Bui An H, Waks Jonathan W
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
J Innov Card Rhythm Manag. 2018 Feb 15;9(2):3035-3049. doi: 10.19102/icrm.2018.090201. eCollection 2018 Feb.
Despite advances in the diagnosis and treatment of acute coronary syndromes and an overall improvement in outcomes, mortality after myocardial infarction (MI) remains high. Sudden death, which is most frequently due to ventricular tachycardia or ventricular fibrillation, is the cause of death in 25% to 50% of patients with prior MI, and therefore represents an important public health problem. Use of the implantable cardioverter-defibrillator (ICD), which is the primary method of reducing the chance of arrhythmic sudden death after MI, is costly to the medical system and is associated with procedural and long-term risks. Additionally, assessment of left ventricular ejection fraction (LVEF), which is the primary method of assessing a patient's post-MI sudden death risk and appropriateness for ICD implantation, lacks both sensitivity and specificity for sudden death, and may not be the optimal way to select the subgroup of post-MI patients who are most likely to benefit from ICD implantation. To optimally utilize ICDs, it is therefore critical to develop and prospectively validate sudden death risk stratification methods beyond measuring LVEF. A variety of tests that assess left ventricular systolic function/morphology, potential triggers for ventricular arrhythmias, ventricular conduction/repolarization, and autonomic tone have been proposed as sudden death risk stratification tools. Multivariable models have also been developed to assess the competing risks of arrhythmic and non-arrhythmic death so that ICDs can be utilized more effectively. This manuscript will review the epidemiology of sudden death after MI, and will discuss the current state of sudden death risk stratification in this population.
尽管急性冠脉综合征的诊断和治疗取得了进展，且总体预后有所改善，但心肌梗死（MI）后的死亡率仍然很高。猝死是导致既往心肌梗死患者死亡的原因，在这些患者中，25%至50%的死亡是由室性心动过速或心室颤动引起的，因此这是一个重要的公共卫生问题。植入式心脏复律除颤器（ICD）是降低心肌梗死后心律失常性猝死风险的主要方法，但对医疗系统来说成本高昂，且存在手术风险和长期风险。此外，左心室射血分数（LVEF）评估是评估患者心肌梗死后猝死风险及ICD植入适用性的主要方法，但该评估对猝死缺乏敏感性和特异性，可能不是选择最有可能从ICD植入中获益的心肌梗死后患者亚组的最佳方式。因此，为了最佳地利用ICD，开发并前瞻性验证除测量LVEF之外的猝死风险分层方法至关重要。已提出多种评估左心室收缩功能/形态、室性心律失常潜在触发因素、心室传导/复极化以及自主神经张力的测试作为猝死风险分层工具。还开发了多变量模型来评估心律失常性死亡和非心律失常性死亡的竞争风险，以便更有效地利用ICD。本文将综述心肌梗死后猝死的流行病学，并讨论该人群中猝死风险分层的现状。
