Stevenson W G, Sweeney M O
Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115, USA.
Jpn Circ J. 1997 Sep;61(9):727-40. doi: 10.1253/jcj.61.727.
Survival of patients with heart failure has improved over the past decade due to advances in medical therapy. Sudden death continues to cause 20 to 50% of deaths. Ventricular arrhythmias are common in patients with heart failure. Ventricular hypertrophy, scars from prior myocardial infarction, sympathetic activation, and electrolyte abnormalities contribute. Some sudden deaths are due to bradyarrhythmias and electromechanical dissociation rather than ventricular arrhythmias. The risks and benefits of antiarrhythmic therapies continue to be defined. Class I antiarrhythmic drugs should be avoided due to proarrhythmic and negative inotropic effects that may increase mortality. For patients resuscitated from sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) amiodarone or an implantable cardioverter defibrillator (ICD) should be considered. ICDs markedly reduce sudden death in VT/VF survivors, but in advanced heart failure, this may not markedly extend survival. Catheter or surgical ablation can be considered for selected patients with bundle branch reentry VT or difficult to control monomorphic VT. For patients who have not had sustained VT/VF antiarrhythmic therapy should generally be avoided, but may benefit some high risk patients. Amiodarone may be beneficial in patients with advanced heart failure and rapid resting heart rates. ICDs may improve survival in selected survivors of myocardial infarction who have inducible VT.
在过去十年中，由于医学治疗的进步，心力衰竭患者的生存率有所提高。猝死仍占死亡人数的20%至50%。室性心律失常在心力衰竭患者中很常见。心室肥厚、既往心肌梗死留下的瘢痕、交感神经激活和电解质异常都有影响。一些猝死是由于缓慢性心律失常和电机械分离，而非室性心律失常。抗心律失常治疗的风险和益处仍有待明确。由于可能增加死亡率的促心律失常和负性肌力作用，应避免使用I类抗心律失常药物。对于从持续性室性心动过速（VT）或心室颤动（VF）中复苏的患者，应考虑使用胺碘酮或植入式心脏复律除颤器（ICD）。ICD可显著降低VT/VF幸存者的猝死率，但在晚期心力衰竭患者中，这可能不会显著延长生存期。对于患有束支折返性VT或难以控制的单形性VT的特定患者，可考虑进行导管消融或手术消融。对于未发生持续性VT/VF的患者，一般应避免抗心律失常治疗，但某些高危患者可能会从中受益。胺碘酮可能对晚期心力衰竭且静息心率较快的患者有益。ICD可能会提高所选心肌梗死幸存者（其可诱发出VT）的生存率。
