Yamashita S, Miyagawa K, Inagaki T, Dohi Y
Department of Internal Medicine, Nagoyashi Kohseiin Geriatric Hospital.
Nihon Ronen Igakkai Zasshi. 1999 Aug;36(8):561-4. doi: 10.3143/geriatrics.36.561.
An 86-year-old man had a history of hypertension and had been treated with calcium antagonist but no medications that could reduce heart rate. As a 12-lead electrocardiogram showed sinus bradycardia, complete right bundle branch block and left anterior fascicular hemiblock on his first visit to our hospital on January 1998, he was admitted to our hospital for further examination and treatment. A 24-hour Holter electrocardiogram demonstrated a total number of 74,182 heartbeats per day with pauses (> 2.0 sec) of 187/day. Overdrive atrial pacing study and His bundle electrogram revealed a prolonged corrected sinus node recovery time (5.820msec at a stimulation rate of 130/min) and H-V conduction time (80msec) with normal A-H conduction time, respectively. We diagnosed these abnormalities as sick sinus syndrome (Rubenstein II). His activity of daily living score was 30 points by the Barthel index on the day of admission. Oral administration of orciprenaline sulfate (30 mg/day), a beta-adrenoceptor agonist, was initially chosen rather than implantation of a cardiac pacemaker to increase his heart rate since he did not have any symptoms due to bradycardia and he did not give us an informed consent for the implantation. Orciprenaline sulfate, however, failed to increase total heartbeats (73,079/day). Then, oral cilostazol (100 mg/day), a phosphodiesterase III inhibitor, was administered. After two weeks of the regimen total heart beats were increased (85,642/day) with no pauses. The increase in heart rate resulted in the improvement of his activity of daily living (Barthel index: 55 points). Cilostazol could be the first line medication for elderly patients with bradyarrhythmia in whom implantation of cardiac pacemaker is not absolutely indicated.
一名86岁男性有高血压病史，一直使用钙拮抗剂治疗，但未使用过可降低心率的药物。1998年1月他首次来我院就诊时，12导联心电图显示窦性心动过缓、完全性右束支传导阻滞和左前分支阻滞，遂入院进一步检查和治疗。24小时动态心电图显示每日总心跳数为74182次，停搏（>2.0秒）为187次/天。超速心房起搏研究和希氏束电图分别显示校正窦房结恢复时间延长（刺激频率为130次/分钟时为5.820毫秒）和H-V传导时间延长（80毫秒），而A-H传导时间正常。我们将这些异常诊断为病态窦房结综合征（鲁宾斯坦II型）。入院当天，根据Barthel指数，他的日常生活活动评分为30分。由于他没有因心动过缓出现任何症状且未签署植入心脏起搏器的知情同意书，最初选择口服硫酸奥西那林（30毫克/天），一种β肾上腺素能受体激动剂，以提高他的心率，而不是植入心脏起搏器。然而，硫酸奥西那林未能增加总心跳数（73079次/天）。随后，给予口服西洛他唑（100毫克/天），一种磷酸二酯酶III抑制剂。该治疗方案实施两周后，总心跳数增加（85642次/天）且无停搏。心率增加使他的日常生活活动得到改善（Barthel指数：55分）。对于并非绝对需要植入心脏起搏器的老年缓慢性心律失常患者，西洛他唑可能是一线用药。
