Steinbeck G, Andresen D, Bach P, Haberl R, Oeff M, Hoffmann E, von Leitner E R
Medical Hospital I, University of Munich, Germany.
N Engl J Med. 1992 Oct 1;327(14):987-92. doi: 10.1056/NEJM199210013271404.
Antiarrhythmic drug therapy guided by invasive electrophysiologic testing is now widely used in patients with symptomatic, sustained ventricular tachyarrhythmias.
We conducted a prospective, randomized trial in 170 patients to investigate whether this approach would improve long-term outcome. Patients whose arrhythmia was inducible by programmed electrical stimulation were assigned to treatment with electrophysiologically guided drug therapy based on serial testing (61 patients) or with metoprolol (54 patients). Electrophysiologically guided therapy consisted of serial testing of antiarrhythmic agents to identify the first one that rendered the arrhythmia noninducible. The 55 patients whose arrhythmia was noninducible during the initial electrophysiologic test were also treated with metoprolol.
During a mean (+/- SD) follow-up period of 23 +/- 17 months, recurrent, nonfatal arrhythmia occurred in 44 patients and sudden death due to cardiac factors in 27. The incidence of symptomatic arrhythmia and sudden death combined was virtually the same in the two groups with inducible arrhythmia after two years of observation (electrophysiologically guided therapy vs. metoprolol therapy, 46 percent vs. 48 percent). The outcome was more favorable in the patients with noninducible arrhythmia at base line (75 percent had neither adverse event) than in those with inducible arrhythmia who were assigned to metoprolol therapy (P = 0.009 by log-rank test). Only 6 of the 29 patients (21 percent) with inducible arrhythmia that became noninducible during drug therapy had recurrent arrhythmia or sudden death, as compared with 21 of the 32 patients (66 percent) with arrhythmia that continued to be inducible (P less than 0.001). A multivariate regression analysis identified continued inducibility of the arrhythmia as an independent predictor of recurrent arrhythmia or sudden death (relative risk, 7.3; 95 percent confidence interval, 2.3 to 23.2; P less than 0.001).
As compared with metoprolol therapy, electrophysiologically guided antiarrhythmic drug therapy did not improve the overall outcome of patients with sustained ventricular tachyarrhythmias. However, effective suppression of inducible arrhythmia by antiarrhythmic drugs was associated with a better outcome than was lack of suppression.
侵入性电生理检查指导下的抗心律失常药物治疗目前广泛应用于有症状的持续性室性心律失常患者。
我们对170例患者进行了一项前瞻性随机试验，以研究这种方法是否能改善长期预后。心律失常可通过程序电刺激诱发的患者被分配接受基于系列检查的电生理指导药物治疗（61例患者）或美托洛尔治疗（54例患者）。电生理指导治疗包括对抗心律失常药物进行系列检查，以确定第一种能使心律失常不可诱发的药物。55例在初始电生理检查期间心律失常不可诱发的患者也接受了美托洛尔治疗。
在平均（±标准差）23±17个月的随访期内，44例患者发生复发性非致命性心律失常，27例患者因心脏因素猝死。观察两年后，两组可诱发心律失常患者的症状性心律失常和猝死合并发生率几乎相同（电生理指导治疗组与美托洛尔治疗组，分别为46%和48%）。基线时心律失常不可诱发的患者预后较好（75%无不良事件），优于分配接受美托洛尔治疗的可诱发心律失常患者（对数秩检验P = 0.009）。在药物治疗期间心律失常从可诱发变为不可诱发的29例患者中，只有6例（21%）发生复发性心律失常或猝死，而32例持续可诱发心律失常的患者中有21例（66%）发生（P<0.001）。多变量回归分析确定心律失常持续可诱发是复发性心律失常或猝死的独立预测因素（相对风险，7.3；95%置信区间，2.3至23.2；P<0.001）。
与美托洛尔治疗相比，电生理指导的抗心律失常药物治疗并未改善持续性室性心律失常患者的总体预后。然而，抗心律失常药物有效抑制可诱发心律失常与未抑制相比，预后更好。
