McAlister F A, Teo K K
Division of General Internal Medicine, University of Ottawa, Ontario, Canada.
Drugs. 1997 Aug;54(2):235-52. doi: 10.2165/00003495-199754020-00003.
Despite remarkable advances in cardiovascular therapeutics, sudden cardiac death remains a significant problem. In this review, data from clinical trials and other studies on antiarrhythmic therapies have been evaluated in order to determine effective strategies for the prevention of sudden cardiac death in high risk patients. Overall, routine prophylactic use of class I antiarrhythmic agents in high risk patients, mostly survivors of acute myocardial infarction, is associated with increased risk of death [61 trials, 23,486 patients: odds ratio (OR) 1.13; 95% confidence interval (CI) 1.01 to 1.27, p < 0.05]. Conversely, beta-blockers are associated with highly significant reductions in risk of death in postinfarction patients (56 trials, 53,521 patients: OR 0.81; 95% CI 0.75 to 0.87, p < 0.00001). Overall data from the amiodarone trials on high risk patients, including postinfarction patients, patients with congestive heart failure or survivors of cardiac arrest, suggest that this agent is effective in reducing the risk of death (14 trials, 5713 patients: OR 0.83; 95% CI 0.72 to 0.95, p = 0.01) although further studies are needed to better define which types of patients will potentially benefit most from this agent. No benefits were seen with calcium channel blockers (26 trials, 21,644 patients: OR 1.03; 95% CI 0.94 to 1.13, p = NS). The implantable cardioverter-defibrillator is a promising option for high risk patients, but definition of its role awaits the completion of ongoing clinical trials. Since causes of sudden death are heterogeneous, the clinician should pursue a multifactorial approach to its prevention. Primary and secondary prevention of cardiac ischaemia, through the treatment of cardiovascular risk factors and maximising the use of aspirin, beta-blockers, lipid-lowering drugs, and angiotensin converting enzyme inhibitors after acute myocardial infarction, should lead to a future decrease in the incidence of sudden cardiac death.
尽管心血管治疗取得了显著进展，但心脏性猝死仍然是一个重大问题。在本综述中，对来自临床试验和其他关于抗心律失常治疗研究的数据进行了评估，以确定预防高危患者心脏性猝死的有效策略。总体而言，在高危患者（主要是急性心肌梗死幸存者）中常规预防性使用I类抗心律失常药物与死亡风险增加相关[61项试验，23486例患者：比值比（OR）1.13；95%置信区间（CI）1.01至1.27，p<0.05]。相反，β受体阻滞剂与心肌梗死后患者的死亡风险显著降低相关（56项试验，53521例患者：OR 0.81；95%CI 0.75至0.87，p<0.00001）。关于高危患者（包括心肌梗死后患者、充血性心力衰竭患者或心脏骤停幸存者）的胺碘酮试验的总体数据表明，该药物可有效降低死亡风险（14项试验，5713例患者：OR 0.83；95%CI 0.72至0.95，p = 0.01），不过还需要进一步研究以更好地确定哪些类型的患者可能从该药物中获益最多。钙通道阻滞剂未显示出益处（26项试验，21644例患者：OR 1.03；95%CI 0.94至1.13，p = 无统计学意义）。植入式心脏复律除颤器对高危患者是一个有前景的选择，但其作用的界定有待正在进行的临床试验完成。由于猝死原因多种多样，临床医生应采取多因素方法进行预防。通过治疗心血管危险因素以及在急性心肌梗死后最大限度地使用阿司匹林、β受体阻滞剂、降脂药物和血管紧张素转换酶抑制剂，对心脏缺血进行一级和二级预防，有望在未来降低心脏性猝死的发生率。
