充血性心力衰竭患者室性心律失常与心脏性猝死

Ventricular Arrhythmias and Sudden Cardiac Death in Patients with Chronic Congestive Heart Failure

目的:探讨充血性心力衰竭(CHF)患者室性心律失常(VA)的易患因素及其与心脏性猝死的关系。方法:应用前瞻性方法研究137例CHF患者动态心电图中室性心律失常与临床、血流动力学和心功能改变及其与预后的关系。结果:本组患者室性心律失常的检出率为95％,其中复杂型心律失常48％,多因素分析示血清K^+和射血分数为复杂型室性心律失常独立易患因素。随访期间[26±15(2～46月)月]50例发生心脏性死亡,心脏性猝死29例。Cox回归分析显示,QTc间期延长(≥440mm)、AOPm(≤90mmHg)和LVEF(≤25％)降低为心脏性猝死独立危险因素。复杂型室性心律失常组和简单型室性心律失常组心脏猝死的发生率分别为22.7％和19.7％。生存率分析显示复杂型室性心律失常组总生存率显著低于简单型室性心律失常组(P=0.0399),而非猝死生存率则无显著性差异(P=0.4687)。结论:充血性心力衰竭患者血清钾异常和严重收缩功能减退易患复杂型室性心律失常,复杂型室性心律失常并不能预示充血性心力衰竭患者心脏性猝死的发生。

Objects: To investigate the risk factors and its predictive value for suddeng cardiac death (SCD) of ventricular arrhythmias on ambulatory electroeardiographie momitoring in chronic congestive heart failure(CHF) . Methods: 137CHF patients [113 man, age 42 - 72(59 ± 9) years, left ventricular ejection fraction less than 40% ] were studied prospectively. A 24h ambulatory lectrocardiographic mornitoring, clinical, body surface electrocardiogram findings and detailed invasive right and left heart hemodynamic and functional study were evaluated in all patients. Results: During a follow-up of 26 ± 15(2 -46) months, there were 50 cardiac death: 29 were sudden, 21 were due to progressive pump failure (17cases) and acute myocardial infarction (4cases) . At baseline, 66 patients had complex, (Lown grades Ⅳv to Ⅴ) ventricular arrhythmias, 71 patients had simple (Lown grades 0 to 3) ventricular arrhythmias during the 24h ambulatory electrocardiographic mornitoring, Multivariated analysis identified serum poum level and left ventricular ejection fraction as independent statistically significant risk factors for complex ventricular arrhythmias. Cox Proportional hazard analysis identified QTc prolongation, low mean aortic pressure and ejection fraction to be independent predictors for sudden cardiac death. Patients with complex ventricular arrhythmias had an increased risk of all - cause cardiac death mortality (Logrank =4. 22, P =0. 039 9), but not for sudden cardiac death mortality (Lohrank = 0. 53, P = 0. 468 7) as compared with those with simple ventricular arrhythmias. Conclusion: Poor left ventricular systolic function and electrolyte deficits have a higher incidence of complex ventricular arrhythmias, the presence of complex ventricular arrhythmias on 24h ambulatory eleetrocardiographic mornitoring dose not identify patients at risk of sudden cardiac death.