儿童室上性心动过速临床特征及治疗多中心研究

An analysis of clinical characteristics and acute treatment of supraventricular tachycardia in children from a multicenter study

目的 探讨儿童室上性心动过速（室上速）的临床特点及静脉用抗心律失常药物疗效.方法 多中心前瞻性研究2014年7月至2017年2月清华大学第一附属医院、北京大学第一医院、首都儿科研究所附属儿童医院、北京安贞医院收治的257例室上速患儿的临床资料、不同静脉抗心律失常药物治疗效果及不良反应.组间比较计量资料采用独立样本t检验、配对样本t检验、Mann-WhitneyU检验或H检验;计数资料采用x2检验或H检验.结果 257例患儿室上速发病年龄为：＜1岁148例（57.6％）,1 ～ ＜3岁45例（17.5％）,3～＜6岁27例（10.5％）,≥6岁37例（14.4％）.室上速构成比：房室折返性心动过速49.4％（127例）,房室结折返性心动过速4.3％（11例）,分类未明的阵发性室上速26.8％（69例）,房性心动过速19.5％（50例）.30例（13.3％）患儿并发心动过速性心肌病（TIC）.27例TIC患儿有效控制心动过速后,左室射血分数由（41.1±6.3）％升至（60.3±9.2）％（t=-10.397,P=0.000）.静脉抗心律失常药物终止室上速发作显著有效率63.8％（164/257）,有效率18.7％ （48/257）,无效率17.5％（45/257）.显著有效率普罗帕酮73.1％（98/134）、胺碘酮76.7％（23/30）,均高于三磷酸腺苷（44.1％,26/59）（x2=20.524,P=0.000）.阵发性室上速药物治疗的显著有效率（67.1％,139/207）高于房速（50.0％,25/50） （x2=6.337,P=0.042）.不同年龄组间的疗效比较差异有统计学意义（x2=13.904,P=0.031）,＜1岁患儿疗效最差,显著有效率55.4％（51/92）.静脉用药不良反应率3.5％（9/257）,其中4例低血压休克（普罗帕酮3例,三磷酸腺苷1例）,3例窦性停搏（三磷酸腺苷）.结论 儿童室上速57.6％于婴儿期起病,房室折返性心动过速最多见.TIC发生率13.3％.静脉抗心律失常药物终止心动过速显著有效率63.8％,不良反应率3.5％.普罗帕酮和胺碘酮终止儿童室上速效果优于三磷酸腺苷,普罗帕酮可发生严重不良反应.

 Objective The study assessed the clinical characteristics and response to acute intravenous antiarrhythmic drug therapy of supraventricular tachycardia （SVT） in children.Methods This was a multicenter prospective descriptive study including 257 children from First Hospital of Tsinghua University,Peking University First Hospital,Children＇s Hospital Affiliated to Capital Institute of Pediatrics and Beijing Anzhen Hospital who received intravenous antiarrhythmic drug therapy for SVT from July 2014 to February 2017.The clinical and tachycardia features,response to intravenous antiarrhythmic drug therapy of these children were characterized.Statistical analyses were performed using t test,Mann-Whitney U test,x2 test and H test.Results The onset of SVT occurred at any age with a distribution with positive skewness,57.6% （n=148） children〈l year,17.5% （n=45） childrenl ～ 〈3 years,10.5% （n=27）children 3 ～ 〈6 years and 14.4% （n=37） children ≥ 6 years of age.The percentages of SVT types were 49.4% （n=127） for atrioventricular reentry tachycardia （AVRT）,4.3% （n=11） for atrioventricular nodal reentry tachycardia （AVNRT）,26.8% （n=69） for unclassified paroxysmal SVT and 19.5% （n=50） for atrial tachycardia （AT）,respectively.Tachycardia-induced cardionyopathy （TIC）secondary to SVT developed in 30 of 225 （13.3%）.Left ventricular ejection fraction （LVEF） of the 27 children attacked by TIC returned to normal after successful control of SVT （41.1%-±6.3% vs.60.3%±9.2%,t=-10.397,P=0.000）.Complete termination of SVT by antiarrhythmic drugs was achieved in 164 of 257 （63.8%）,partial termination rate was 18.7% （48 of 257） and failure to terminate rate was 17.5% （45 of 257）.Propafenone （complete cardioversion in 98 （73.1%） of 134） and amiodarone （complete cardioversion in 23 （76.7%） of 30） showed better efficacy for SVT termination than adenosine （complete cardioversion in 26 （44.1%）59） （x2=20.524,P=0.000）.Paroxysmal SVT had a higher termination rate on pharmacological therapy than AT （67.1% vs.50.0%,x2=6.337,P=0.042）.Patients of different age groups had significantly different response to antiarrhythmic therapy （x2=13.904,P=0.031）.Children〈l year of age showed the least response to antiarrhythmic drug therapy with complete termination in 51 （55.4%）of 92.Adverse effects occurred in 9 patients （3.5%）：Four patients had severe hypotensive shock using propafenone （n=3） and adenosine （n=1）,and 3 patients had sinus arrest using adenosine.Conclusion Most （57.6%） children with SVT have their first clinical episode within 1 year of age,and AVRT is the most common type.TIC occurs in 13.3% of children with SVT.Intravenous antiarrhythmic drug therapy has a 63.8% complete termination rate for children with SVT and incidence of adverse effects is 3.5%.Propafenone and amiodarone are more effective for SVT termination in children than adenosine.Serious adverse effects may occur when using propafenone.