心肌梗死伴室速的处理策略和时机 PCI 还是 ICD?

1. 心肌梗死伴室速的处理策略和时机 PCI还是ICD? 浙江大学医学院附属第一医院心内科 郑良荣

2. I I I I I I I I I 植入式心律转复除颤器的治疗建议 IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III III III III III 非可逆性原因引起的室颤或血流动力学不稳定的持续室速所致的心脏骤停 伴有器质性心脏病的自发的持续性室性心动过速，无论血流动力学是否稳定 原因不明的晕厥，在心电生理检查时能诱发有血流动力学显著临床表现的持续室速或室颤. A B B

3. I I I I I I I I I I I I 植入式心律转复除颤器的治疗建议 IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III III III III III III III III III 心肌梗死所致LVEF<35%且心肌梗死40天以上，NYHA II或III级 NYHA II或III级，LVEF≤35%的非缺血性心肌病患者 心肌梗死所致LVEF<30%，且心肌梗死40天以上，NYHA I级(原为IIa) 心肌梗死所致非持续性室速，LVEF<40％，且心电生理检查能诱发出室颤或持续室速 A B A B

4. 影响策略选择的因素

5. Post-MI NSVT the proximity of the NSVT to MI The first 48 hours Related to ischemia or reperfusion No prognostic significance 在心肌梗死后患者和透壁性心肌梗死急性期发生的心脏骤停幸存者中进行的研究表明， 梗死后24～48小时发生的致命性室速并不意味着随时间延长危险持续 Prevalence, characteristics and significance of ventricular tachycardia detected by 24-hour continuous electrocardiographic recordings in the late hospital phase of acute myocardial infarction. Bigger JT Jr et al. Am J Cardiol. (1986)

6. Incidence of and Outcomes Associated With Ventricular Tachycardia or Fibrillation in Patients Undergoing PrimaryPercutaneous Coronary Intervention 90%在48小时之内，64%发生在PCI结束之前 另7例时间不详 JAMA. 2009;301(17):1779-1789

7. Incidence of and Outcomes Associated With Ventricular Tachycardia or Fibrillation in Patients Undergoing PrimaryPercutaneous Coronary Intervention 33.3% 17.2% 3.6%

8. Factors related to lateVT/VF

9. Conclusions • In this study, occurrence of VT/VF before or after the end of cardiac catheterization in patients presenting for primary PCI was associated with increased 90-day mortality. 提示：1.PPCI后仍有部分患者会发生延迟T/Vf，并伴有90天的死亡率增高-有必要植入ICD吗？ 2. 对那些>4个以上危险因素、TIMI<3、ST段回复<70%的患者是否需要ICD一级预防？ JAMA. 2009;301(17):1779-1789

10. STEMI Management--primary PCI Assessment of Left Ventricular Function --transthoracic echocardiogram >2 days after PPCI Electrophysiological Study--If sustained monomorphic VT with a cycle length (CL) 200 ms was induced by 4 extra stimuli, the EPS result was considered positive for inducible VT ICD Implantation Outcomes of Early Risk Stratification and Targeted Implantable Cardioverter-Defibrillator Implantation After ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

11. Flow chart of patient recruitment and group outcome (mean, 4±2 days) (mean, 10 days after infarction • Zaman, S. et al. Circulation 2009;120:194-200

12. Group3 • 6/28(22%)有恰当的ICD治疗 • 共42阵VT（365±78 ms），ATP终止 • The mean time to first event was 11±10 months Conclusions 对于ST段抬高患者PPCI后，LVEF<40%、EPS诱发出VT者早期植入ICD能降低死亡率 更有理由相信在此期间发生Vf者有必要植入ICD

13. 提示 Early measurement of LVEF after STEMI, combined withtargeted EPS, may provide a viable method of selecting patientsmost likely to benefit from ICD therapy and may have advantages over the current clinical standard of using LVEF<30% at ≥40 days after MI as the sole selection criterion. Circulation. 2009;120:194-200

14. Effect of reperfusion time on inducible VT early and spontaneous ventricular arrhythmias late after STEMI treated with PPCI Patients were divided into three groups based on reperfusion time as early(≦3h), intermediate(3-5 h),or delayed reperfusion(＞5) 6-10days after PPCI .

15. Effect of reperfusion time on inducible VT early and spontaneous ventricular arrhythmias late after STEMI treated with PPCI Heart Rhythm 2011;8:493–499

16. The incidence of spontaneous VA at 2 years 14% 8.9%, 0% Heart Rhythm 2011;8:493–499

17. Sudden death or spontaneous ventricular arrhythmia events for ICD patients Heart Rhythm 2011;8:493–499 10/29

18. Predictors of spontaneous ventricular arrhythmias/suddendeath 延迟PPCI、EF＜40%和EPS阳性组植入ICD后约有30%左右的患者在平均8.5个月后发生VT/Vf而得到恰当治疗

19. CONCLUSION • 延迟PPCI、EF＜40%和EPS阳性是决定梗死后早期和晚期心室电不稳定的重要因素。 • 这类患者具有较高（30%左右）的VT/Vf事件发生率 更有理由相信在此期间发生Vf者有必要植入ICD

20. Prophylactic Use of an Implantable CardioverterDefibrillator after Acute Myocardial Infarction （DINAMIT） Hence, the exclusion of patients with sustained ventriculararrhythmia>48 h post-MI and the limited use of revascularization therapy in patients with significant anterior MI mayhave inadvertently resulted in a selected group of patientsat relatively lower risk of sudden arrhythmic death andperhaps proportionately at a higher risk of death fromre-infarction and heart failure. N Engl J Med 2004;351:2481-8.

21. Post MI VT １．血运重建可改善冠心病患者的心电稳定性，降低室性心律失常的风险． 　２．但很多研究表明，PCI后仍有相当部分病人能够被诱发出VT，并导致13%的SCD比例。 　３．对于不能血运重建，或伴有左室功能障碍的陈旧心梗患者应植入ICD ESC: guidelines on myocardial revascularization( 2010)

22. 冠心病患者持续单型室速/室颤伴轻度心肌酶普增高的处理与不伴有酶普增高者一样冠心病患者持续单型室速/室颤伴轻度心肌酶普增高的处理与不伴有酶普增高者一样 如没有其他临床资料支持发生新的MI，对这类患者心律失常的处理方法与不伴有心肌酶普升高者一样。

23. ICD在AMI不同时间不同的角色 48小时内 48小时到40天 大于40天 此次MI相关的心律 失常，非ICD适应症 ？ 没有进一步心肌缺血 的证据，VT/VF与本 次MI无关，ICD为二 级预防适应症？ 无VT/VF事件，陈旧性心梗， 左室功能显著性不全，最佳 药物治疗，预计良好生存率 ，为ICD一级预防适应症

24. 1.最优的药物治疗 2.评估缺血以及血管再通（如果有适应症）- PCI 急性心肌梗死 48小时内伴VT 48h-40day 后 发生在PCI前或后 LVEF>40% No 延迟PPCI TIMI<3 ST段回复<70% 前 Yes NO ICD VF与缺血/再梗是否有关？ Yes No NO ICD ICD

25. Case 1 70岁男性，因疲乏就诊，ECG示下壁Q波和ST段抬高，CK及肌钙蛋白升高，既往无冠心病史。提示近期发生下壁心肌梗死。ASP、β-B、ACEI以及他汀类药物治疗。期间无反复心肌缺血及其他心梗早期并发症。 入院3天（出现最初症状5天后），发生持续性单形心室扑动（280次/分），进而发展为室颤，并且需要即刻进行除颤。

26. Case 1 • 问题：心脏导管造影提示LVEF=40%，下壁无活动，右冠脉闭塞，左前降支<50%狭窄。该患者是否需要接受ICD植入？ VF与缺血/再梗是否有关; LVEF>40%; 延迟PPCI; TIMI<3; ST段回复<70%

27. Case 2 • 女，73岁， 发作性胸闷，胸口压榨感2次，每次约持续4-5分钟左右。 • 住院后次日早晨患者于床边坐位休息时突发神志不清，面色发青，呼之不应，颈动脉搏动消失，立即予平卧，胸外心脏按压，约1分钟后患者神志恢复。

28. 入院时发生事件之前ECG

32. 该患者需植入ICD吗？

33. 谢谢！