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1、,心脏性猝死的高危因素,直击猝死!(残酷的事实),2003年6月27日,在联合会杯的比赛中,喀麦隆国脚维维安福猝死赛场,震惊了整个足球界。最后经严格的尸检证实为心脏性猝死,54岁的爱立信(中国)有限公司总裁杨迈于2004年4月8日晚,由于心脏病突发在京猝死,直击猝死!(残酷的事实),全球快餐业巨头麦当劳公司董事长兼首席执行官吉姆坎塔卢波于2004年4月19日凌晨猝死于家中,最终死因为心脏病突发,享年60岁,直击猝死!(残酷的事实),直击猝死!(残酷的事实),直击猝死!(残酷的事实),他们的猝然离世为人们敲响了警钟:小心心脏性猝死!,现代SCD的定义,(1) 临床上有心脏骤停的证据 (2) 从突
2、发症状到死亡的时间在1小时之内 或 (3) 不明原因的死亡,之前24小时内病人情况良好注意: SCD (Sudden Cardiac Death) and SCA (Sudden Cardiac Arrest) 两者的定义有所不同,Kim SG. Standardized reporting of ICD patient outcome: the report of a North American Society of Pacing and Electrophysiology Policy Conference, February 9-10, 1993. PACE 1993;16:1358-
3、1362.,美国SCA的发病情况,1 U.S. Census Bureau, Statistical Abstract of the United States: 2001. 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001. 3 2002 Heart and Stroke Statistical Update, American Heart Association. 4 Zheng Z. Circulation. 2001;104:2158-2163.,AIDS1,乳腺癌
4、2,肺癌2,中风3,SCA4,在美国,每年SCA 的发病人数超过所有这些疾病的总和,450,000,167,366,157,400,40,600,42,156,每年450,000例 每天1200例 每小时50例 每80秒1例大多数的SCA发生在临床确诊的心脏病患者中,特别是心梗后和心衰的患者,1Circulation. 2001;104:2158-2163. 2 Myerburg RJ, Castellanos A. Cardiac Arrest and Sudden Cardiac Death, in Braunwald E, Zipes DP, Libby P, Heart Disease
5、, A textbook of Cardiovascular Medicine. 6th ed. 2001. W.B. Saunders, Co. 3 Every N, et al. Risk of Sudden versus Non Sudden Cardiac Death in Patient with Coronary Artery Disease. Am Heart J 2002; 144: 390-6.,美国SCA的发病情况,在美国,所有心脏原因引起的死亡中,SCA大约占63%1在发达国家中,SCA是最常见的死亡原因之一,1 MMWR. Vol 51(6) Feb. 15, 2002
6、. 2 Myerberg RJ, Catellanos A. Cardiac Arrest and Sudden Cardiac Death. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th Ed. New York: WB Saunders. 1997: 742-779. 3 Circulation. 2001;104:2158-2163. 4 Vreede-Swagemakers JJ et al. J Am Coll Cardiol 1997; 30: 1500-1505.,SC
7、A的统计情况,SCA的病因,Huikuri HV. N Engl J Med. 2001;345:1473-1482. Myerburg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6th ed. W.B. Saunders, Co. 2001.,*ion-channel abnormalities, valvular or congenital heart disease, other causes,CAD已成为西方国家人群发生SCA的主要病因,不常见病因,心肌病,冠状动脉粥样硬化高危因素:老年,男性,高血脂,吸烟, 高
8、血压,糖尿病,遗传因素,高血压,遗传因素,感染,其他,冠状动脉粥样硬化,肥厚型心肌病,扩张型心肌病,心梗后慢性心肌瘢痕,原发性电活动和遗传性离子通道异常,瓣膜病或先天性心脏疾患,其他原因,急性的瘢块不稳定:破裂,出血,血栓,SCA的触发机制: 短暂的缺血,血液动力学波动,神经心脏血管影响,环境因素,SCA的病因,Heikki HV,Castellanos A,Myerburg RJ.Sudden cardiac death due to cardiac arrhythmias.N Engl J Med.2001;20:1473-1482.,Bays de Luna A. Am Heart J.
9、 1989;117:151-159.,心动过缓 17%,单形性VT 62%,原发性VF 8%,尖端扭转性VT 13%,SCA发生时的心律失常情况,中国人口基数大,每年SCA的发病人数超过100万,!,40% SCA发生在睡眠时或没有旁人在现场的情况下 1 80% SCA发生在家里 1 院外SCA的存活率仅5% 2,3 (美国),SCA 存活率统计,即使在紧急救护系统非常完善/可早期给予除颤治疗的地区,SCA的存活率仍很低,因为大多数SCA发生时无旁人在场,或即便被发现,也很难在6-8分钟内给予有效的治疗,1 Swagemakers V. J Am Cardiol. 1997;30:1500-1
10、505. 2 Ginsburg W. Am J Emer Med. 1998;16:315-319. 3 Cobb LA. Circulation. 1992;85:I98-102.,发现SCA的高危患者,给予有效预防措施,SCA干预的首要环节,SCA高危因素1,2,左室射血分数(LVEF)低下 冠心病(CAD)、心梗后 心梗后伴LVEF低下 曾经发生过SCA或VT事件 有SCA家族史 扩张型心肌病伴心衰(缺血性/非缺血性) 遗传异常:HCM、LQTS、Brugada综合征,1 Priori SG.et al.Task Force on Sudden Cardiac Death of the
11、European Society of Cardiology.European Heart Journal.2001;22:1374-1450. 2 Maron BJ,et al.Efficacy of implantable cardioverter defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy.N Engl J Med.2004;342:363-373,不同危险人群猝死发生情况1,2,1 Adapted from: Myerburg RJ. Sud
12、den Cardiac Death: Exploring the Limits of Our Knowledge. J Cardiovasc Electrophysiol Vol. 12, pp. 369-381, March 2001. 2 Bunch,JT.et al.Long-term outcomes of out-of-hospital cardiac arrest after successful defibrillation.N Engl J Med.2003;348:2626-2633.,300,000,200,000,100,000,0,猝死发生次数/年,有冠心病高危因素,冠
13、心病,EF35%,心衰,院外SCA幸存者,心梗后,EF低下伴VT,总人群,30,25,20,10,5,0,猝死发生率(%),SCA的高危因素(一),左室射血分数(LVEF)低下,左室射血分数(LVEF)已成为评估SCA非常重要的独立危险因素1,1 Myerberg RJ,Castellanos A.Cardiac arrest and sudden cardiac death.Braunwald E.Heart Disease,A Textbook of Cardiovascular Medicine.5th ed,Vol.Philadelphia:WB Saunders Co;1997:ch
14、apter 24,LVEF30%的患者发生SCA的危险性极高,LVEF与SCA,1 Gorgels, PMA Out-of-hospital cardiac arrest-the relevance of heart failure.The Maastricht Circulatory Arrest Registry.European Heart Journal.2003;24:1204-1209.,LVEF,% SCA Victims,7.5%,5.1%,2.8%,1.4%,LVEF与SCA的相关性1,1 Yap Y,Duong T,Blend M,et al.Heart.2000;83:8
15、5.,不同LVEF的死亡危险性1,冠心病、心梗后,SCA的高危因素(二),1 Myerberg RJ,Castellanos A.Cardiac arrest and sudden cardiac death.Braunwald E.Heart Disease,A Textbook of Cardiovascular Medicine.5th ed,Vol.Philadelphia:WB Saunders Co;1997:chapter 24 2 Lombardi G,Gallagher J,Gennis P.Outcome of out-of hospital cardiac arrest
16、in New York City.JAMA.1994;271:678-683. 3 Bigger JT,Fleiss JL,Kleiger R et al.The relationships among ventricular arrhythmias,left ventricular dysfunction,and mortality in the 2 years after myocardial infarction.Circulation.1984;69:250-258,Post-MI占所有SCA病因的50-75%1,2,3,这些患者的SCA发生率比正常人高出4-6倍1,2,3,CAD,Post-MI与SCA,(n = 300),(n = 283),(n = 284),(n = 292),Hazard Ratio,.98 (p = 0.92),