CRTD在心衰患者猝死防治中的價值學習教案

1、會計學1CRTD在心衰患者猝死防治中的價值在心衰患者猝死防治中的價值預后比大多數(shù)腫瘤還要惡劣心 衰 與 猝 死第1頁/共35頁21世紀的心血管流行病 CHF and AF （2003年統(tǒng)計）第2頁/共35頁1 American Heart Association. Heart Disease and Stroke Statistics 2005 Update.2 Jemel A. CA Cancer J Clin. 2003;53:5-26.3 U.S. HIV & AIDS Statistic Summary. A.Breast Cancer2335,000SCA31

2、8,00040,000152,200163,000AIDS3Lung Cancer2Stroke1在美國，每年SCA 的發(fā)病人數(shù)超過所有這些疾病的總和第3頁/共35頁1 American Heart Association. Heart Disease and Stroke Statistics 2005 Update.2 NHLBI, CHF Data Fact Sheet, September 1996.3 Sweeney MO. PACE. 2001;24:871-888.4 SOLVD Investigators. N Engl J Med 1992;327:685-6915 SOLV

3、D Investigators. N Engl J Med 1991;325:293-302.6 Goldman S. Circulation 1993;87:V124-V131第4頁/共35頁中國人口基數(shù)大，每年SCA的發(fā)病人數(shù)超過54萬第5頁/共35頁第6頁/共35頁在 Framingham 心臟研究39年的隨訪中, 無論男性還是女性，CHF 的出現(xiàn)明顯增加心臟性猝死和全因死亡.11 Redrawn from Kannel WB, Wilson PWF, DAgostino RB, Cobb J. Sudden coronary death in women. Am Heart J 199

4、8 Aug; 136: 205-212心衰的出現(xiàn)增加60-115%猝死第7頁/共35頁Adapted from: Myerburg RJ. Sudden Cardiac Death: Exploring the Limits of Our Knowledge. J Cardiovasc Electrophysiol Vol. 12, pp. 369-381, March 2001. 300,000200,000100,0000Incidence of Sudden Deaths Per Year (number)Multiple risk subgroupsPatients with any

5、previous coronary eventPatients with ejectionfraction 35% or CHFCardiac arrest, VT/VF survivorsHigh-risk post-MI subgroupsGeneral adult population3025201050Incidence of Sudden Death(% of group)MADIT, MUSTT, MADIT IIAVID, CASH, CIDSSCD-HeFT第8頁/共35頁1 Gorgels, PMA Out-of-hospital cardiac arrest-the rel

6、evance of heart failure.The Maastricht Circulatory Arrest Registry.European Heart Journal.2003;24:1204-1209.LVEF% SCA Victims7.5%5.1%2.8%1.4%SCA危險性增加了6+ 倍第9頁/共35頁總死亡率 15-40%；SCD占總死亡的 50%.12 months16 months41.4 months27 months 13 months45 months6 monthsControl Group Mortality %第10頁/共35頁 American Hear

7、t Association. Heart Disease and Stroke Statistics 2005 Update. 第11頁/共35頁心衰患者SCD的預防及治療第12頁/共35頁盡管給予理想的藥物治療，心衰的猝死率仍非常高1 MERIT-HF Study Group.Effect of metroprolol CR/XL in chronic heart failure.Lancet.1999;353:2001-2007.2 CIBIS Investigations and Committees.The cardiac insufficiency bisprolol study I

8、I (CIBIS-II).Lancet.1999;353:9-13.3 Packer M,Bristow MR,Cohn JN,et al.The effect of carvedilol on morbitity and nortality in patients with chronic heart Heart Failure Study Group.N Engl J Med.1996;334:1349-1355.4 The RALE Investigators.Effectiveness of spironolactone added to an aniotensin-convertin

9、g enzyme inhibitor and a loop diuretic for severe chronic congestive heart failure(the Randomized Aldactone Evaluation StudyRALES.Am J Cardiol.1997;78:902.研究研究人數(shù)人數(shù)死亡人數(shù)死亡人數(shù)心血管病心血管病死亡人數(shù)死亡人數(shù)猝死人數(shù)猝死人數(shù) 猝死率猝死率%MERIT-HF399136233122158.2CIBIS-II246738428013134.1CARVEDILOL(U.S.)109453532750.9RALES166371064019

10、227第13頁/共35頁CRT治療隨機臨床試驗進展累計圖第14頁/共35頁第15頁/共35頁1 MERIT-HFStudy Group. Effect of Metoprolol CR/XL in chronic heart failure:Metoprolol CR/XL randomized intervention trial in congestive heart failure(MERIT-HF).LANCET. 1999;353:2001-2007.NYHA Class III n = 103NYHA Class II n = 103NYHA Class IV n = 2764%1

11、2%24%11%56%33%59%15%26%MERIT-HF研究死亡模式分析發(fā)現(xiàn)研究死亡模式分析發(fā)現(xiàn),NYHA II/III級患者的主要死因為級患者的主要死因為SCA，而，而NYHA IV級的患者大多死級的患者大多死于心衰于心衰第16頁/共35頁第17頁/共35頁Buxton AE. N Engl J Med. 1999;341:1882-90.Time after Enrollment (Years)0心律失常死亡和心臟驟停發(fā)生率123450EP-指導的抗心律失常藥物治療沒有抗心律失常藥物治療EP-指導的ICD治療與EP指導的抗性律失常藥物治療組和無抗心律失常藥物治療組相比，只有ICD能夠

12、明顯降低死亡率第18頁/共35頁Moss AJ. N Engl J Med. 2002;346:877-83.除顫器組傳統(tǒng)組生存率01234YearNo. At Risk除顫器組 742502 (0.91)274 (0.94)110 (0.78)9傳統(tǒng)組 490329 (0.90)170 (0.78) 65 (0.69)3傳統(tǒng)組2年死亡率25%第19頁/共35頁0Mortality06121824303642485460Months of follow-upAmiodaroneICD TherapyPlaceboHR97.5% ClP-Value第20頁/共35頁Hazard Ratio (9

13、5% CI) ICD vs. OMTP-ValueReduction in Death w/ICD全因死亡 (All Pts)0.65 (0.40 - 1.06)0.0835%全因死亡 (NYHA Class III)0.37 (0.15 - 0.90)0.0263%心律失常所致猝死0.20 (0.06 - 0.71)0.00680%非缺血性DCM(LVEF36%) 預防性 ICD治療：n=454, 79% NYHA I-II第21頁/共35頁第22頁/共35頁第23頁/共35頁第24頁/共35頁主要研究終點主要研究終點：CRT和CRTD均明顯降低全原因死亡率 和全原因住院率的復合終點第25頁

14、/共35頁二級終點二級終點：CRT可以降低全原因死亡率24%， CRT-D可降低36，第26頁/共35頁 J Am Coll Cardiol. 2005 Dec 20;46(12):2329-34. 第27頁/共35頁第28頁/共35頁CRT : 159 pts (39%)348118232292404Medical Therapy768166273323409CRTNumber at risk0500100015000.000.250.500.75HR 0.63 (95% CI 0.51 to 0.77)Event-free SurvivalDaysP .0001Medical : 224 ptsTherapy (55 %)心臟再同步治療與對照組相比使所有原因死心臟再同步治療與對照組相比使所有原因死亡率或心血管病因住院聯(lián)合終點下降亡率或心血管病因住院聯(lián)合終點下降37%37%第29頁/共35頁CRTMedicalTherapy01600SurvivalTime (days)4008001200CRT = 32 sudden deaths (7.8%)Medical Therapy = 54 sudden deaths (13.4%)Hazard Ratio 0.54 (95% CI 0.35 to 0.84; P=0.006)Main Study 平均隨訪時間：Extens