Maggioni A P, Zuanetti G, Franzosi M G, Rovelli F, Santoro E, Staszewsky L, Tavazzi L, Tognoni G
GISSI-2 Coordinating Center, Milano, Italy.
Circulation. 1993 Feb;87(2):312-22. doi: 10.1161/01.cir.87.2.312.
Several studies performed before the advent of thrombolysis have shown that the presence of ventricular arrhythmias is an independent risk factor for subsequent mortality in patients recovering from acute myocardial infarction. Since fibrinolysis affects the natural history of infarction and may alter the clinical relevance of different risk factors, the aim of the present study was to establish the prevalence and prognostic value of ventricular arrhythmias in post-myocardial infarction patients treated with fibrinolytic agents during the acute phase.
Twenty-four-hour Holter recordings obtained before discharge from the hospital in 8,676 post-myocardial infarction patients of the GISSI-2 study were analyzed for the presence of ventricular arrhythmias. Patients were followed for 6 months from the acute event; total and sudden cardiovascular mortality rates were computed, and relative risks in univariate and multivariate analyses were calculated. Ventricular arrhythmias were present in 64.1% of the patients, more than 10 premature ventricular beats per hour were recorded in 19.7% of the patients, and nonsustained ventricular tachycardia was present in 6.8% of the patients. Ventricular arrhythmias were more frequent when signs or symptoms of left ventricular damage were present. During follow-up, there was a total of 256 deaths 2.0% in patients without ventricular arrhythmias, 2.7% in patients with one to 10 premature ventricular beats per hour, 5.5% in those with more than 10 premature ventricular beats per hour, and 4.8% in those with complex premature ventricular beats. Even after adjusting for several risk factors, the presence of frequent (more than 10 premature ventricular beats per hour) ventricular arrhythmias remained a significant predictor of total (RRCox, 1.62; 95% confidence interval, 1.16-2.26) and sudden mortality (RRCox, 2.24; 95% confidence interval, 1.22-4.08). On the other hand, the presence of nonsustained ventricular tachycardia was not associated with a worsening of the prognosis in the adjusted analysis (RRCox, 1.20; 95% confidence interval, 0.80-1.79).
This study shows that approximately 36% of patients recovering from acute myocardial infarction presented with less than one premature ventricular beat per hour in Holter recordings obtained before discharge from the hospital, whereas almost 20% of patients showed frequent (more than 10 premature ventricular beats per hour) ventricular arrhythmias. Due to the large size of the population of this study, these figures may be used as a reliable estimate of the prevalence of arrhythmias in postinfarction patients treated with fibrinolytic agents during the acute phase. Frequent premature ventricular beats are confirmed as independent risk factors of total and sudden death in the first 6 months following the acute event; the significance of nonsustained ventricular tachycardia in this population appears more controversial.
在溶栓治疗出现之前进行的多项研究表明，室性心律失常的存在是急性心肌梗死恢复期患者后续死亡的独立危险因素。由于纤维蛋白溶解会影响梗死的自然病程，并可能改变不同危险因素的临床相关性，本研究的目的是确定急性期接受纤维蛋白溶解剂治疗的心肌梗死后患者室性心律失常的患病率和预后价值。
对GISSI - 2研究中8676例心肌梗死后患者出院前进行的24小时动态心电图记录进行分析，以确定是否存在室性心律失常。从急性事件开始对患者进行6个月的随访；计算总心血管死亡率和心源性猝死率，并计算单因素和多因素分析中的相对风险。64.1%的患者存在室性心律失常，19.7%的患者每小时记录到超过10次室性早搏，6.8%的患者存在非持续性室性心动过速。当出现左心室损害的体征或症状时，室性心律失常更为常见。在随访期间，共有256例死亡，无室性心律失常的患者死亡率为2.0%，每小时有1至10次室性早搏的患者死亡率为2.7%，每小时超过10次室性早搏的患者死亡率为5.5%，有复杂性室性早搏的患者死亡率为4.8%。即使在调整了多个危险因素后，频繁（每小时超过10次室性早搏）室性心律失常的存在仍然是总死亡率（RRCox，1.62；95%置信区间，1.16 - 2.26）和心源性猝死（RRCox，2.24；95%置信区间，1.22 - 4.08）的显著预测因素。另一方面，在调整分析中，非持续性室性心动过速的存在与预后恶化无关（RRCox，1.20；95%置信区间，0.80 - 1.79）。
本研究表明，在出院前进行的动态心电图记录中，约36%的急性心肌梗死恢复期患者每小时室性早搏少于1次，而近20%的患者表现为频繁（每小时超过10次室性早搏）室性心律失常。由于本研究样本量较大，这些数据可作为急性期接受纤维蛋白溶解剂治疗的心肌梗死后患者心律失常患病率的可靠估计。频繁室性早搏被确认为急性事件后最初6个月总死亡和心源性猝死的独立危险因素；非持续性室性心动过速在该人群中的意义似乎更具争议性。
