Arrhythmic risk stratification of post-myocardial infarction patients.
Arrhythmic risk stratification of post-myocardial infarction patients.
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DOI：
10.1097/00001573-200001000-00001
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发表时间：
2000
影响因子：
2.3
通讯作者：
F. Naccarella;G. Lepera;A. Rolli
中科院分区：
文献类型：
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作者：
F. Naccarella;G. Lepera;A. Rolli
心肌梗死后风险分层，特别是心律失常风险分层，是现代临床心脏病学尚未完全解决的问题。在过去的10年里，心律失常的风险分层主要是通过评估在动态心电图监测中检测到的室性早搏的频率和复杂性来进行的，通常与射血分数的测定有关。根据心律失常抑制试验I和II （CAST I，II）的结果，这种方法已被证明是有限和谬误的，其中抗心律失常药物自始至终抑制室性早搏或室性早搏导致心脏和心律失常死亡率的增加。最近的欧洲心肌梗死胺碘酮试验（emat）和加拿大胺碘酮心肌梗死试验（CAMIAT）证实，只有胺碘酮作为抗心律失常药物，在主要因射血分数降低、伴有和不伴有室性早搏的患者中，有效降低心律失常死亡率而不影响心脏死亡率。相反，众所周知，β受体阻滞剂可有效预防急性心肌梗死（AMI）后患者的猝死，从而降低心脏和心律失常死亡率。相反，在其他机构中，ami后患者的风险分层是通过电生理研究进行的，在所有ami后患者中没有任何先前的无创心律失常风险分层。近年来，许多其他无创心电参数，如晚电位（信号平均心电图）、心率变异性、压力反射敏感性，以及最近的t波交替，已被证明是有用的，但它们在无创识别心律失常死亡率高风险患者时特异性较低。相反，在多中心自动除颤植入试验（MADIT）中，电生理学证实室性心动过速的诱导性对心律失常事件具有高特异性和高预测价值。然而，MADIT研究人群不能与最近发生心肌梗死的连续患者队列进行比较。在这种情况下，可以在射血分数百分比降低（10/h或心率变异性降低< 70 ms或平均心电图信号阳性）的患者中观察到心律失常事件的最高风险，然后通过电生理学研究进一步进行心律失常风险分层。本文回顾了几项已发表和正在进行的试验，这些试验利用各种心律失常风险分层技术作为其方案的一部分。
Post-myocardial infarction risk stratification, especially arrhythmic risk stratification, is an issue that has still not been wholly addressed in modern clinical cardiology. In the past 10 years, arrhythmic risk stratification has been approached mainly by evaluating frequency and complexity of premature ventricular contractions, detected on Holter monitoring, often in association with determination of percent ejection fraction. This methodology has been proven to be limited and fallacious according to the Cardiac Arrhythmia Suppression Trial I and II (CAST I,II) results, in which suppression of premature ventricular contractions or premature ventricular beats throughout by antiarrhythmic drugs resulted in an increase in both cardiac and arrhythmic mortality. Only amiodarone as an antiarrhythmic drug, as proven in the recent European Myocardial Infarct Amiodarone Trial (EMIAT) and Canadian Amiodarone Myocardial Infarction Trial (CAMIAT), was effective in reducing arrhythmic mortality without affecting cardiac mortality, in patients selected mainly because of a reduced ejection fraction, with and without premature ventricular contractions. Conversely, it is well known that beta-blockers are effective in preventing sudden death in post-acute myocardial infarction (AMI) patients, thus reducing cardiac and arrhythmic mortality. Conversely, in other institutions, risk stratification in post-AMI patients has been performed by electrophysiologic study obtained, without any previous noninvasive arrhythmic risk stratification, in all post-AMI patients. In recent years, many other noninvasive electrocardiology parameters, such as late potentials (signal-averaged electrocardiography), heart rate variability, baroreflex sensitivity, and, more recently, T-wave alternance, have been shown to be useful, but they are associated with a low specificity in the noninvasive identification of patients at high risk for arrhythmic mortality. Conversely, in the Multicenter Automatic Defibrillation Implantation Trial (MADIT), electrophysiology confirmed that inducibility of ventricular tachycardia shows high specificity and a high predictive value for arrhythmic events. Nevertheless, the MADIT study population is not comparable to a cohort of consecutive patients who have recently had a myocardial infarction. In this setting, the highest risk of arrhythmic events can be observed in patients with depressed percent ejection fraction ( 10/h or reduced heart rate variability < 70 ms or a positive signal-averaged electrocardiogram) followed by a further arrhythmic risk stratification, obtained through electrophysiologic study. Several published and ongoing trials that utilize various arrhythmic risk stratification techniques as part of their protocol are reviewed.