)(ji)缺(que)血缺(que)氧10s即(ji)可(ke)(ke)代謝底物(wu)耗竭,心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)即(ji)完全(quan)失去收縮功能。在常溫下,如(ru)(ru)果心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)(ji)缺(que)血3~4min,心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)(ji)內(nei)(nei)磷酸(suan)(suan)肌(ji)(ji)酸(suan)(suan)含量減(jian)(jian)少70%~75%,ATP減(jian)(jian)少15%。如(ru)(ru)在此(ci)期(qi)內(nei)(nei)進(jin)行(xing)有(you)效(xiao)的(de)心(xin)(xin)(xin)(xin)(xin)(xin)肺復蘇(su)(su),心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)(ji)供(gong)血改善,則心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)(ji)張(zhang)力可(ke)(ke)完全(quan)恢復;缺(que)血8~10min,心(xin)(xin)(xin)(xin)(xin)(xin)肌(ji)(ji)內(nei)(nei)磷酸(suan)(suan)肌(ji)(ji)酸(suan)(suan)和(he)ATP將(jiang)全(quan)部耗盡(jin),如(ru)(ru)在此(ci)期(qi)內(nei)(nei)進(jin)行(xing)有(you)效(xiao)的(de)心(xin)(xin)(xin)(xin)(xin)(xin)肺復蘇(su)(su),心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)的(de)收縮和(he)舒張(zhang)功能仍可(ke)(ke)恢復,10min后(hou)才進(jin)行(xing)有(you)效(xiao)的(de)心(xin)(xin)(xin)(xin)(xin)(xin)肺復蘇(su)(su)者,復蘇(su)(su)的(de)成功機會顯著(zhu)減(jian)(jian)少。
腦(nao)(nao):腦(nao)(nao)的(de)(de)(de)(de)(de)能(neng)(neng)(neng)量代(dai)謝(xie)(xie)主(zhu)要來自葡萄(tao)糖(tang),但腦(nao)(nao)組(zu)織本身(shen)對葡萄(tao)糖(tang)的(de)(de)(de)(de)(de)儲備很少,必須依賴于(yu)(yu)循環血(xue)(xue)液(ye)來供應(ying)。并且腦(nao)(nao)組(zu)織的(de)(de)(de)(de)(de)代(dai)謝(xie)(xie)85%~90%為有氧(yang)(yang)(yang)(yang)代(dai)謝(xie)(xie),而(er)無氧(yang)(yang)(yang)(yang)酵解只占腦(nao)(nao)組(zu)織代(dai)謝(xie)(xie)的(de)(de)(de)(de)(de)5%~15%,所以,腦(nao)(nao)組(zu)織的(de)(de)(de)(de)(de)代(dai)謝(xie)(xie)和(he)(he)生理功(gong)能(neng)(neng)(neng)的(de)(de)(de)(de)(de)維持則(ze)完全依賴于(yu)(yu)有效(xiao)的(de)(de)(de)(de)(de)血(xue)(xue)液(ye)供應(ying)。血(xue)(xue)液(ye)供應(ying)障礙引(yin)(yin)起腦(nao)(nao)細(xi)(xi)(xi)(xi)胞(bao)(bao)功(gong)能(neng)(neng)(neng)的(de)(de)(de)(de)(de)改(gai)變(bian)的(de)(de)(de)(de)(de)基(ji)礎是(shi)缺(que)血(xue)(xue)缺(que)氧(yang)(yang)(yang)(yang)引(yin)(yin)起腦(nao)(nao)組(zu)織的(de)(de)(de)(de)(de)原(yuan)發和(he)(he)繼發損害(hai)。原(yuan)發損害(hai)為腦(nao)(nao)組(zu)織缺(que)血(xue)(xue)缺(que)氧(yang)(yang)(yang)(yang)時,ATP不(bu)能(neng)(neng)(neng)合成,細(xi)(xi)(xi)(xi)胞(bao)(bao)鈉(na)泵功(gong)能(neng)(neng)(neng)喪(sang)失,細(xi)(xi)(xi)(xi)胞(bao)(bao)內(nei)鈉(na)離子不(bu)能(neng)(neng)(neng)轉運到細(xi)(xi)(xi)(xi)胞(bao)(bao)外(wai),鉀離子不(bu)能(neng)(neng)(neng)從細(xi)(xi)(xi)(xi)胞(bao)(bao)內(nei)逸出,細(xi)(xi)(xi)(xi)胞(bao)(bao)膜電(dian)位(wei)發生改(gai)變(bian),因此不(bu)能(neng)(neng)(neng)產(chan)生電(dian)活動(dong),細(xi)(xi)(xi)(xi)胞(bao)(bao)也失去了產(chan)生和(he)(he)傳(chuan)導沖動(dong)的(de)(de)(de)(de)(de)功(gong)能(neng)(neng)(neng)。研(yan)究(jiu)表明,在完全缺(que)氧(yang)(yang)(yang)(yang)情況下(xia),20s后大腦(nao)(nao)皮質的(de)(de)(de)(de)(de)生物電(dian)活動(dong)完全消(xiao)失,30~90s后小腦(nao)(nao)和(he)(he)延髓的(de)(de)(de)(de)(de)生物電(dian)活動(dong)完全消(xiao)失。而(er)缺(que)血(xue)(xue)缺(que)氧(yang)(yang)(yang)(yang)所致(zhi)的(de)(de)(de)(de)(de)繼發損害(hai)包括兩個方(fang)面:
A.細胞內電解質紊亂和(he)各種代謝產物(wu)的堆積(ji)而使腦(nao)組織(zhi)腫(zhong)脹和(he)腦(nao)水(shui)腫(zhong)。
B.腦(nao)(nao)組(zu)織的局部循環功(gong)(gong)能(neng)障礙(ai)進一步加重(zhong)。已有(you)(you)研究(jiu)提示,心臟驟停引起的腦(nao)(nao)組(zu)織缺(que)(que)血(xue)缺(que)(que)氧(yang)(yang)時,病變(bian)主要在大腦(nao)(nao)海馬回先出(chu)現,如缺(que)(que)血(xue)進一步加重(zhong),則迅速波及(ji)全(quan)腦(nao)(nao),包括腦(nao)(nao)干和延髓(sui)。而(er)患(huan)者(zhe)發(fa)生(sheng)心臟性猝死后,如果能(neng)及(ji)時、有(you)(you)效地進行心肺復蘇(su),則腦(nao)(nao)組(zu)織的血(xue)流有(you)(you)可(ke)能(neng)恢復,但腦(nao)(nao)組(zu)織由于受到(dao)完全(quan)缺(que)(que)血(xue)缺(que)(que)氧(yang)(yang)的影(ying)(ying)響,腦(nao)(nao)水腫和微循環障礙(ai)將繼續發(fa)展。腦(nao)(nao)組(zu)織的缺(que)(que)血(xue)缺(que)(que)氧(yang)(yang)時間(jian)長短直接(jie)影(ying)(ying)響大腦(nao)(nao)功(gong)(gong)能(neng)的恢復及(ji)患(huan)者(zhe)的臨床(chuang)預后。
腎:
心臟驟停時(shi)(shi),腎臟的(de)血(xue)流(liu)供應和(he)濾過功(gong)能(neng)完全停止。首先受累的(de)是腎小管(guan),引起腎小管(guan)細胞(bao)壞死,并(bing)逐(zhu)步累及基(ji)底(di)膜及整(zheng)個腎單位。如果(guo)發生(sheng)(sheng)(sheng)時(shi)(shi)間(jian)短(duan),基(ji)底(di)膜可保持相對完整(zheng),腎臟功(gong)能(neng)可恢(hui)復,但缺血(xue)缺氧(yang)的(de)時(shi)(shi)間(jian)過長(chang),腎小管(guan)及腎小球產生(sheng)(sheng)(sheng)廣泛的(de)嚴重破壞,則易發生(sheng)(sheng)(sheng)急性腎功(gong)能(neng)衰竭。
肺:發(fa)生心臟性猝死后,肺可發(fa)生淤(yu)血(xue)(xue)(xue)、水腫。顯(xian)微鏡下其主要特(te)征是肺間(jian)質水腫,并可見(jian)微血(xue)(xue)(xue)栓形成。長時間(jian)的肺缺(que)血(xue)(xue)(xue)缺(que)氧容易發(fa)生彌漫性血(xue)(xue)(xue)管(guan)內凝血(xue)(xue)(xue),不僅可通(tong)過機械堵塞使肺部(bu)缺(que)血(xue)(xue)(xue)缺(que)氧進(jin)一步(bu)加重,而且(qie)還可引起血(xue)(xue)(xue)小板聚集,釋放5-HT等物質產生終末氣(qi)道(dao)痙攣,結果(guo)血(xue)(xue)(xue)液(ye)-氣(qi)體交換障礙進(jin)一步(bu)惡(e)化。
(3)與心臟性(xing)猝(cu)死發生的相關因素
自主(zhu)神(shen)(shen)經系統(tong)在(zai)心(xin)臟性(xing)(xing)猝死(si)的(de)發(fa)(fa)(fa)(fa)生(sheng)(sheng)中具(ju)(ju)有(you)(you)重(zhong)(zhong)要作用(yong)。臨(lin)床觀(guan)察發(fa)(fa)(fa)(fa)現(xian),冠心(xin)病患(huan)者的(de)心(xin)臟性(xing)(xing)猝死(si)常(chang)發(fa)(fa)(fa)(fa)生(sheng)(sheng)在(zai)凌晨至午間(jian)這段(duan)時(shi)間(jian),與自主(zhu)神(shen)(shen)經活動的(de)晝(zhou)夜節律性(xing)(xing)變化相一(yi)致。此時(shi)間(jian)段(duan),交感神(shen)(shen)經活動較高,血(xue)壓(ya)(ya)與心(xin)率增(zeng)加,血(xue)小板聚集性(xing)(xing)也(ye)增(zeng)加。實驗研究表明,刺(ci)激(ji)心(xin)臟的(de)交感神(shen)(shen)經可降低(di)室(shi)顫(zhan)閾值,增(zeng)加室(shi)顫(zhan)發(fa)(fa)(fa)(fa)生(sheng)(sheng)的(de)危險性(xing)(xing);刺(ci)激(ji)迷走(zou)神(shen)(shen)經,可降低(di)室(shi)顫(zhan)發(fa)(fa)(fa)(fa)生(sheng)(sheng)的(de)危險性(xing)(xing)。所以交感神(shen)(shen)經的(de)過(guo)度興奮可促(cu)進惡性(xing)(xing)室(shi)性(xing)(xing)心(xin)律失常(chang)的(de)發(fa)(fa)(fa)(fa)生(sheng)(sheng),而興奮迷走(zou)神(shen)(shen)經則具(ju)(ju)有(you)(you)保護(hu)心(xin)臟及(ji)抗室(shi)顫(zhan)的(de)作用(yong)。但是(shi),對下后(hou)壁急(ji)性(xing)(xing)心(xin)肌缺血(xue)或缺血(xue)性(xing)(xing)再灌(guan)注(zhu)的(de)患(huan)者,因迷走(zou)神(shen)(shen)經的(de)傳入受體多數分(fen)布在(zai)心(xin)室(shi)的(de)下后(hou)壁,該(gai)部位發(fa)(fa)(fa)(fa)生(sheng)(sheng)心(xin)肌缺血(xue)或缺血(xue)后(hou)再灌(guan)注(zhu),可觸發(fa)(fa)(fa)(fa)Bezold-Jarish反(fan)射,導致或加重(zhong)(zhong)緩慢性(xing)(xing)心(xin)律失常(chang),如(ru)嚴重(zhong)(zhong)竇性(xing)(xing)心(xin)動過(guo)緩,高度房(fang)室(shi)傳導阻(zu)滯,周圍(wei)血(xue)管(guan)擴張和低(di)血(xue)壓(ya)(ya),嚴重(zhong)(zhong)者可發(fa)(fa)(fa)(fa)生(sheng)(sheng)心(xin)臟驟停。
許多(duo)心臟性(xing)(xing)猝(cu)死的患者(zhe)發(fa)生在睡眠(mian)中。其機(ji)制主(zhu)要為睡眠(mian)時迷(mi)走神經興奮,冠(guan)狀動(dong)脈痙攣,心臟傳導系統發(fa)生缺氧(yang),心電(dian)不穩定,發(fa)生室顫而(er)引起(qi)心臟性(xing)(xing)猝(cu)死。但目(mu)前尚未能提供(gong)冠(guan)狀動(dong)脈痙攣的形態學依據。
(1)心臟病發作前,身體上例(li)如頸、后背(bei)、頭(tou)皮、手心或者腳(jiao)掌都會大量出汗,此(ci)時應(ying)提高警惕,當心猝死發生,最好停(ting)止(zhi)活動休息,及時服(fu)用藥物,必要時應(ying)立即撥(bo)打120。
(2)在無(wu)(wu)激烈(lie)運動、缺少(shao)睡眠或者生病等誘因的情況下,連續幾(ji)天(tian)、幾(ji)周甚至幾(ji)月(yue)出現極度(du)疲(pi)勞感(gan),伴有(you)焦慮(lv)、失(shi)眠、無(wu)(wu)癥狀驚醒等癥狀,此(ci)時(shi)應考慮(lv)心臟(zang)出現問題。
(3)心臟病患(huan)者經(jing)常感到(dao)肩膀、頸部、下巴、手(shou)臂疼痛,這是心肌缺(que)血的信號,因為(wei)心肌缺(que)血疼痛在傳遞至(zhi)大(da)腦(nao)中樞神經(jing)時,會同(tong)時反映在水(shui)平相(xiang)同(tong)的脊髓段區(qu)域。
(4)心(xin)(xin)臟病發作(zuo)前的(de)典型癥狀是突(tu)然、或者無緣由的(de)心(xin)(xin)跳加劇,一旦發生心(xin)(xin)室性心(xin)(xin)搏(bo)過速,則極有可能在短時間(jian)內(nei)突(tu)然死(si)亡。
(5)很多心(xin)源性猝死患(huan)者在死亡前(qian)都反(fan)復出(chu)現胃(wei)腸道癥狀,不(bu)(bu)少(shao)人生(sheng)前(qian)并沒有胃(wei)病(bing)病(bing)史,這是心(xin)臟病(bing)發(fa)作的信號之一,腸胃(wei)不(bu)(bu)適是因(yin)為心(xin)血管出(chu)現異(yi)常。動脈(mo)由于脂(zhi)肪(fang)沉積物堵(du)塞將會減少(shao)甚至阻(zu)斷血液傳(chuan)輸給心(xin)臟,而這會引(yin)起(qi)心(xin)絞痛。
心(xin)(xin)(xin)(xin)臟(zang)性猝(cu)死(si)的(de)(de)經過大體(ti)上可(ke)分(fen)為(wei)4 個時(shi)期。即前(qian)驅(qu)期,終末事件開始,心(xin)(xin)(xin)(xin)臟(zang)驟(zou)停(ting)和生(sheng)(sheng)物學死(si)亡。不同的(de)(de)患者(zhe)各期表現(xian)(xian)也有明顯差異。在(zai)發(fa)(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)臟(zang)性猝(cu)死(si)的(de)(de)前(qian)數天(tian)到數月,有些患者(zhe)可(ke)出現(xian)(xian)心(xin)(xin)(xin)(xin)前(qian)區不適、心(xin)(xin)(xin)(xin)悸(ji)、氣短、乏力(li)等非特(te)異性表現(xian)(xian)。但亦可(ke)無前(qian)驅(qu)表現(xian)(xian),直接發(fa)(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)臟(zang)驟(zou)停(ting)。而有些報道佩帶動態心(xin)(xin)(xin)(xin)電圖的(de)(de)猝(cu)死(si)患者(zhe),當時(shi)心(xin)(xin)(xin)(xin)電記錄多(duo)為(wei)心(xin)(xin)(xin)(xin)室顫動,說明心(xin)(xin)(xin)(xin)臟(zang)驟(zou)停(ting)時(shi)多(duo)為(wei)心(xin)(xin)(xin)(xin)室顫動。部分(fen)患者(zhe)先(xian)有心(xin)(xin)(xin)(xin)臟(zang)缺血(xue)(xue)或左室功能不全癥(zheng)狀(zhuang)(zhuang),迅即發(fa)(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)臟(zang)驟(zou)停(ting)。心(xin)(xin)(xin)(xin)臟(zang)驟(zou)停(ting)前(qian)未訴有不適感(gan)覺者(zhe),是否(fou)有無癥(zheng)狀(zhuang)(zhuang)心(xin)(xin)(xin)(xin)肌(ji)缺血(xue)(xue)則(ze)不能確定。心(xin)(xin)(xin)(xin)臟(zang)驟(zou)停(ting)后腦血(xue)(xue)流銳(rui)減,可(ke)導致意識突然喪失。下列體(ti)征有助于判斷是否(fou)發(fa)(fa)生(sheng)(sheng)心(xin)(xin)(xin)(xin)臟(zang)驟(zou)停(ting):意識喪失,頸、股動脈搏動消(xiao)失,呼(hu)吸斷續或停(ting)止(zhi),皮膚蒼白(bai)或明顯發(fa)(fa)紺。如聽(ting)診(zhen)心(xin)(xin)(xin)(xin)音消(xiao)失更可(ke)確立診(zhen)斷。經檢查確立診(zhen)斷后,應立即進行有效的(de)(de)心(xin)(xin)(xin)(xin)肺復蘇(su)。
(1)心電圖
目前(qian)已知,心(xin)肌(ji)肥厚是心(xin)臟性猝死的(de)標(biao)志(zhi)性心(xin)電圖。QRS波(bo)群(qun)高電壓和側壁導聯明顯的(de)間隔部(bu)Q波(bo)的(de)出(chu)現(xian)可能(neng)是猝死的(de)危險(xian)因素(su)。大面(mian)積前(qian)壁心(xin)肌(ji)梗(geng)死的(de)患(huan)者,心(xin)電圖出(chu)現(xian)右束支阻(zu)滯,6個月的(de)猝死風(feng)險(xian)約30%。
(2)動態心電(dian)圖(Holter)
動(dong)態(tai)(tai)心(xin)(xin)(xin)(xin)電圖可使39%~82%的(de)室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)患者(zhe)得到(dao)診斷(duan),并(bing)能了解室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)的(de)頻度、復(fu)雜程(cheng)度、晝夜節(jie)律(lv)(lv)等變化,尤(you)其是心(xin)(xin)(xin)(xin)肌(ji)梗死和嚴重(zhong)的(de)冠(guan)心(xin)(xin)(xin)(xin)病患者(zhe)。動(dong)態(tai)(tai)心(xin)(xin)(xin)(xin)電圖發(fa)(fa)現的(de)室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)對心(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝(cu)死的(de)發(fa)(fa)生有(you)明確(que)的(de)預測價(jia)值(zhi)。心(xin)(xin)(xin)(xin)臟性(xing)(xing)(xing)猝(cu)死的(de)危險(xian)性(xing)(xing)(xing)隨著室(shi)性(xing)(xing)(xing)心(xin)(xin)(xin)(xin)律(lv)(lv)失(shi)常(chang)(chang)的(de)復(fu)雜性(xing)(xing)(xing)和頻發(fa)(fa)性(xing)(xing)(xing)而增(zeng)加。
(3)運動試驗
有研究(jiu)表(biao)明,運動試驗對心肌梗(geng)死后的(de)患者(zhe)發生心臟性(xing)猝(cu)死有一定(ding)的(de)預測價值。
(4)心室晚(wan)電位
(ventricular late potential,VLP) 心室(shi)(shi)(shi)晚(wan)電(dian)位(wei)是體(ti)表記錄到(dao)的局部(bu)心室(shi)(shi)(shi)延(yan)遲(chi)碎裂電(dian)活動,一般出現在QRS終末部(bu)并可延(yan)伸到(dao)ST內,呈高頻(20~80Hz)、低(di)幅(25V=碎裂波),持續(xu)10s以上。從(cong)目前已有的資料(liao)來看,心室(shi)(shi)(shi)晚(wan)電(dian)位(wei)在預測患(huan)者(zhe)(zhe)發(fa)生致命性(xing)快速性(xing)心律失常方(fang)面具有一定的價值。Brethard等報道,冠心病患(huan)者(zhe)(zhe)伴(ban)有心室(shi)(shi)(shi)晚(wan)電(dian)位(wei)陽性(xing)者(zhe)(zhe),發(fa)生心臟性(xing)猝死的危險性(xing)比心室(shi)(shi)(shi)晚(wan)電(dian)位(wei)陰性(xing)者(zhe)(zhe)高3.3倍。
臨(lin)床上須與暈(yun)厥、癔(yi)癥或癲癇相鑒別。
(1)心(xin)臟(zang)性(xing)猝(cu)(cu)死(si)的緊(jin)急治(zhi)療(liao)(liao):①心(xin)肺(fei)復蘇(su)(CPR)。早期、有(you)效(xiao)的措施(shi)至關重要(具體措施(shi)請參(can)閱心(xin)肺(fei)復蘇(su))。②進一步(bu)的心(xin)臟(zang)生(sheng)命支(zhi)持(ACLS)。早期除顫對改(gai)善(shan)存活至關重要。大約40%心(xin)臟(zang)性(xing)猝(cu)(cu)死(si)患(huan)者(zhe)在醫務人員(yuan)到達時發現(xian)有(you)心(xin)室(shi)顫動(dong)。目(mu)前至少有(you)兩個正在進行的前瞻性(xing)隨機臨床實驗,研究胺(an)(an)碘酮在院外心(xin)臟(zang)性(xing)猝(cu)(cu)死(si)患(huan)者(zhe)對電擊(ji)難治(zhi)性(xing)心(xin)室(shi)顫動(dong)中的作用。有(you)一個實驗的初步(bu)結(jie)果提示胺(an)(an)碘酮是這類患(huan)者(zhe)急診治(zhi)療(liao)(liao)的有(you)效(xiao)藥物。
(2)心(xin)臟性猝死(si)的預防性治療
一級預防治療:
可聯合使用心(xin)臟性猝(cu)死的多種預測因(yin)素。
鑒于大多數心(xin)(xin)(xin)臟(zang)性(xing)(xing)猝死(si)(si)(si)發生在(zai)冠心(xin)(xin)(xin)病的(de)患(huan)者(zhe),減(jian)輕心(xin)(xin)(xin)肌(ji)(ji)缺血(xue)(xue)(xue),預防心(xin)(xin)(xin)肌(ji)(ji)梗(geng)(geng)死(si)(si)(si)或縮小梗(geng)(geng)死(si)(si)(si)范圍,改變心(xin)(xin)(xin)肌(ji)(ji)梗(geng)(geng)死(si)(si)(si)后(hou)心(xin)(xin)(xin)室重(zhong)構(gou)的(de)藥物(wu)應能(neng)減(jian)少心(xin)(xin)(xin)臟(zang)性(xing)(xing)猝死(si)(si)(si)的(de)發生率。早期研究(jiu)顯示(shi)與藥物(wu)治療相比,外科血(xue)(xue)(xue)管重(zhong)建,使(shi)3支血(xue)(xue)(xue)管病變及左(zuo)心(xin)(xin)(xin)室功(gong)能(neng)不全(quan)(quan)的(de)冠心(xin)(xin)(xin)病患(huan)者(zhe)的(de)心(xin)(xin)(xin)臟(zang)性(xing)(xing)猝死(si)(si)(si)下降(jiang)。最近的(de)研究(jiu)顯示(shi),應用(yong)溶栓藥和(或)經皮介(jie)入治療可獲得心(xin)(xin)(xin)肌(ji)(ji)再灌注和血(xue)(xue)(xue)管重(zhong)建。已有研究(jiu)證實β-阻(zu)滯(zhi)劑在(zai)預防心(xin)(xin)(xin)肌(ji)(ji)梗(geng)(geng)死(si)(si)(si)存(cun)活者(zhe)心(xin)(xin)(xin)臟(zang)性(xing)(xing)猝死(si)(si)(si)及降(jiang)低(di)其總死(si)(si)(si)亡(wang)率方面(mian)是有效(xiao)的(de)。血(xue)(xue)(xue)管緊(jin)張素(su)轉(zhuan)換酶抑(yi)制劑(ACEI)在(zai)這方面(mian)的(de)證據要少一些(xie),但有少數研究(jiu)提示(shi),血(xue)(xue)(xue)管緊(jin)張素(su)轉(zhuan)換酶抑(yi)制劑(ACEI)使(shi)左(zuo)心(xin)(xin)(xin)室功(gong)能(neng)不全(quan)(quan)的(de)患(huan)者(zhe)的(de)心(xin)(xin)(xin)臟(zang)性(xing)(xing)猝死(si)(si)(si)減(jian)少。
已有(you)幾個隨(sui)機試(shi)(shi)驗(yan)(yan)開始(shi)實施,以比較(jiao)ICD和藥(yao)物對心(xin)臟性(xing)(xing)猝死(si)一(yi)級預防的(de)效果(guo)。在多中心(xin)自動(dong)心(xin)臟復(fu)律除顫器(qi)植入試(shi)(shi)驗(yan)(yan)(MADIT)中,對非持續性(xing)(xing)室性(xing)(xing)心(xin)動(dong)過速、心(xin)肌梗死(si)后左室功(gong)能(neng)差以及(ji)電生理檢查時可誘發出用普魯卡因胺(an)不能(neng)抑制的(de)室性(xing)(xing)心(xin)動(dong)過速患(huan)者(zhe)(zhe),ICD比常(chang)(chang)規抗心(xin)律失常(chang)(chang)藥(yao)物更(geng)有(you)效。但(dan)最(zui)近報道的(de)冠狀動(dong)脈旁路移植(CABG)補片試(shi)(shi)驗(yan)(yan)(patch trail)證明(ming)給伴(ban)左室功(gong)能(neng)不全和信號平均心(xin)電圖異常(chang)(chang)的(de)患(huan)者(zhe)(zhe)做CABG時,預防性(xing)(xing)植入ICD,并(bing)不能(neng)改善存(cun)活。
二級預防治療:
①抗(kang)心律失(shi)常(chang)藥:
心(xin)(xin)(xin)臟性猝死的發生機制(zhi)主(zhu)要是心(xin)(xin)(xin)室(shi)顫動(dong),從理論(lun)上講,使用抗心(xin)(xin)(xin)律失(shi)常藥物控制(zhi)或消(xiao)除各種室(shi)性心(xin)(xin)(xin)律失(shi)常具有防治心(xin)(xin)(xin)臟性猝死的作用,但是,不同抗心(xin)(xin)(xin)律失(shi)常藥物的臨(lin)床(chuang)使用結果卻不盡相同。
Ⅰ類(lei)抗心律失(shi)常(chang)藥(yao)物(wu)一度(du)使(shi)用(yong)(yong)十分廣泛(fan),但到目前(qian)為止,一些大規模隨機臨床試驗的結果表(biao)明,許多(duo)Ⅰ類(lei)抗心律失(shi)常(chang)藥(yao)物(wu)的使(shi)用(yong)(yong)并不能降低(di)心臟性猝(cu)(cu)死(si)(si)的發生率,相反卻(que)使(shi)心臟性猝(cu)(cu)死(si)(si)的發生率升(sheng)高,其中,比較典型(xing)的是CAST。
CAST即心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)抑(yi)制(zhi)(zhi)實驗(yan)(Cardiac arrhythmic suppression trial,CAST),是(shi)一(yi)(yi)項(xiang)由美(mei)國(guo)國(guo)立心(xin)(xin)(xin)(xin)肺(fei)血液研究組(zu)織的(de)(de)隨機、雙盲(mang)對照的(de)(de)多中心(xin)(xin)(xin)(xin)臨床試(shi)驗(yan)。旨(zhi)在確定抗(kang)(kang)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)藥(yao)物(wu)抑(yi)制(zhi)(zhi)心(xin)(xin)(xin)(xin)肌梗死(si)后(hou)無癥狀(zhuang)或伴(ban)有輕度癥狀(zhuang)的(de)(de)室(shi)(shi)性(xing)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang),并了解能否降低(di)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)所致的(de)(de)病死(si)率。1989年報(bao)道的(de)(de)CASTⅠ結果發表(biao)在《新英格蘭醫院學雜志》第321卷上。這(zhe)些(xie)研究結果表(biao)明(ming),Ⅰc類(lei)抗(kang)(kang)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)藥(yao)物(wu)不(bu)僅(jin)不(bu)能降低(di)心(xin)(xin)(xin)(xin)肌梗死(si)后(hou)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)的(de)(de)發生(sheng)(sheng)率,相反卻可(ke)使患(huan)者(zhe)的(de)(de)心(xin)(xin)(xin)(xin)臟猝死(si)率增加。其原因可(ke)能與下列2個因素有關,一(yi)(yi)是(shi)Ⅰ類(lei)抗(kang)(kang)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)藥(yao)物(wu)本(ben)身(shen)具有促(cu)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)作(zuo)用;二是(shi)Ⅰc類(lei)抗(kang)(kang)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)藥(yao)物(wu)具有不(bu)同程度的(de)(de)心(xin)(xin)(xin)(xin)肌抑(yi)制(zhi)(zhi)作(zuo)用,可(ke)使患(huan)者(zhe)的(de)(de)心(xin)(xin)(xin)(xin)功能進一(yi)(yi)步減退,射血分數進一(yi)(yi)步降低(di)。但是(shi),CAST僅(jin)僅(jin)是(shi)在心(xin)(xin)(xin)(xin)肌梗死(si)后(hou)的(de)(de)室(shi)(shi)性(xing)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)患(huan)者(zhe)中進行的(de)(de),在非心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)的(de)(de)患(huan)者(zhe)發生(sheng)(sheng)的(de)(de)室(shi)(shi)性(xing)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)中,Ⅰc類(lei)抗(kang)(kang)心(xin)(xin)(xin)(xin)律(lv)失(shi)(shi)常(chang)(chang)藥(yao)物(wu)能否降低(di)心(xin)(xin)(xin)(xin)臟性(xing)猝死(si)的(de)(de)發生(sheng)(sheng)率,目前尚不(bu)清(qing)楚。
在(zai)抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)藥(yao)物(wu)中(zhong)(zhong),目前Ⅲ類抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)藥(yao)物(wu)是(shi)最(zui)受推崇(chong)的(de)(de)(de)(de),其原因是(shi)這些藥(yao)物(wu)不(bu)僅能(neng)有(you)(you)(you)(you)(you)效控(kong)制各(ge)種室(shi)(shi)性(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang),而(er)且(qie)一些多中(zhong)(zhong)心(xin)(xin)(xin)(xin)(xin)(xin)隨(sui)(sui)機臨床(chuang)試(shi)驗(yan)(yan)結(jie)果表(biao)(biao)明胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong),長期(qi)口服時(shi)能(neng)增(zeng)加各(ge)種心(xin)(xin)(xin)(xin)(xin)(xin)肌組(zu)(zu)(zu)(zu)織的(de)(de)(de)(de)動(dong)(dong)作(zuo)(zuo)(zuo)(zuo)電位時(shi)程和(he)(he)(he)有(you)(you)(you)(you)(you)效不(bu)應期(qi),對各(ge)種室(shi)(shi)上性(xing)(xing)(xing)(xing)和(he)(he)(he)室(shi)(shi)性(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang),包括(kuo)心(xin)(xin)(xin)(xin)(xin)(xin)房顫動(dong)(dong)、心(xin)(xin)(xin)(xin)(xin)(xin)房撲動(dong)(dong)和(he)(he)(he)室(shi)(shi)上性(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)動(dong)(dong)過速等都有(you)(you)(you)(you)(you)較好的(de)(de)(de)(de)效果。口服劑(ji)(ji)量為(wei)200~800mg/d,,胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)除了Ⅲ類抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)藥(yao)物(wu)的(de)(de)(de)(de)特(te)性(xing)(xing)(xing)(xing)外(wai),還有(you)(you)(you)(you)(you)Ⅰ類抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)藥(yao)物(wu)作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong),表(biao)(biao)現(xian)為(wei)使用(yong)(yong)(yong)依(yi)賴性(xing)(xing)(xing)(xing)動(dong)(dong)力學(xue)(xue)特(te)征,并具(ju)有(you)(you)(you)(you)(you)一定(ding)的(de)(de)(de)(de)阻(zu)滯(zhi)作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)和(he)(he)(he)鈣通道阻(zu)滯(zhi)作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong),其主(zhu)要代謝產物(wu)脫(tuo)乙基胺(an)(an)(an)腆(tian)酮(tong)(tong)(tong)(tong)仍具(ju)有(you)(you)(you)(you)(you)抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)。胺(an)(an)(an)腆(tian)酮(tong)(tong)(tong)(tong)和(he)(he)(he)Ⅰc類抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)藥(yao)物(wu)不(bu)同,除了發(fa)揮抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)之外(wai),還有(you)(you)(you)(you)(you)冠狀動(dong)(dong)脈擴(kuo)張作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)、抗(kang)(kang)(kang)(kang)(kang)交感神經的(de)(de)(de)(de)激活(huo)作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)和(he)(he)(he)抗(kang)(kang)(kang)(kang)(kang)甲狀腺作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)。近年來,一些研究(jiu)發(fa)現(xian)胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)還有(you)(you)(you)(you)(you)抗(kang)(kang)(kang)(kang)(kang)氧化作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)和(he)(he)(he)拮抗(kang)(kang)(kang)(kang)(kang)鈣調節(jie)蛋白的(de)(de)(de)(de)作(zuo)(zuo)(zuo)(zuo)用(yong)(yong)(yong)。在(zai)心(xin)(xin)(xin)(xin)(xin)(xin)肌缺血(xue)時(shi),胺(an)(an)(an)腆(tian)酮(tong)(tong)(tong)(tong)能(neng)保護線粒體的(de)(de)(de)(de)完(wan)整性(xing)(xing)(xing)(xing)和(he)(he)(he)高(gao)能(neng)磷酸鹽的(de)(de)(de)(de)功能(neng)。因此,從(cong)理論上講(jiang),胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)在(zai)室(shi)(shi)性(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)的(de)(de)(de)(de)防(fang)治(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)具(ju)有(you)(you)(you)(you)(you)自己獨(du)特(te)的(de)(de)(de)(de)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)價值(zhi)(zhi)。“巴塞爾心(xin)(xin)(xin)(xin)(xin)(xin)肌梗幸存(cun)者(zhe)(zhe)(zhe)的(de)(de)(de)(de)抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)研究(jiu)(Basel antiarrhythmic study of infarction survival,BASIS)”在(zai)臨床(chuang)實踐(jian)中(zhong)(zhong)提(ti)示胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)在(zai)心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)(xing)猝死(si)(si)(si)防(fang)治(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)的(de)(de)(de)(de)價值(zhi)(zhi)。BASIS由(you)瑞士學(xue)(xue)者(zhe)(zhe)(zhe)完(wan)成,入選病(bing)例為(wei)心(xin)(xin)(xin)(xin)(xin)(xin)肌梗死(si)(si)(si)后(hou)8~24天(tian)并伴(ban)有(you)(you)(you)(you)(you)室(shi)(shi)性(xing)(xing)(xing)(xing)期(qi)前收縮(suo)(suo)在(zai)Lown氏(shi)分(fen)(fen)級4~6級的(de)(de)(de)(de)患者(zhe)(zhe)(zhe)。321例患者(zhe)(zhe)(zhe)被隨(sui)(sui)機分(fen)(fen)為(wei)2組(zu)(zu)(zu)(zu),分(fen)(fen)別用(yong)(yong)(yong)安(an)慰劑(ji)(ji)、胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)和(he)(he)(he)其他抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)藥(yao)物(wu)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao),結(jie)果胺(an)(an)(an)腆(tian)酮(tong)(tong)(tong)(tong)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)的(de)(de)(de)(de)心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)(xing)猝死(si)(si)(si)率(lv)(lv)為(wei)5%,顯著低于安(an)慰劑(ji)(ji)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)的(de)(de)(de)(de)11.4%t和(he)(he)(he)其他抗(kang)(kang)(kang)(kang)(kang)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)藥(yao)物(wu)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)的(de)(de)(de)(de)9%。此外(wai),另外(wai)兩項大規模(mo)隨(sui)(sui)機臨床(chuang)試(shi)驗(yan)(yan)“加拿大胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)心(xin)(xin)(xin)(xin)(xin)(xin)肌梗死(si)(si)(si)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)試(shi)驗(yan)(yan)(Canadian amiodarone myocardial infarction arrhythmia trial,CAMIAT)”和(he)(he)(he)歐洲心(xin)(xin)(xin)(xin)(xin)(xin)肌梗死(si)(si)(si)胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)試(shi)驗(yan)(yan)“European myocardial infarction amiodarone trial,EMIAT)”正在(zai)進(jin)行,最(zui)后(hou)結(jie)果尚未揭(jie)曉。CAMLAT有(you)(you)(you)(you)(you)21個(ge)醫(yi)學(xue)(xue)中(zhong)(zhong)心(xin)(xin)(xin)(xin)(xin)(xin)參加,計劃(hua)入選心(xin)(xin)(xin)(xin)(xin)(xin)肌梗死(si)(si)(si)后(hou)6~45天(tian)伴(ban)室(shi)(shi)性(xing)(xing)(xing)(xing)期(qi)前收縮(suo)(suo)10次(ci)/h以上或(huo)室(shi)(shi)性(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)動(dong)(dong)過速1次(ci)以上的(de)(de)(de)(de)患者(zhe)(zhe)(zhe),隨(sui)(sui)機分(fen)(fen)為(wei)胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)和(he)(he)(he)安(an)慰劑(ji)(ji)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu),預(yu)試(shi)完(wan)成77例,20個(ge)月的(de)(de)(de)(de)觀(guan)察(cha)表(biao)(biao)明,胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)的(de)(de)(de)(de)病(bing)死(si)(si)(si)率(lv)(lv)4%而(er)安(an)慰劑(ji)(ji)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)的(de)(de)(de)(de)病(bing)死(si)(si)(si)率(lv)(lv)14%。EMIAT由(you)61個(ge)醫(yi)學(xue)(xue)中(zhong)(zhong)心(xin)(xin)(xin)(xin)(xin)(xin)參加,計劃(hua)入選心(xin)(xin)(xin)(xin)(xin)(xin)肌梗死(si)(si)(si)后(hou)5~21天(tian)、左心(xin)(xin)(xin)(xin)(xin)(xin)室(shi)(shi)射血(xue)分(fen)(fen)數(shu)在(zai)40%以下的(de)(de)(de)(de)室(shi)(shi)性(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)患者(zhe)(zhe)(zhe),隨(sui)(sui)機分(fen)(fen)為(wei)安(an)慰劑(ji)(ji)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)和(he)(he)(he)胺(an)(an)(an)碘(dian)酮(tong)(tong)(tong)(tong)治(zhi)(zhi)(zhi)(zhi)療(liao)(liao)組(zu)(zu)(zu)(zu)。中(zhong)(zhong)期(qi)結(jie)果表(biao)(biao)明,胺(an)(an)(an)腆(tian)酮(tong)(tong)(tong)(tong)可顯著降低心(xin)(xin)(xin)(xin)(xin)(xin)肌梗死(si)(si)(si)后(hou)室(shi)(shi)性(xing)(xing)(xing)(xing)心(xin)(xin)(xin)(xin)(xin)(xin)律(lv)(lv)(lv)失(shi)(shi)(shi)(shi)常(chang)(chang)(chang)(chang)患者(zhe)(zhe)(zhe)的(de)(de)(de)(de)心(xin)(xin)(xin)(xin)(xin)(xin)臟(zang)(zang)性(xing)(xing)(xing)(xing)猝死(si)(si)(si)率(lv)(lv)。
索(suo)他(ta)洛爾(sotalol)與胺碘酮相(xiang)似,也(ye)具(ju)有(you)混合性抗(kang)心律失(shi)常(chang)作用(yong)。許多(duo)(duo)學者(zhe)的臨(lin)床觀(guan)察(cha)表明,索(suo)他(ta)洛爾對(dui)心律失(shi)常(chang)患者(zhe)的生存有(you)益,但還(huan)缺乏長(chang)期多(duo)(duo)中(zhong)心臨(lin)床試驗的結果(guo)。
②β-腎(shen)上(shang)腺(xian)素(su)受(shou)體阻(zu)滯藥(yao):β-腎(shen)上(shang)腺(xian)能受(shou)體阻(zu)滯藥(yao)的(de)作(zuo)用在(zai)于競(jing)爭心臟,血(xue)管和(he)支氣管等組織器官β腎(shen)上(shang)的(de)腺(xian)素(su)能受(shou)體,使受(shou)體不能恢復(fu)到高親和(he)力狀態而(er)與激動劑結(jie)合,從(cong)而(er)抑制β腎(shen)上(shang)腺(xian)素(su)能受(shou)體的(de)活性而(er)發揮一系(xi)列的(de)藥(yao)理作(zuo)用。
β受體阻滯(zhi)藥在心臟(zang)(zang)性猝死中的(de)應用價值仍(reng)有(you)爭(zheng)議(yi),但(dan)多數學者認(ren)為在一些心臟(zang)(zang)的(de)某一亞(ya)組(zu)可使(shi)心臟(zang)(zang)性猝死的(de)發生(sheng)率降低。
到(dao)目前為止,已有(you)大量的(de)研(yan)究提示,心肌(ji)梗死(si)(si)后的(de)患者接受(shou)β受(shou)體阻滯(zhi)(zhi)劑治療(liao)非(fei)常(chang)有(you)益,特(te)別是在(zai)(zai)降低(di)(di)(di)心臟(zang)(zang)性猝(cu)死(si)(si)方面(mian)有(you)較顯(xian)著的(de)意義,并且還有(you)人發現,在(zai)(zai)一定范圍內心率(lv)(lv)降得越慢效果(guo)越明顯(xian)。已有(you)2項(xiang)多中心隨機臨床(chuang)試驗-(MIAMI)和(he)(ISIS-I)觀察(cha)了β受(shou)體阻滯(zhi)(zhi)劑在(zai)(zai)胸痛發作(zuo)12~24h內早期干(gan)預的(de)作(zuo)用(yong)。MIAMI入(ru)(ru)選(xuan)胸痛發作(zuo)24h以(yi)內的(de)心肌(ji)梗死(si)(si)患者5778例,首先使用(yong)美托洛爾15mg靜脈注射,然后200mg/d口服(fu),1周(zhou)病死(si)(si)率(lv)(lv)下降13%。ISIS-I入(ru)(ru)選(xuan)胸痛發作(zuo)12h內的(de)心肌(ji)梗死(si)(si)患者16000例,首先靜脈注射阿替(ti)洛爾5~10mg,然后每周(zhou)口服(fu)100mg,1周(zhou)內心血(xue)管病死(si)(si)率(lv)(lv)下降15%。β-受(shou)體阻滯(zhi)(zhi)藥的(de)作(zuo)用(yong)主要(yao)是降低(di)(di)(di)了心室顫動或(huo)心臟(zang)(zang)破裂的(de)發生率(lv)(lv)。在(zai)(zai)心肌(ji)梗死(si)(si)的(de)后期,使用(yong)β-受(shou)體阻滯(zhi)(zhi)藥可使心血(xue)管總病死(si)(si)率(lv)(lv)降低(di)(di)(di)20%~25%,但對心臟(zang)(zang)性猝(cu)死(si)(si)發生率(lv)(lv)的(de)影響尚不(bu)清楚。
在高(gao)血壓患者中(zhong),β-受(shou)體(ti)阻滯藥治(zhi)療也對心(xin)臟(zang)性(xing)(xing)(xing)猝死具有(you)防治(zhi)作用(yong)。但更(geng)多的學者認為,只(zhi)有(you)脂溶性(xing)(xing)(xing)的β-受(shou)體(ti)阻滯藥如(ru)美托洛(luo)爾(er)才能(neng)有(you)效地降(jiang)低心(xin)臟(zang)性(xing)(xing)(xing)猝死的發生率。脂溶性(xing)(xing)(xing)β-受(shou)體(ti)阻滯藥在消化道易于(yu)吸收(shou),易于(yu)通過血腦(nao)屏障,在中(zhong)樞神經系(xi)統可以達到較高(gao)的血藥濃度。一些小樣(yang)本研究提示(shi),選(xuan)擇性(xing)(xing)(xing)β-受(shou)體(ti)阻滯藥美托洛(luo)爾(er)和阿替(ti)爾(er)對心(xin)臟(zang)性(xing)(xing)(xing)猝死的防治(zhi)有(you)效。
③正性肌力藥物:
在(zai)(zai)充血(xue)性(xing)心(xin)(xin)(xin)力(li)衰(shuai)竭患者中,心(xin)(xin)(xin)臟(zang)性(xing)猝死的(de)(de)(de)發生很高。1993年,Goldman等報(bao)道,冠心(xin)(xin)(xin)病引(yin)起的(de)(de)(de)充血(xue)性(xing)心(xin)(xin)(xin)力(li)衰(shuai)竭患者中44%死于心(xin)(xin)(xin)臟(zang)性(xing)猝死;非(fei)冠心(xin)(xin)(xin)病引(yin)起的(de)(de)(de)充血(xue)性(xing)心(xin)(xin)(xin)力(li)衰(shuai)竭患者中,心(xin)(xin)(xin)臟(zang)性(xing)猝死的(de)(de)(de)發生率為48%。因(yin)此,正性(xing)肌力(li)藥物在(zai)(zai)心(xin)(xin)(xin)臟(zang)性(xing)猝死防治中的(de)(de)(de)價值受到人們的(de)(de)(de)關注。
正性(xing)肌力(li)藥物主要包括兩(liang)類,即(ji)洋地黃類藥物和cAMP依賴(lai)性(xing)強(qiang)心劑。
洋(yang)地(di)黃類藥(yao)物仍(reng)是目前治療(liao)心(xin)(xin)力(li)(li)(li)衰(shuai)竭(jie)的(de)(de)(de)(de)(de)基本(ben)藥(yao)物。近(jin)年來的(de)(de)(de)(de)(de)研究表明,洋(yang)地(di)黃類藥(yao)物不(bu)僅能(neng)(neng)增強心(xin)(xin)肌(ji)收(shou)縮力(li)(li)(li)、減慢心(xin)(xin)率和(he)傳導,而且(qie)具有(you)神經內(nei)分泌調節作用,可改善(shan)心(xin)(xin)力(li)(li)(li)衰(shuai)竭(jie)患者的(de)(de)(de)(de)(de)壓力(li)(li)(li)感受器功(gong)能(neng)(neng)低下(xia)和(he)交(jiao)感神經系(xi)統、腎素(su)-血管(guan)緊張素(su)-醛固酮系(xi)統的(de)(de)(de)(de)(de)功(gong)能(neng)(neng)亢(kang)進,并(bing)可提(ti)(ti)高(gao)心(xin)(xin)鈉素(su)的(de)(de)(de)(de)(de)分泌,降低心(xin)(xin)臟前負荷(he)。盡管(guan)洋(yang)地(di)黃的(de)(de)(de)(de)(de)應用已(yi)有(you)200多年的(de)(de)(de)(de)(de)歷史,但(dan)他(ta)在充血性心(xin)(xin)力(li)(li)(li)衰(shuai)竭(jie)治療(liao)中是否(fou)能(neng)(neng)降低心(xin)(xin)臟性猝(cu)(cu)死的(de)(de)(de)(de)(de)發生率仍(reng)不(bu)十分清楚。1998年以來,已(yi)有(you)幾項大規模(mo)隨(sui)機臨床試(shi)驗結果可直接或(huo)間接反(fan)映(ying)地(di)高(gao)辛(xin)治療(liao)心(xin)(xin)力(li)(li)(li)衰(shuai)竭(jie)是有(you)效的(de)(de)(de)(de)(de),不(bu)僅能(neng)(neng)改善(shan)充血性心(xin)(xin)力(li)(li)(li)衰(shuai)竭(jie)的(de)(de)(de)(de)(de)癥狀,而且(qie)可以提(ti)(ti)高(gao)患者的(de)(de)(de)(de)(de)運(yun)動量(liang)和(he)心(xin)(xin)功(gong)能(neng)(neng),但(dan)均(jun)未闡明地(di)高(gao)辛(xin)對(dui)心(xin)(xin)臟性猝(cu)(cu)死的(de)(de)(de)(de)(de)防治作用。
CAMP依(yi)(yi)賴性強心劑(ji)(ji)包括(kuo):受體激動劑(ji)(ji)和(he)磷酸二酯(zhi)酶Ⅲ抑制劑(ji)(ji)。前者主要多巴酚丁(ding)胺、沙丁(ding)胺醇(chun)等;后者包括(kuo)氨(an)力農。米力農。臨床實踐的(de)(de)結果(guo)表明,cAMP依(yi)(yi)賴性強心劑(ji)(ji)在增(zeng)強心肌收縮力和(he)改(gai)善患者的(de)(de)癥狀方面具(ju)有一度的(de)(de)療(liao)效(xiao),但口服給(gei)藥(yao)的(de)(de)不良反應較多,而且可增(zeng)加心臟性猝(cu)死的(de)(de)發生(sheng)率。因(yin)此,氨(an)力農和(he)米力農等藥(yao)物的(de)(de)口服給(gei)藥(yao)已經禁(jin)止(zhi)采用(yong)。
④抗血小板藥:
A.臨床常用的(de)抗血小板藥物及其作用原理:
抗血小板(ban)(ban)藥物(wu)是指能阻礙血小板(ban)(ban)黏附、聚集和釋放反應,以防止(zhi)血栓(shuan)形成的藥物(wu)。根據作用的環節,常(chang)用的抗血小板(ban)(ban)藥物(wu)包括以下幾類:
a.環(huan)氧化(hua)酶抑制藥:
包括阿司匹林(lin)(aspirin)、磺吡酮(苯磺唑(zuo)酮)等。阿司匹林(lin)是一種(zhong)非(fei)甾體(ti)抗炎藥,1971年發現它有(you)抑制環氧化酶的(de)作用,目前已成為最常用的(de)抗血小板藥物。
花生四烯酸在環氧化酶(即(ji)前列腺素(su)合成(cheng)(cheng)(cheng)酶)的作(zuo)用(yong)下(xia)形(xing)成(cheng)(cheng)(cheng)不(bu)穩(wen)(wen)定(ding)的環內過氧化物(wu)(wu),即(ji)前列腺素(su)C2(PGG2)和前列腺素(su)H2(PGH2)。環內過氧化物(wu)(wu)在血(xue)(xue)(xue)小(xiao)板微(wei)粒體中血(xue)(xue)(xue)栓(shuan)烷合酶的作(zuo)用(yong)下(xia)生成(cheng)(cheng)(cheng)血(xue)(xue)(xue)栓(shuan)素(su)A2(TXA2),但TXA2不(bu)穩(wen)(wen)定(ding),半(ban)衰期為30s,迅速轉(zhuan)變為穩(wen)(wen)定(ding)的TXB2。在血(xue)(xue)(xue)管壁(bi)微(wei)粒體中,環內過氧化物(wu)(wu)在6(9)-環氧化酶作(zuo)用(yong)下(xia)合成(cheng)(cheng)(cheng)前列腺素(su)I2(PGl2),然后(hou)代謝為6-酮-PGFla。TAX2使血(xue)(xue)(xue)管收縮(suo),降低(di)血(xue)(xue)(xue)小(xiao)板cAMP,促(cu)進血(xue)(xue)(xue)小(xiao)板聚集和血(xue)(xue)(xue)栓(shuan)形(xing)成(cheng)(cheng)(cheng)。
阿司匹林(lin)主要抑制(zhi)環氧化(hua)酶,使其活性基(ji)團乙酰化(hua),從而(er)阻止TXA2和(he)PGI2的(de)生成。由于阿司匹林(lin)在抑制(zhi)TXB2的(de)同時,也對(dui)PGI2造成了抑制(zhi),則阿司匹林(lin)使用(yong)的(de)有益作(zuo)用(yong)被削弱或(huo)抵消。大(da)量研究(jiu)表(biao)明,75~325mg/d的(de)阿司匹林(lin)給藥對(dui)PGI2的(de)影(ying)響(xiang)較弱或(huo)幾乎(hu)沒有影(ying)響(xiang),而(er)對(dui)TXB2的(de)仍(reng)有明顯的(de)抑制(zhi)作(zuo)用(yong)。
磺吡(bi)酮(苯(ben)磺唑酮)是(shi)保太松類藥物(wu)(wu)的衍生物(wu)(wu),1950年被用于治療(liao)痛(tong)風,1965年發現它對(dui)血小板功能具(ju)有明(ming)顯影(ying)響。現已知道(dao),主要抑制(zhi)(zhi)血小板的環(huan)氧化酶而(er)抑制(zhi)(zhi)TXA2的合成,并可抑制(zhi)(zhi)血小板的聚集和釋放反應。對(dui)血管內(nei)皮細胞(bao)合成的PGI2影(ying)響極小。
b.磷酸二(er)酯酶(mei)抑制藥(yao):
包括雙(shuang)嘧(mi)達(da)(da)莫(persantine)等。雙(shuang)嘧(mi)達(da)(da)莫又(you)叫(jiao)潘(pan)生丁(ding),是(shi)一種廣泛應用(yong)于臨床(chuang)的(de)(de)抗(kang)血(xue)小(xiao)板(ban)藥物,其機(ji)制是(shi)抑制血(xue)小(xiao)板(ban)的(de)(de)磷(lin)酸二酯酶(mei),使血(xue)小(xiao)板(ban)的(de)(de)cAMP含量升高。同時,雙(shuang)嘧(mi)達(da)(da)莫(潘(pan)生丁(ding))還(huan)可(ke)通(tong)過(guo)增加(jia)血(xue)液的(de)(de)腺苷(gan)(gan)(gan)濃(nong)度(du)而抑制血(xue)小(xiao)板(ban)的(de)(de)聚集和釋(shi)放反應。潘(pan)生丁(ding)可(ke)抑制紅細(xi)胞(bao)和心、肺等組織細(xi)胞(bao)對血(xue)中(zhong)腺苷(gan)(gan)(gan)的(de)(de)攝取。則腺苷(gan)(gan)(gan)不能被腺苷(gan)(gan)(gan)脫(tuo)胺(an)酶(mei)所破壞,血(xue)液中(zhong)腺苷(gan)(gan)(gan)水平增加(jia),一般口服給藥,每次400mg,1~2次/d。主要不良反應為胃腸道癥狀。
c.血栓(shuan)合成(cheng)酶抑制藥:
包括水楊酸(suan)咪唑(咪唑)、達唑氧苯(dazoxiben)、對(dui)乙(yi)酰氨基(ji)酚(APA)等(deng)。
d.腺苷酸環(huan)化酶激活劑:
依(yi)前(qian)(qian)列醇(chun)(前(qian)(qian)列腺(xian)素I2)和前(qian)(qian)列地(di)爾(前(qian)(qian)列腺(xian)素E1) 等(deng)。
e.其他:
噻氯匹(pi)定(ding)(噻氯吡啶)、舒洛地爾(suloctidil)等。
B.抗血小板藥物防治心臟性猝死的價(jia)值:
在(zai)(zai)抗血(xue)小板藥物的(de)(de)研(yan)究(jiu)中(zhong),較(jiao)多的(de)(de)資(zi)料為(wei)(wei)阿(a)(a)司(si)匹(pi)林(lin)。許(xu)多研(yan)究(jiu)表明,阿(a)(a)司(si)匹(pi)林(lin)在(zai)(zai)穩(wen)定(ding)性和不(bu)穩(wen)定(ding)性心(xin)(xin)絞痛患者中(zhong)的(de)(de)應用(yong)后,可(ke)顯著(zhu)降(jiang)低(di)致(zhi)死(si)(si)(si)性和非致(zhi)死(si)(si)(si)性心(xin)(xin)肌梗(geng)(geng)死(si)(si)(si)的(de)(de)發(fa)(fa)生率(lv);在(zai)(zai)心(xin)(xin)肌梗(geng)(geng)死(si)(si)(si)患者應用(yong)后,可(ke)顯著(zhu)降(jiang)低(di)再梗(geng)(geng)死(si)(si)(si)的(de)(de)發(fa)(fa)生率(lv)。但是,有(you)關阿(a)(a)司(si)匹(pi)林(lin)防治心(xin)(xin)臟(zang)病(bing)猝(cu)死(si)(si)(si)的(de)(de)價(jia)值,不(bu)同(tong)學者的(de)(de)報道不(bu)盡一致(zhi)。德國-奧地利多中(zhong)心(xin)(xin)研(yan)究(jiu)結果(guo)(guo)提(ti)示,阿(a)(a)司(si)匹(pi)林(lin)對心(xin)(xin)臟(zang)性猝(cu)死(si)(si)(si)的(de)(de)防治有(you)一定(ding)作用(yong)。Elwood等報道用(yong)阿(a)(a)司(si)匹(pi)林(lin)治療心(xin)(xin)肌梗(geng)(geng)死(si)(si)(si)進行隨(sui)機、雙(shuang)盲大宗病(bing)例研(yan)究(jiu)的(de)(de)結果(guo)(guo),發(fa)(fa)現在(zai)(zai)心(xin)(xin)肌梗(geng)(geng)死(si)(si)(si)后6周以內使用(yong)阿(a)(a)司(si)匹(pi)林(lin)者,33個月隨(sui)訪期間(jian)的(de)(de)心(xin)(xin)臟(zang)性猝(cu)死(si)(si)(si)率(lv)在(zai)(zai)阿(a)(a)司(si)匹(pi)林(lin)組(zu)為(wei)(wei)7.8%、安慰劑組(zu)為(wei)(wei)13.5%,阿(a)(a)司(si)匹(pi)林(lin)組(zu)心(xin)(xin)臟(zang)性猝(cu)死(si)(si)(si)的(de)(de)發(fa)(fa)生率(lv)降(jiang)低(di)了42%。如(ru)果(guo)(guo)阿(a)(a)司(si)匹(pi)林(lin)的(de)(de)使用(yong)時(shi)間(jian)較(jiao)晚則對心(xin)(xin)臟(zang)性猝(cu)死(si)(si)(si)的(de)(de)發(fa)(fa)生率(lv)無明顯作用(yong)。
雙(shuang)嘧達(da)莫(潘生丁(ding))在心(xin)臟(zang)性猝死防治中的評價研究多為與阿司(si)(si)匹林聯(lian)合應用(yong)。雙(shuang)嘧達(da)莫(潘生丁(ding))和(he)阿司(si)(si)匹林的再梗死研究(PARIS)的結果提示,雙(shuang)嘧達(da)莫(潘生丁(ding))和(he)阿司(si)(si)匹林合用(yong)可降(jiang)低心(xin)肌梗死后(hou)的總病死率和(he)心(xin)臟(zang)性猝死發生率。
磺(huang)吡(bi)酮(tong)(苯磺(huang)唑(zuo)(zuo)酮(tong))在心臟(zang)性猝死防治(zhi)中的價(jia)值研(yan)究不多。美國磺(huang)吡(bi)酮(tong)(苯磺(huang)唑(zuo)(zuo)酮(tong))研(yan)究組報(bao)道,在6個月內,磺(huang)吡(bi)酮(tong)(苯磺(huang)唑(zuo)(zuo)酮(tong))可(ke)顯著降低心臟(zang)性猝死的發生率;而在6個月后(hou)對心臟(zang)性猝死的發生率無(wu)明(ming)顯影響。
⑤血管緊張素轉換(huan)酶抑(yi)制藥:
血管緊張素轉換酶抑制藥(yao)(angiotensin converting enzyme inhibitor,ACEI)是目(mu)前世(shi)界上發展最快的一(yi)類心血管藥(yao)物,目(mu)前在臨(lin)床上得到廣泛(fan)應用,許(xu)多(duo)研究發現(xian),ACEI對心肌(ji)梗死(si)、高血壓(ya)和充血性心力衰竭(jie)等(deng)疾病可能并發的心臟性猝死(si)具有一(yi)定的防治作用。
目(mu)前(qian),ACEI已發(fa)展到幾十(shi)種(zhong)(zhong)。根據其(qi)含(han)有(you)(you)的(de)(de)(de)基(ji)(ji)(ji)團不同,ACEI可(ke)(ke)分(fen)為3種(zhong)(zhong)類型:A.含(han)巰基(ji)(ji)(ji)的(de)(de)(de)ACEI。主要有(you)(you)卡托普(pu)利(li)(captopril);B.含(han)羥基(ji)(ji)(ji)的(de)(de)(de)ACEI。主要有(you)(you)依(yi)那(nei)普(pu)利(li)(enalapril)、雷米(mi)普(pu)利(li)(ramipril)、貝那(nei)普(pu)利(li)(苯(ben)拉普(pu)利(li))等。C.含(han)磷(lin)(lin)酰基(ji)(ji)(ji)的(de)(de)(de)ACEI。主要有(you)(you)福辛普(pu)利(li)(fosinopril)等。其(qi)基(ji)(ji)(ji)本作用機(ji)制是抑制血管(guan)(guan)緊張(zhang)(zhang)素轉(zhuan)換酶(mei),血管(guan)(guan)緊張(zhang)(zhang)素轉(zhuan)換酶(mei)是一種(zhong)(zhong)含(han)有(you)(you)鋅離(li)子的(de)(de)(de)金屬蛋白,各個活(huo)(huo)性(xing)(xing)部位都(dou)含(han)有(you)(you)鋅離(li)子,ACEI的(de)(de)(de)巰基(ji)(ji)(ji)、羥基(ji)(ji)(ji)或磷(lin)(lin)酰基(ji)(ji)(ji)可(ke)(ke)與(yu)鋅離(li)子發(fa)生牢固的(de)(de)(de)絡合(he)作用而(er)使(shi)血管(guan)(guan)緊張(zhang)(zhang)素轉(zhuan)換酶(mei)失去(qu)活(huo)(huo)性(xing)(xing)。結果血管(guan)(guan)緊張(zhang)(zhang)素Ⅰ不能(neng)轉(zhuan)變為血管(guan)(guan)緊張(zhang)(zhang)素Ⅱ,可(ke)(ke)導致血管(guan)(guan)擴(kuo)張(zhang)(zhang)、醛固酮分(fen)泌減少和交(jiao)感(gan)神(shen)經(jing)張(zhang)(zhang)力降(jiang)低。此外,ACEI還可(ke)(ke)抑制激肽酶(mei),減慢緩(huan)激肽的(de)(de)(de)降(jiang)解,引(yin)(yin)起血管(guan)(guan)擴(kuo)張(zhang)(zhang);同時(shi),緩(huan)激肽的(de)(de)(de)濃度(du)增(zeng)(zeng)高(gao)(gao)可(ke)(ke)激活(huo)(huo)前(qian)磷(lin)(lin)脂酶(mei)而(er)使(shi)前(qian)列腺素的(de)(de)(de)生成增(zeng)(zeng)加。ACEI還可(ke)(ke)減少鈣離(li)子內流,使(shi)心(xin)肌細(xi)胞內鈣離(li)子超負荷而(er)引(yin)(yin)起的(de)(de)(de)心(xin)律失常減少。這些作用對于冠(guan)心(xin)病、高(gao)(gao)血壓病和充血性(xing)(xing)心(xin)力衰竭(jie)等具有(you)(you)治療(liao)價值,還可(ke)(ke)增(zeng)(zeng)加心(xin)肌細(xi)胞電活(huo)(huo)動(dong)的(de)(de)(de)穩定性(xing)(xing)。
⑥代謝類藥物:
曲美他嗪(萬爽力),抑制心(xin)(xin)肌(ji)細(xi)胞(bao)線(xian)粒(li)體內脂肪酸的(de)(de)氧化(hua),加(jia)速糖原酵解(jie),增(zeng)加(jia)心(xin)(xin)肌(ji)細(xi)胞(bao)無(wu)氧代謝下ATP的(de)(de)產生(sheng),增(zeng)強心(xin)(xin)肌(ji)細(xi)胞(bao)的(de)(de)抗缺血能力,從而(er)可預(yu)防(fang)心(xin)(xin)臟性猝死(si)的(de)(de)發生(sheng)。
埋(mai)藏式自動心(xin)臟(zang)復律除顫器(ICD)的(de)應用是防治心(xin)臟(zang)性猝死(si)的(de)重要進展,對(dui)致命(ming)性室性心(xin)律失常(chang)引起的(de)心(xin)臟(zang)性猝死(si)具有(you)肯定的(de)防治作用。
植入ICD的(de)臨床價(jia)值在(zai)(zai)于有效地(di)防治心(xin)臟(zang)(zang)猝(cu)死(si)(si)。據文獻(xian)報道,美(mei)國每年因心(xin)臟(zang)(zang)驟停(ting)(ting)而發生心(xin)臟(zang)(zang)性(xing)猝(cu)死(si)(si)的(de)患(huan)者(zhe)達50萬(wan)人以上,歐洲約40萬(wan)人。其中(zhong)75%~80%的(de)患(huan)者(zhe)在(zai)(zai)第1次心(xin)臟(zang)(zang)驟停(ting)(ting)發作時死(si)(si)亡,經有效心(xin)肺(fei)腦復蘇而幸存(cun)者(zhe)中(zhong)20%~25%的(de)患(huan)者(zhe)可在(zai)(zai)1年內再次發生心(xin)臟(zang)(zang)驟停(ting)(ting),因此,ICD的(de)應用范圍非(fei)常廣(guang)泛。
也有一些(xie)學者(zhe)對植(zhi)入ICD的(de)兩種不(bu)同方(fang)式進行了對比,結(jie)果發(fa)現經(jing)靜(jing)脈植(zhi)入ICD的(de)圍術期(qi)病(bing)死(si)(si)率(lv)(lv)較低(di),長期(qi)隨訪的(de)存活率(lv)(lv)高,應列為(wei)首選(xuan)方(fang)法(fa)。Saksena等總(zong)(zong)結(jie)了221例多中心植(zhi)入ICD的(de)結(jie)果,開胸(xiong)法(fa)植(zhi)入ICD的(de)圍術期(qi)病(bing)死(si)(si)率(lv)(lv)為(wei)4.2%,經(jing)靜(jing)脈法(fa)為(wei)0.8%,隨訪2年的(de)總(zong)(zong)成活率(lv)(lv)分別為(wei)81.9%和87.6%,并無顯(xian)著性差異(yi)。
為(wei)了明(ming)確揭(jie)示埋藏式(shi)(shi)心(xin)(xin)(xin)臟(zang)(zang)復(fu)(fu)律(lv)(lv)除顫器防治(zhi)心(xin)(xin)(xin)臟(zang)(zang)猝(cu)死的(de)價值(zhi),有(you)學者(zhe)進行了一些多(duo)中心(xin)(xin)(xin)隨機(ji)化(hua)前瞻性(xing)對(dui)照研(yan)(yan)究(jiu)。抗心(xin)(xin)(xin)律(lv)(lv)失(shi)常藥物與埋藏式(shi)(shi)心(xin)(xin)(xin)臟(zang)(zang)復(fu)(fu)律(lv)(lv)除顫器對(dui)致命(ming)性(xing)室(shi)(shi)性(xing)心(xin)(xin)(xin)律(lv)(lv)失(shi)常復(fu)(fu)蘇患者(zhe)治(zhi)療比較研(yan)(yan)究(jiu)(AVID)表明(ming),室(shi)(shi)顫復(fu)(fu)蘇者(zhe)或有(you)癥狀(zhuang)和血流動力(li)學障礙的(de)持續性(xing)室(shi)(shi)性(xing)心(xin)(xin)(xin)動過速患者(zhe),應用埋藏式(shi)(shi)心(xin)(xin)(xin)臟(zang)(zang)復(fu)(fu)律(lv)(lv)除顫器與抗心(xin)(xin)(xin)律(lv)(lv)失(shi)常藥物相比,可明(ming)顯提高生存(cun)率。其他一些多(duo)中心(xin)(xin)(xin)試驗如(ru)多(duo)中心(xin)(xin)(xin)自動除顫器埋藏試驗(MADIT)、加拿大埋藏式(shi)(shi)除顫器研(yan)(yan)究(jiu)(CIDS)、漢(han)堡心(xin)(xin)(xin)臟(zang)(zang)驟停研(yan)(yan)究(jiu)(CASH)、美(mei)國心(xin)(xin)(xin)、肺和血液(ye)研(yan)(yan)究(jiu)所(suo)埋藏式(shi)(shi)心(xin)(xin)(xin)臟(zang)(zang)復(fu)(fu)律(lv)(lv)除顫器(NHLBHCD)等有(you)的(de)已經完成,有(you)的(de)正(zheng)在進行,最后將揭(jie)示ICD防治(zhi)心(xin)(xin)(xin)臟(zang)(zang)性(xing)猝(cu)死的(de)確切價值(zhi)。
從心臟性猝死復蘇過來的幸運者在1年內發生致命性心律失常的復發率達25%~30%。已有試驗表明,ICD能有效轉復心臟性猝死患者的復發性心室顫動。Newman等對心臟驟停復蘇過來的幸存者進行了回顧性研究,60例患者植入ICD而120例患者僅僅使用藥物治療,兩組病例的年齡、左心室射血分數、心律失常類型、基礎心臟病和藥物治療情況相似。結果,ICD植入者的心臟性猝死率降低50%(10%∶5%,P<0.01),3年實際病死率降低31%(51%∶35%,P<0.01),5年的生存曲線也有明顯差異。但是,也必須注意,許多心臟性猝死幸存者(20%~70%)最后并不一定死于致命性心律失常,大約5%的心臟性猝死幸存者死于電-機械分離,而ICD對這種類型的心律失常無效。
①經(jing)導管射頻消融(rong)(rong)治療室(shi)(shi)性(xing)心(xin)律(lv)失常:室(shi)(shi)性(xing)心(xin)動(dong)過(guo)速(su)(su)發作(zuo)時(shi)常引起嚴重的(de)(de)(de)血流(liu)動(dong)力學(xue)障礙,心(xin)臟性(xing)猝死的(de)(de)(de)發生率(lv)高。1988年,Davis首次使(shi)用(yong)射頻消融(rong)(rong)治療室(shi)(shi)性(xing)心(xin)動(dong)過(guo)速(su)(su)成功(gong),開創射頻消融(rong)(rong)的(de)(de)(de)新(xin)領域,但至今仍(reng)不如(ru)室(shi)(shi)上性(xing)心(xin)動(dong)過(guo)速(su)(su)使(shi)用(yong)普遍。室(shi)(shi)性(xing)心(xin)動(dong)過(guo)速(su)(su)的(de)(de)(de)消融(rong)(rong),成功(gong)的(de)(de)(de)關鍵之一是(shi)心(xin)動(dong)過(guo)速(su)(su)的(de)(de)(de)起源定位,其方法是(shi)進行心(xin)內膜標測(ce),一般(ban)根據Josephson提出的(de)(de)(de)18個點標測(ce),左心(xin)室(shi)(shi)12,右心(xin)室(shi)(shi)6個,標測(ce)方法有(you)3種:
A.竇性心律(lv)時的(de)標測(ce):
在竇性心律下,在心室的不同部位尋找有明顯延遲碎裂電位的部位。延遲破裂電位是缺血區殘存心肌纖維的非同步除極,常常被大量結締組織所包繞,彼此連接較少,因此傳導很慢,形成緩慢傳導區,成為室性心動過速折返環的重要組成部分。在低倍放大條件下,延遲碎裂電位表現為高頻成分組成的低振幅波(<1mV),持續100ms以上。但必須注意,延遲破裂電位僅僅表示該部位有傳導延緩。并不表示一定為室性心動過速的起源部位,因此,竇性心律下的標測是不可靠的。
B.起搏標測:
用電(dian)極在心(xin)(xin)室的(de)不同部位(wei)作心(xin)(xin)內膜(mo)起搏,起搏頻率與心(xin)(xin)動(dong)(dong)(dong)過速(su)的(de)頻率相同,記錄12導(dao)聯心(xin)(xin)電(dian)圖,若11個以(yi)上導(dao)聯的(de)圖形與心(xin)(xin)動(dong)(dong)(dong)過速(su)發(fa)作時的(de)相同,可認為(wei)該起搏部位(wei)即(ji)是心(xin)(xin)動(dong)(dong)(dong)過速(su)的(de)起源部位(wei),但起搏標測也(ye)不可靠。
C.心動過速時(shi)的標(biao)測:
有心動(dong)(dong)過(guo)速(su)發作時,在心室內不同部位(wei)記錄心內膜電圖,比(bi)較哪一部位(wei)的(de)(de)心室激動(dong)(dong)時間比(bi)體表心電圖的(de)(de)QRS波提前,則(ze)最早(zao)激動(dong)(dong)的(de)(de)部位(wei)是心動(dong)(dong)過(guo)速(su)的(de)(de)起源(yuan)點。心運過(guo)速(su)的(de)(de)標測是室性(xing)心動(dong)(dong)過(guo)速(su)定(ding)位(wei)的(de)(de)較可(ke)靠方法。
準確定位(wei)后,行射頻消(xiao)融(rong),一般用30~40W,10~30s。成功的(de)因素(su)是(shi):精確的(de)起搏標測;最早的(de)局部心(xin)室(shi)激(ji)動(dong)(dong);導管電(dian)極與心(xin)內(nei)(nei)(nei)膜(mo)密切接(jie)(jie)觸(chu)。失敗的(de)因素(su)是(shi):消(xiao)融(rong)電(dian)極未到達起源點;導管電(dian)極與心(xin)內(nei)(nei)(nei)膜(mo)接(jie)(jie)觸(chu)不緊密;室(shi)性心(xin)動(dong)(dong)過速的(de)起源點位(wei)于(yu)心(xin)肌(ji)內(nei)(nei)(nei)或心(xin)外膜(mo)。
不(bu)(bu)同類型的(de)(de)室速,消融(rong)的(de)(de)療效不(bu)(bu)同,其中,無器質心(xin)(xin)臟(zang)病的(de)(de)特發(fa)性(xing)(xing)室速,成(cheng)功(gong)(gong)(gong)率達94%。束支折(zhe)(zhe)(zhe)返(fan)(fan)(fan)性(xing)(xing)心(xin)(xin)動(dong)(dong)過速,是由希氏-心(xin)(xin)肌傳導(dao)系統參與(yu)的(de)(de)大(da)(da)折(zhe)(zhe)(zhe)返(fan)(fan)(fan),消融(rong)右束即可(ke)終止室速,成(cheng)功(gong)(gong)(gong)率超過90%。目(mu)前較困難的(de)(de)是梗(geng)死(si)(si)后室性(xing)(xing)心(xin)(xin)動(dong)(dong)過速成(cheng)功(gong)(gong)(gong)率不(bu)(bu)高,一(yi)般在(zai)45%~93%,差異較大(da)(da),其原因在(zai)于梗(geng)死(si)(si)性(xing)(xing)心(xin)(xin)動(dong)(dong)過速的(de)(de)機制較復雜(za)所致。梗(geng)死(si)(si)后室性(xing)(xing)心(xin)(xin)動(dong)(dong)過速的(de)(de)射(she)(she)頻消融(rong),包括以下(xia)幾種情形:a.瘢(ban)(ban)痕(hen)周圍折(zhe)(zhe)(zhe)返(fan)(fan)(fan):必須在(zai)瘢(ban)(ban)痕(hen)組織周圍產生(sheng)較大(da)(da)損傷,折(zhe)(zhe)(zhe)返(fan)(fan)(fan)才(cai)能終止;b.瘢(ban)(ban)痕(hen)內折(zhe)(zhe)(zhe)返(fan)(fan)(fan):大(da)(da)部分病例可(ke)用射(she)(she)頻消融(rong)成(cheng)功(gong)(gong)(gong);c.功(gong)(gong)(gong)能性(xing)(xing)折(zhe)(zhe)(zhe)返(fan)(fan)(fan):射(she)(she)頻消融(rong)常(chang)常(chang)無效。有時(shi),射(she)(she)頻消融(rong)術后可(ke)在(zai)功(gong)(gong)(gong)能性(xing)(xing)上折(zhe)(zhe)(zhe)返(fan)(fan)(fan)的(de)(de)基(ji)礎(chu)上,增加一(yi)個解剖性(xing)(xing)因素而產生(sheng)更為(wei)頑固(gu)的(de)(de)折(zhe)(zhe)(zhe)返(fan)(fan)(fan)性(xing)(xing)心(xin)(xin)律失(shi)常(chang)。
②經(jing)皮球(qiu)囊冠狀動脈(mo)成形(xing)術治療冠心(xin)(xin)病。從理(li)論(lun)上(shang)講,經(jing)皮球(qiu)囊冠狀動脈(mo)形(xing)成術治療冠心(xin)(xin)病應能有效降低心(xin)(xin)臟(zang)性猝死的發(fa)生率。當迄今(jin)未見到多中心(xin)(xin)隨機臨床觀察資料。
①室性(xing)心律(lv)失(shi)常的外科(ke)治療(liao):
近(jin)10幾年(nian)來,用手(shou)術(shu)切割、冷凍或(huo)激光(guang)等手(shou)段可成功地(di)控制(zhi)或(huo)根治(zhi)室(shi)性心動過速/或(huo)心室(shi)顫動,從而減少心臟性猝死(si)的發生率。
A.內膜病灶切(qie)除術:
這種(zhong)治療方(fang)法于1979年由(you)Harken用(yong)于臨床,其方(fang)法是首(shou)先進行病灶定位(wei)。Harken等的(de)方(fang)法是在常(chang)溫體(ti)外循環下(xia),用(yong)手持移動電極在心(xin)(xin)內(nei)膜面(mian)進行標測,找出最(zui)早(zao)心(xin)(xin)室(shi)激動部位(wei),經左(zuo)心(xin)(xin)室(shi)切口(kou)對標測出來的(de)最(zui)早(zao)心(xin)(xin)室(shi)激動部位(wei)作直徑2~3cm厚約數(shu)毫米的(de)盤狀(zhuang)切除。心(xin)(xin)內(nei)膜病灶切除術適用(yong)于病灶局限,尤其適用(yong)于位(wei)于室(shi)壁瘤邊緣而遠(yuan)離心(xin)(xin)臟傳導系(xi)統和(he)乳(ru)頭肌(ji)的(de)病灶。
B.心內膜(mo)環形心室肌切(qie)除(chu)術:
對于(yu)有室(shi)壁瘤而伴(ban)發(fa)室(shi)性心(xin)動過(guo)速的患者可在室(shi)壁瘤邊緣(yuan)的正常(chang)心(xin)內膜作弧(hu)形切口,深達(da)心(xin)肌(ji)(ji)層,直到(dao)僅(jin)留(liu)一層靠近心(xin)外(wai)膜的肌(ji)(ji)橋。該法由Guiraudon等于(yu)1987年首創。因術后左室(shi)受損,現(xian)已(yi)少(shao)用(yong)。
C.心室隔離術:
僅適(shi)用于(yu)右(you)心室游離(li)壁或右(you)心室流出道的(de)病灶(zao)。其(qi)方法是以右(you)房溝為基底(di),圍繞某(mou)一(yi)分(fen)支(zhi)血管對可疑心室壁做半島狀切開,使它和右(you)心室壁的(de)其(qi)余部分(fen)分(fen)離(li)。
D.外科冷凍消融術:
對于靠近心臟(zang)傳導系統或腱(jian)索的病灶,直接進行(xing)外科手術(shu)切(qie)除術(shu)可(ke)發生嚴重(zhong)的并發癥,則(ze)宜在(zai)外科手術(shu)直視下進行(xing)冷凍(dong)治(zhi)療,使(shi)病灶降(jiang)溫至0℃持續1min。如果有(you)效則(ze)降(jiang)溫至-60℃持續2min。
E.外科激光(guang)消融術:
用激(ji)光(guang)代替冷凍而消(xiao)除(chu)心律失常的病灶。
②冠狀動脈(mo)旁路術:
對于(yu)嚴(yan)重冠(guan)狀(zhuang)(zhuang)動(dong)(dong)脈(mo)病(bing)(bing)變的(de)患(huan)者進行冠(guan)狀(zhuang)(zhuang)動(dong)(dong)脈(mo)旁路術(shu)可有(you)效(xiao)的(de)改善心(xin)肌供血(xue),減輕或消(xiao)除(chu)心(xin)絞痛的(de)癥狀(zhuang)(zhuang)。已有(you)一些多中心(xin)研究(jiu)結果(guo)顯示,冠(guan)狀(zhuang)(zhuang)動(dong)(dong)脈(mo)旁路術(shu)可延長冠(guan)心(xin)病(bing)(bing)患(huan)者的(de)生(sheng)存期,但(dan)對心(xin)臟性猝死發生(sheng)率的(de)影響(xiang),所見報道(dao)極少。
(1)判斷意識
拍雙(shuang)肩(jian),喚雙(shuang)耳(er),搭(da)脈(mo)搏,10秒鐘內完成
(2)呼救(撥打120)
完成第(di)一步(bu)后,馬上拔(ba)打120,給病人爭取救治的第(di)一時間(jian)。
(3)擺放仰臥體(ti)位
(4)胸外按壓(ya)30次(兒童15次)
位置:胸(xiong)部正(zheng)中(zhong),兩(liang)乳頭連線(xian)中(zhong)點;
姿勢:肩關節、肘關節、腕(wan)關節垂直(zhi)成(cheng)一條直(zhi)線。
雙手掌(zhang)重疊,手指抬起;掌(zhang)根用力。
力度:按(an)下去至(zhi)少5cm;
頻率(lv):至少(shao)100次(ci)/分鐘;
(5)開放(fang)氣道(仰頭舉頦(ke)法)
(6)人工吹氣2次(兒童1次)捏鼻,口包口,吹氣
(7)重復第四、五、六步
(8)注意事項:研究(jiu)發現,倒地1分(fen)鐘(zhong)(zhong)(zhong)內(nei)進行心(xin)肺(fei)復蘇,救活的概率(lv)為90%;2分(fen)鐘(zhong)(zhong)(zhong)內(nei)60%;4分(fen)鐘(zhong)(zhong)(zhong)內(nei)40%;8分(fen)鐘(zhong)(zhong)(zhong)內(nei)為20%;超過10分(fen)鐘(zhong)(zhong)(zhong),基本上就是零了。為了預防心(xin)源性猝死,中、老年人和肥胖者、糖尿病(bing)者、應定期(qi)到醫院檢查(cha),發現潛在性心(xin)血管病(bing)就及時治療(liao),并應防止(zhi)各種誘發因(yin)素。
飲食適宜
建議適當限制辛辣生冷刺激性食(shi)(shi)物(wu)。缺血(xue)性心臟(zang)病常伴有高(gao)血(xue)壓(ya)高(gao)血(xue)脂糖(tang)尿病,如果你同時(shi)伴有以上疾病,可針對給予(yu)低鹽低脂低糖(tang)飲食(shi)(shi)。
建(jian)議平(ping)時(shi)飲食(shi)清淡,不(bu)可集中食(shi)用過多(duo)(duo)蔬菜或高脂(zhi)(zhi)食(shi)物,低鹽低脂(zhi)(zhi)飲食(shi),少吃動(dong)物的內臟,多(duo)(duo)喝水,避(bi)免(mian)辛辣和生冷,戒煙酒,適當(dang)運動(dong)鍛煉,保(bao)持樂觀舒暢的心情,保(bao)持良好的睡(shui)眠,不(bu)要長時(shi)間熬夜,放松精(jing)神,心態平(ping)和。
飲食禁忌
紅(hong)肉:這些肉類含有大量阻(zu)塞動(dong)脈的飽和脂肪,不(bu)利于心臟健康。
汽水:汽水含有大量單糖和(he)熱量,是引起兒(er)童和(he)成人肥胖(pang)的(de)食(shi)品之(zhi)一。
薯條:薯條含有飽和脂肪和轉(zhuan)脂肪,會引起人(ren)們(men)肥胖,增加心臟(zang)病風險(xian)。
(1)定期體(ti)檢(jian):老年人(ren)(ren)本身是心臟(zang)病(bing)及各種(zhong)疾病(bing)的高發人(ren)(ren)群,應(ying)定期到醫院進(jin)行體(ti)檢(jian)。青、中(zhong)年人(ren)(ren)工作緊張、生(sheng)活(huo)節奏快、工作生(sheng)活(huo)壓(ya)力大也容易患(huan)冠心病(bing)、高血(xue)壓(ya)等疾病(bing)。定期體(ti)檢(jian)及早檢(jian)查便于及時發現疾病(bing),及早進(jin)行治療,減少猝死風(feng)險。
(2)避免過(guo)度疲(pi)勞(lao)和(he)精(jing)神緊(jin)張(zhang)(zhang):過(guo)度疲(pi)勞(lao)和(he)精(jing)神緊(jin)張(zhang)(zhang)會使(shi)(shi)(shi)機(ji)體(ti)處于應(ying)激狀態,使(shi)(shi)(shi)血壓升高,心臟負擔加重,使(shi)(shi)(shi)原(yuan)有(you)心臟病(bing)(bing)加重。即使(shi)(shi)(shi)原(yuan)來沒有(you)器質(zhi)性(xing)心臟病(bing)(bing)也會引(yin)發(fa)(fa)室顫(zhan)的(de)發(fa)(fa)生。所(suo)以,每個人應(ying)該對自己的(de)工作、生活有(you)所(suo)安排(pai),控制(zhi)工作節(jie)奏和(he)工作時間,不可過(guo)快(kuai)過(guo)長。
(3)戒(jie)煙、限酒(jiu)、平衡膳食(shi)、控(kong)制體(ti)重、適當運動,保(bao)持良好的(de)生活習慣會(hui)減(jian)少心腦血管疾(ji)病的(de)發生。
(4)注(zhu)意過度疲勞的(de)危(wei)險信號及(ji)重(zhong)視發病的(de)前兆(zhao)癥狀(zhuang):長期(qi)過度疲勞會引發身體出(chu)現一些改(gai)變。如焦慮(lv)易怒、記憶力(li)減退(tui)、注(zhu)意力(li)不(bu)集中、失眠及(ji)睡(shui)眠質量差、頭痛(tong)頭暈耳鳴、性功能減退(tui)、脫(tuo)發明顯(xian)等。當機體出(chu)現這些情(qing)況,應調整(zheng)(zheng)工(gong)作節奏(zou)、適當休息(xi),調整(zheng)(zheng)節奏(zou),保持愉(yu)快的(de)心情(qing)。讓機體功能得以(yi)恢(hui)復。如不(bu)能緩(huan)解,應立即前往醫院救(jiu)治。
(5)對已患(huan)有冠心病、高血(xue)壓等疾病的患(huan)者應(ying)在醫生(sheng)指(zhi)導(dao)下堅持(chi)服藥治療(liao)。
(6)注意對(dui)室性心(xin)(xin)律失(shi)常(chang)(chang)進行危險(xian)評估,包括(kuo)進行常(chang)(chang)規心(xin)(xin)電圖(tu)、動態心(xin)(xin)電圖(tu)、其他心(xin)(xin)電學技術(shu)、超聲心(xin)(xin)動圖(tu)、心(xin)(xin)內(nei)電生理檢(jian)查(cha)等檢(jian)查(cha),以明確心(xin)(xin)律失(shi)常(chang)(chang)類型(xing),評估心(xin)(xin)臟猝(cu)死風險(xian),做出治療決策。
(7)注(zhu)意加強(qiang)心梗后心臟猝死的(de)預防(fang)。