Coumel P, Leenhardt A
Hôpital Lariboisière, Paris, France.
Circulation. 1991 Apr;83(4 Suppl):II58-70.
All of the electrophysiological mechanisms of arrhythmias are sensitive to the influences of the autonomic nervous system, particularly to its adrenergic limb. Arrhythmogenic areas may also be dependent on the inhomogeneity of these influences because of their pathophysiological structure and/or the neurogenic or humoral nature of the vector of modulation. The complexity of the various possible scenarios, combined with the role of the rate dependence, explains why standardized protocols exploring the autonomic nervous system in clinical arrhythmias are difficult to define. Invasive electrophysiology is not adapted to address the problem. Isoprenaline infusion only reproduces the humoral adrenergic stimulation to which only a few types of arrhythmias are sensitive. The exercise test is a very complex investigation if the multiple parameters involved are considered. Only a part of its limitations are obviated by the mental stress. Under natural conditions, the neurogenic origin, the intensity of the sympathetic stimulation, and its suddenness are all critical factors responsible for severe tachyarrhythmias. Arrhythmias of the long QT syndrome are particularly demonstrative of the importance of the autonomic nervous system, but this evidence can also be documented in more trivial circumstances of diseased or apparently undiseased hearts. Exploring the autonomic nervous system behavior through heart rate variability in ambulatory recordings is the most recent and fruitful method of investigation. This nonprovocative approach has technical obstacles and practical and theoretical limitations related to the fundamental nature of the autonomic nervous system, which is both a marker of the cardiac status and a determinant of arrhythmias.
心律失常的所有电生理机制均对自主神经系统的影响敏感，尤其是对其肾上腺素能分支。由于致心律失常区域的病理生理结构和/或调制向量的神经源性或体液性质，这些区域也可能依赖于这些影响的不均匀性。各种可能情况的复杂性，再加上心率依赖性的作用，解释了为何难以定义用于探索临床心律失常中自主神经系统的标准化方案。有创电生理并不适合解决该问题。输注异丙肾上腺素仅能重现体液性肾上腺素能刺激，而只有少数类型的心律失常对此敏感。如果考虑到运动试验涉及的多个参数，那么它是一项非常复杂的检查。心理应激只能消除其部分局限性。在自然条件下，神经源性起源、交感神经刺激的强度及其突然性都是导致严重快速性心律失常的关键因素。长QT综合征的心律失常尤其能说明自主神经系统的重要性，但在患病或看似未患病心脏的更普通情况下也能证明这一点。通过动态记录中的心率变异性来探索自主神经系统行为是最新且富有成效的研究方法。这种非激发性方法存在技术障碍以及与自主神经系统的基本性质相关的实践和理论局限性，自主神经系统既是心脏状态的标志物，也是心律失常的决定因素。
