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院内获得性尖端扭转型室速防治 -- AHA/ACC 院内获得性 TdP 防治专家共识临床要点

院内获得性尖端扭转型室速防治 -- AHA/ACC 院内获得性 TdP 防治专家共识临床要点. 伍伟锋 2010.12.4. 尖端扭转型室速 （ torsade de pointes ,TdP ）. TdP 定义. TdP 一词也能用描述少数 QT 间期不延长的多形性室速，因为部分患者伴有隐匿性长 QT 综合征 但最好用来描述 QT 间期显著延长（ >500ms ），伴 T- U 波畸形的多形性室速，因为这类室速有着不同的发生机制和治疗方法. 问题的提出. 药物引起的获得性长 QT 综合征 (LQTS) 伴 TdP 发作心脏骤停恶性事件极罕见

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院内获得性尖端扭转型室速防治 -- AHA/ACC 院内获得性 TdP 防治专家共识临床要点

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  1. 院内获得性尖端扭转型室速防治--AHA/ACC院内获得性TdP防治专家共识临床要点院内获得性尖端扭转型室速防治--AHA/ACC院内获得性TdP防治专家共识临床要点 伍伟锋 2010.12.4

  2. 尖端扭转型室速（torsade de pointes,TdP）

  3. TdP定义 TdP一词也能用描述少数QT 间期不延长的多形性室速，因为部分患者伴有隐匿性长QT 综合征 但最好用来描述QT 间期显著延长（>500ms），伴T- U 波畸形的多形性室速，因为这类室速有着不同的发生机制和治疗方法

  4. 问题的提出 药物引起的获得性长QT综合征(LQTS)伴TdP发作心脏骤停恶性事件极罕见 与院外服用同一种药物患者相比，住院患者药物LQTS伴TdP发生可能性明显增高 住院患者还其它心律失常促发因素 老年人：有心脏病基础、肝肾功能受损 电解质紊乱 心动过缓 静脉用药

  5. 内容 The ECG characteristics of TdP Premonitory ECG Signs of TdP Drugs That Cause TdP TdP Risk Factors Management of Drug-Induced QT Prolongation Management of Drug-Induced TdP

  6. 一、Characteristic Pattern of TdP

  7. typical feature 1、twisting of the QRS complexes around the isoelectric line not be evident in all ECG leads 2、short-long-short pattern of R-R cycles R-on-T PVC 3、warm-up phenomenon The rate ofTdP:160-240 beats/minute 4、frequently terminates spontaneously Some cases degenerates into VF

  8. VF 与TdP 的区别 R-on-T PVC： short coupling interval The rate of VF:250~500 beats/minute does not terminate without defibrillation

  9. 二、Premonitory ECG Signs of TdP QT-interval prolongation： male QTc>470ms，female>480ms QTc >500 ms T-U deformity macroscopic T-wave alternans

  10. Circulation.2010,121:1049

  11. 三、Drugs That Cause TdP

  12. Antiarrhythmic： Procainamide、Quinidine、Sotalol 、Disopyramide、Ibutilide、 Antibiotic： Erythromycin（红霉素）、Clarithromycin、Sparfloxacin pain control： Methadone（美沙酮） Antipsychotic： Chlorpromazine（氯丙嗪）、Thioridazine(硫利达嗪) Gastrointestinal stimulant： Cisapride(西沙比利) Cancer/leukemia： Arsenic trioxide(三氧化二砷)

  13. 四、TdP Risk Factors

  14. 1、QTc >500 ms 2、Use of QT-prolonging drugs Concurrent use of more than 1 QT-prolonging drug Rapid infusion by intravenous route 3、Heart disease Congestive heart failure Myocardial infarction 4、Advanced age 5、Female sex

  15. 6、Hypokalemia 7、Hypomagnesemia 8、Hypocalcemia 9、Treatment with diuretics 10、Impaired hepatic drug metabolism (hepatic dysfunction or drug-drug interactions) 11、Bradycardia Sinus bradycardia, heart block, incomplete heart block with pauses 12、Premature complexes leading to short-long-short cycles

  16. 五、Management of Drug-Induced QT Prolongation 1、Continuous QTc monitoring QTc>500 ms or increase>60ms accompanied by Premonitory ECG Signs of TdP

  17. 2、 Appropriate actions include discontinuation of the culprit drug Bradyarrhythmias、electrolyte abnormalities the ready availability of an external defibrillator highest possible ECG monitoring surveillance： Patients should not be transported from the unit for diagnostic or therapeutic procedures Intravenous Magnesium sulfate 2 g (Class IIa, Level of Evidence: B)

  18. 六、Management of Drug-Induced TdP directcurrent cardioversion Sustained TdP does not terminate spontaneously degenerates into ventricular fibrillation

  19. intravenous magnesium sulfate Magnesium sulfate 2 g (Class IIa, Level of Evidence: B) repeat infusions of magnesium sulfate 2 g TdP persist

  20. temporary transvenous pacing Atrial or ventricular at rates 70 beats/minute Repletionof potassium levels of 4.5 to 5 mmol/L Class IIb, Level of Evidence: C

  21. THANK YOU !

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