Gertsch M, Fuhrer J
Kardiologische Abteilung, Medizinische Universitätsklinik, Bern.
Schweiz Med Wochenschr. 1993 May 1;123(17):833-43.
The usual frequent tachyarrhythmias well known to the specialists in internal medicine, such as ventricular tachycardia and ventricular fibrillation, are not discussed in this publication; nor are the bradycardias connected with the sick sinus syndrome or with atrioventricular block of higher degrees (with one exception). In the first section a stratification of the risk after myocardial infarction is presented including the therapeutic implications. Severely reduced left ventricular function is of most negative prognostic value. After the poor results of the CAST study, which revealed a threefold greater mortality of patients with myocardial infarction and severely impaired left ventricular function under treatment with some antiarrhythmic agents of class I (Vaughan Williams), compared to patients on placebo, cardiologists have resorted to beta-blocking agents again or, in patients with severely reduced left ventricular function, to amiodarone (Cordarone), based on preliminary results of current amiodarone studies. For selected patients, implantable cardioverter-defibrillator (ICD) devices seem to have a promising future. In the second part some rare and persistent arrhythmias are mentioned that may induce heart failure in an otherwise healthy heart, such as ectopic atrial tachycardia, atrioventricular junctional tachycardia with RP > PR, His bundle tachycardia and idiopathic ventricular tachycardia (this arising only in infants). In the third section some infrequent forms of tachycardia are discussed that may be sporadically encountered in a medical office. Ventricular tachycardia of the type "torsades de pointes" is associated with on a prolonged QT or QTU time in the ECG and is mainly due to drugs (especially antiarrhythmic agents). The therapy consists in withdrawal of the drug and may include magnesium intravenously and even a temporary pacemaker. The tachycardias associated to the Wolff-Parkinson-White syndrome have gained more practical importance since it has become possible to localize the accessory pathway involved by mapping with subsequent interruption by surgery or ablation. In atrial fibrillation with an ECG pattern of delta waves at the beginning of QRS complexes, digitalis and verapamil are contraindicated since they may induce ventricular fibrillation. The Mobitz type is one, and the most rare, form of the three atrioventricular blocks of second degree. It is almost always combined with an infra-His-bundle conduction disturbance in the conducted beats, and is an immediate precursor of complete atrioventricular block. Patients with the Mobitz block usually need a pacemaker. Finally, two case reports are presented to show that superficial and incorrect diagnosis of an arrhythmia is followed by incorrect and dangerous therapy.(ABSTRACT TRUNCATED AT 400 WORDS)
内科专家熟知的常见频发快速心律失常，如室性心动过速和心室颤动，本出版物未作讨论；与病态窦房结综合征或高度房室传导阻滞相关的缓慢性心律失常（有一个例外）也未讨论。在第一部分中，介绍了心肌梗死后的风险分层及其治疗意义。左心室功能严重降低具有最负面的预后价值。CAST研究结果不佳，该研究显示，与服用安慰剂的患者相比，心肌梗死且左心室功能严重受损的患者在使用某些I类抗心律失常药物（ Vaughan Williams分类法）治疗时死亡率高出三倍。基于当前胺碘酮研究的初步结果，心脏病专家再次采用β受体阻滞剂，或对左心室功能严重降低的患者使用胺碘酮（可达龙）。对于选定的患者，植入式心脏复律除颤器（ICD）装置似乎前景广阔。在第二部分中，提到了一些罕见且持续的心律失常，这些心律失常可能在原本健康的心脏中诱发心力衰竭，如异位房性心动过速、RP＞PR的房室交界性心动过速、希氏束心动过速和特发性室性心动过速（仅在婴儿中出现）。在第三部分中，讨论了一些在医务室可能偶尔遇到的不常见的心动过速形式。“尖端扭转型”室性心动过速与心电图上QT或QTU时间延长有关，主要由药物（尤其是抗心律失常药物）引起。治疗方法包括停用药物，可能还包括静脉注射镁，甚至使用临时起搏器。由于通过标测可以定位参与的附加通路，随后通过手术或消融进行阻断，与预激综合征相关的心动过速变得更具实际重要性。在QRS波群起始处有δ波心电图模式的心房颤动中，洋地黄和维拉帕米是禁忌的，因为它们可能诱发心室颤动。莫氏I型是二度房室传导阻滞三种类型中最罕见的一种。它几乎总是与传导搏动中的希氏束下传导障碍合并，并且是完全性房室传导阻滞的直接先兆。患有莫氏阻滞的患者通常需要起搏器。最后，给出了两个病例报告，以表明对心律失常的表面和错误诊断会导致错误且危险的治疗。（摘要截选至400字）
