Mitchell L B
Foothills Hospital, University of Calgary, Alberta, Canada.
Annu Rev Med. 1994;45:119-38. doi: 10.1146/annurev.med.45.1.119.
Demonstrated associations between postmyocardial infarction ventricular arrhythmias and a higher subsequent risk of both sudden and all-cause mortality have prompted a search for effective and safe treatment modalities. Recently completed clinical trials have provided a rationale for treatment recommendations in some specific settings. Beta-blocking therapy is recommended for postinfarction patients with frequent or complex ventricular premature beats. In contrast, calcium antagonist therapy is not helpful in these cases, and Class I antiarrhythmic therapy is actually harmful. Early indications of benefit from Class III antiarrhythmic therapies, particularly amiodarone, are under evaluation in large trials. Patients with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) occurring late after myocardial infarction require therapy. Viable therapeutic methods include individualized antiarrhythmic therapy selected by the noninvasive approach, individualized antiarrhythmic therapy selected by the invasive approach, empiric amiodarone therapy, transcatheter or surgical ablative therapy (for VT), and use of an implantable cardioverter defibrillator. Clinical trial data have yet to determine which of these approaches is most effective under which circumstances. Postinfarction patients with nonsustained VT are the focus of several ongoing treatment trials. Early data suggest that risks requiring specific therapy are reached only by those patients who also have significant left ventricular dysfunction. The presence of inducible sustained ventricular tachycardia at an electrophysiologic study may further risk stratify such patients. High-risk patients with nonsustained ventricular tachycardia, left ventricular dysfunction, and inducible sustained ventricular tachycardia should participate in ongoing clinical trials. In the absence of this opportunity, intensive treatment should be considered.
心肌梗死后室性心律失常与随后较高的猝死和全因死亡风险之间的相关性，促使人们寻找有效且安全的治疗方式。近期完成的临床试验为某些特定情况下的治疗建议提供了依据。对于有频发或复杂室性早搏的心肌梗死后患者，推荐使用β受体阻滞剂治疗。相比之下，钙拮抗剂治疗在这些情况下并无帮助，而Ⅰ类抗心律失常药物治疗实际上是有害的。Ⅲ类抗心律失常药物治疗，尤其是胺碘酮治疗的早期获益迹象，正在大型试验中进行评估。心肌梗死后晚期发生持续性室性心动过速（VT）或心室颤动（VF）的患者需要治疗。可行的治疗方法包括通过非侵入性方法选择的个体化抗心律失常治疗、通过侵入性方法选择的个体化抗心律失常治疗、经验性胺碘酮治疗、经导管或手术消融治疗（用于室性心动过速）以及使用植入式心脏复律除颤器。临床试验数据尚未确定这些方法中哪种在何种情况下最为有效。心肌梗死后非持续性室性心动过速患者是几项正在进行的治疗试验的重点。早期数据表明，只有那些同时存在显著左心室功能障碍的患者才会面临需要特定治疗的风险。在电生理研究中可诱发持续性室性心动过速可能会进一步对这类患者进行风险分层。有非持续性室性心动过速、左心室功能障碍且可诱发持续性室性心动过速的高危患者应参与正在进行的临床试验。若没有这个机会，则应考虑强化治疗。
