Weston M J, Talbot I C, Horoworth P J, Mant A K, Capildeo R, Williams R
Br Heart J. 1976 Nov;38(11):1179-88. doi: 10.1136/hrt.38.11.1179.
In a series of 106 patients with fulminant hepatic failure and grade 4 encephalopathy, cardiac arrhythmias and other abnormalities occurred in 92 per cent. The most common was sinus tachycardia (75%) and this was the only abnormality in 22 per cent of the patients. Sudden cardiac arrest occurred in 25 per cent, various ectopic beats in 20 per cent, and heart block or bradycardia in 18 per cent. Other electrocardiographic abnormalities, mostly of the T wave and ST segment, were found in 31 per cent. Cardiac and respiratory arrests were usually unrelated to each other and both frequently occurred without warning. Only 7 out of 71 patients with arrhythmias other than sinus tachycardia survived, compared with 15 out of 31 patients without them (P less than 0-005). During the latter part of the series when an arrhythmia computer was used to monitor 38 patients, it was shown that significantly lower arterial oxygen levels occurred in those with arrhythmias, other than sinus tachycardia, than in those without. They were also found to be more acidotic and hyperkalaemic, and a higher number required dialysis and ventilation. Macroscopical cardiac abnormalities including scattered petechial haemorrhages, small pericardial effusions, and fatty, pale, and flabby ventricles, were found at necropsy in 64 per cent of the patients examined. Combinations of these macroscopical abnormalities occurred, particularly in the paracetamol overdose group. Another necropsy finding of possible significance in the pathogenesis of arrhythmias was cerebral oedema, present in 48 per cent of the patients examined, and often associated with coning of the brain stem. However, 7 of the 16 patients who suffered asystolic cardiac arrests had no macroscopical abnormality of either heart or brain. In the management of patients with fulminant hepatic failure continuous cardiac monitoring is essential. Correction of the biochemical and coagulation defects may decrease the frequency of arrhythmias but studies of the mechanism and control of cerebral oedema and its relation to cardiovascular function are urgently needed.
在106例暴发性肝衰竭伴4级肝性脑病的患者中，92%出现心律失常及其他异常。最常见的是窦性心动过速（75%），22%的患者仅出现这一异常。25%的患者发生心脏骤停，20%出现各种异位搏动，18%出现心脏传导阻滞或心动过缓。31%的患者存在其他心电图异常，主要是T波和ST段异常。心脏骤停和呼吸骤停通常互不相关，且二者常无预警地发生。窦性心动过速以外的心律失常患者中，71例仅7例存活，而无心律失常的31例患者中有15例存活（P小于0.005）。在该系列研究的后期，使用心律失常计算机对38例患者进行监测，结果显示，窦性心动过速以外的心律失常患者的动脉血氧水平显著低于无心律失常者。还发现他们的酸中毒和高钾血症更严重，需要透析和通气的人数更多。尸检发现，64%接受检查的患者存在宏观心脏异常，包括散在的瘀点性出血、少量心包积液以及心室脂肪变性、苍白和松弛。这些宏观异常常合并出现，尤其是在对乙酰氨基酚过量组。尸检的另一项可能对心律失常发病机制具有重要意义的发现是脑水肿，48%接受检查的患者存在脑水肿，且常伴有脑干疝。然而，16例发生心脏停搏的患者中有7例心脏和大脑均无宏观异常。对于暴发性肝衰竭患者的治疗，持续心脏监测至关重要。纠正生化和凝血缺陷可能会降低心律失常的发生率，但迫切需要对脑水肿的机制、控制及其与心血管功能的关系进行研究。
