Zehender M, Meinertz T, Hohnloser S, Geibel A, Gerisch U, Olschewski M, Just H
Abteilung für Kardiologie, Albert-Ludwigs Universität Freiburg, FRG.
Circulation. 1992 May;85(5):1808-15. doi: 10.1161/01.cir.85.5.1808.
Systemic hypertension is a well-known risk factor for coronary artery disease and sudden cardiac death. Recent interest focused on the presence of malignant ventricular arrhythmias (VA) and myocardial ischemia in hypertensive patients and provided a potential link for fatal tachyarrhythmic events.
We studied 150 untreated normokalemic hypertensive patients (56 +/- 9 years; 56 women and 94 men) without manifest coronary artery disease to determine prevalence, severity, and interaction of VA and significant ST segment changes induced by daily activities. One third of the patients were randomized to 4 weeks of placebo and restudied for spontaneous variability of the two parameters. All patients were included in a 3-year follow-up study. VA were observed in 129 of 150 hypertensive patients (86%) and peaked in the early morning and late afternoon. Twenty-two patients (15%) had ventricular pairs, and 20 patients (13%) had nonsustained ventricular tachycardia. Transient ST segment depression observed in 47 patients (33%; mean incidence, 2.7 +/- 0.8 episodes/24 hr) showed a characteristic circadian variation similar to VA and were asymptomatic in 93% of the episodes. At the time of transient ST segment depression, VA increased 4.6 times (p less than 0.01). After 4 weeks of placebo, marked variations in the incidence of VA (VA suppression rate -100%, or increase greater than 400%) were observed in 29% of the patients, and in 60% of all patients repetitive VA were present in only one of the two Holter recordings. Day-and-night variations of VA and transient ST segment changes were highly reproducible during the placebo period. After 3 years of follow-up, eight of 146 patients (5%) had suffered myocardial infarction, and five patients had died from cardiac events (three patients died from sudden cardiac death). Logistic regression analysis revealed left ventricular hypertrophy (relative risk, 6.1; p less than 0.01) and transient ST segment abnormalities during daily activities (relative risk, 4.4; p less than 0.05) to be of independent prognostic significance to predict cardiac events during follow-up instead of repetitive VA (relative risk, 1.3; NS).
VA associated with a high spontaneous variability and predominantly asymptomatic transient ST segment changes are common in hypertensives; the interaction of both risk factors may provide an important link for fatal VA. Antiarrhythmic therapy is not to be recommended in the majority of patients. Presence of left ventricular hypertrophy and transient ST segment changes were the most powerful predictors of cardiac events during the follow-up.
系统性高血压是冠状动脉疾病和心源性猝死的众所周知的危险因素。最近的研究兴趣集中在高血压患者中恶性室性心律失常（VA）和心肌缺血的存在，并为致命性快速心律失常事件提供了潜在联系。
我们研究了150例未经治疗的血钾正常的高血压患者（年龄56±9岁；女性56例，男性94例），这些患者无明显冠状动脉疾病，以确定VA的患病率、严重程度以及日常活动诱发的VA与显著ST段改变之间的相互作用。三分之一的患者被随机分配接受4周安慰剂治疗，之后重新研究这两个参数的自发变异性。所有患者均纳入一项为期3年的随访研究。150例高血压患者中有129例（86%）观察到VA，其在清晨和傍晚达到峰值。22例患者（15%）出现室性成对搏动，20例患者（13%）出现非持续性室性心动过速。47例患者（33%）观察到短暂性ST段压低（平均发生率为2.7±0.8次/24小时），其显示出与VA相似的特征性昼夜变化，且93%的发作无症状。在短暂性ST段压低时，VA增加4.6倍（p<0.01）。接受4周安慰剂治疗后，29%的患者观察到VA发生率有显著变化（VA抑制率为-100%，或增加超过400%），并且在所有患者中有60%在两次动态心电图记录中仅有一次出现重复性VA。在安慰剂治疗期间，VA和短暂性ST段改变的昼夜变化具有高度可重复性。经过3年随访，146例患者中有8例（5%）发生心肌梗死，5例患者死于心脏事件（3例患者死于心源性猝死）。逻辑回归分析显示左心室肥厚（相对风险为6.1；p<0.01）和日常活动期间短暂性ST段异常（相对风险为4.4；p<0.05）对预测随访期间的心脏事件具有独立的预后意义，而重复性VA则不然（相对风险为1.3；无统计学意义）。
VA具有高自发变异性且主要为无症状性短暂性ST段改变在高血压患者中很常见；这两种危险因素的相互作用可能为致命性VA提供重要联系。不建议大多数患者进行抗心律失常治疗。左心室肥厚和短暂性ST段改变的存在是随访期间心脏事件的最有力预测因素。
