Zehender M, Büchner C, Meinertz T, Just H
Innere Medizin III, Albert-Ludwigs-Universitätsklinik Freiburg, FRG.
Circulation. 1992 Feb;85(2):596-605. doi: 10.1161/01.cir.85.2.596.
Permanent cardiac pacing is well established for the improvement of prognosis and quality of life in patients with severe bradycardia. However, sudden cardiac death still remains an unresolved problem, as it occurs in approximately 20-30% of paced patients. This 2-year follow-up study was directed at prospectively assessing prevalence, circumstances, and mechanisms of sudden death in 2,021 permanently paced patients.
During the observation period, 220 patients (11%) died (mean pacing interval, 50.5 +/- 7 months). Lethal cerebrovascular events in 66 of 220 patients (30%) and sudden death in 49 of 220 patients (23%) were the two most frequently reported modes of death. Nonsudden (first year, 20%; subsequent years, 6.9%; p less than 0.01) and sudden death mortality rate (4% versus 1.8%, p less than 0.05) were highest during the first year. Mortality was unrelated to the patient's activity status at the time of death. Sudden cardiac death occurred more often in male patients (increased risk, 1.7 versus female patients; p less than 0.001) and patients younger than 60 years of age (5.2 versus patients older than 60 years, p less than 0.001). Patients with severe bradycardia (sudden death rate, 28%), severe atrioventricular block (25%), or atrial fibrillation with low ventricular rate (25%) before pacemaker implantation were more likely to suffer from sudden cardiac death than patients with previous syncopal attacks (sudden death rate, 15%) or sick sinus syndrome (17%). The highest incidence of sudden death was observed in patients with bifascicular and trifascicular bundle branch block. In this group, 35% of patients died suddenly during the follow-up period compared with 18% of patients without bundle branch block. In a subsequent study in 90 consecutive patients with various types of bundle branch block, undersensing of up to 13% of ectopic ventricular beats occurred in patients with bifascicular block. Pacing-induced tachyarrhythmias and ventricular fibrillation were documented in 10% of undersensed ectopic ventricular beats as well as in the setting of atrial fibrillation associated with ventricular arrhythmias.
Young age, male sex, and a severely diseased heart indicated by the presence of bifascicular and trifascicular bundle branch block are the strongest predictive clinical parameters for sudden cardiac death, especially in the first year after pacemaker implantation.
永久性心脏起搏已被广泛用于改善严重心动过缓患者的预后和生活质量。然而，心脏性猝死仍然是一个未解决的问题，因为在大约20%-30%的起搏患者中会发生。这项为期2年的随访研究旨在前瞻性评估2021例永久性起搏患者心脏性猝死的发生率、情况及机制。
在观察期内，220例患者（11%）死亡（平均起搏间期50.5±7个月）。220例患者中有66例（30%）死于致命性脑血管事件，49例（23%）死于心脏性猝死，这是最常报告的两种死亡方式。非心脏性猝死（第一年为20%，随后几年为6.9%；P<0.01）和心脏性猝死死亡率（4%对1.8%，P<0.05）在第一年最高。死亡率与患者死亡时的活动状态无关。心脏性猝死在男性患者中更常见（风险增加，与女性患者相比为1.7；P<0.001），且在年龄小于60岁的患者中更常见（5.2对年龄大于60岁的患者，P<0.001）。起搏器植入前有严重心动过缓（心脏性猝死率28%）、严重房室传导阻滞（25%）或心室率缓慢的心房颤动（25%）的患者比既往有晕厥发作（心脏性猝死率15%）或病态窦房结综合征（17%）的患者更易发生心脏性猝死。心脏性猝死发生率最高的是双分支和三分支束支传导阻滞患者。在该组中，35%的患者在随访期间心脏性猝死，而无束支传导阻滞的患者为18%。在随后一项对90例连续的各种类型束支传导阻滞患者的研究中，双分支传导阻滞患者中高达13%的室性异位搏动感知不足。在10%的感知不足的室性异位搏动以及伴有室性心律失常的心房颤动情况下记录到起搏诱发的快速性心律失常和心室颤动。
年轻、男性以及存在双分支和三分支束支传导阻滞所提示的严重心脏疾病是心脏性猝死最强的预测临床参数，尤其是在起搏器植入后的第一年。
