心源性猝死SCD.ppt

心源性猝死SCD.ppt

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TheRoleofDrugsinPreventionofSuddenCardiacDeathPresentationOverviewSuddenCardiacDeathEpidemiology,etiology,pathophysiologyOverviewofICDtherapytopreventSCDRolesofDrugsinSCDPreventionSummaryandconclusionsEpidemiologyofSCDAccountsfor63%ofallcardiacrelateddeathsintheUS.Oneofthemostcommoncausesofdeathindevelopedcountries:

MMWR.Vol51（6）Feb.15,2002.MyerbergRJ,CatellanosA.CardiacArrestandSuddenCardiacDeath.In:

BraunwaldE,ed.HeartDisease:

ATextbookofCardiovascularMedicine.5thEd.NewYork:

WBSaunders.1997:

742-779.ZhengZ.Circulation.2001;104:

2158-2163.Vreede-SwagemakersJJetal.JAmCollCardiol1997;30:

1500-1505.GeographyGeographyIncidenceIncidenceWorldwideUS300,000350,0003,000,000W.Europe400,000MagnitudeofSCDinChina0.1%0.04%0.2%ChinaUS544,000300,000350,000ChinaUSIncidenceRateAbsoluteNumber0.04%0.1%0.2%IncidenceofSCDinSpecificPopulationsAdaptedfrom:

MyerburgRJ.SuddenCardiacDeath:

ExploringtheLimitsofOurKnowledge.JCardiovascElectrophysiolVol.12,pp.369-381,March2001.300,000200,000100,000AbsolutenumberofSCDPerYearMultiplerisksubgroupsPatientswithanypreviouscoronaryeventPatientswithejectionfraction35%orCHFCardiacarrest,VT/VFsurvivorsHigh-riskpost-MIsubgroupsGeneraladultpopulation3025201050IncidenceofSCD（%ofgroup）MADITIISCD-HeFTAVID,CASH,CIDSMADIT,MUSTT,nSuddendeathwasthefirstmanifestationofcoronaryheartdiseasein50%ofmenand63%ofwomen.nCHDaccountsforatleast80%ofsuddencardiacdeathsinWesterncultures.80%CoronaryHeartDisease15%Cardiomyopathy5%OtherDiseaseCauseofSCDAmericanHeartAssociation.HeartDiseaseandStrokeStatistics2003Update.Dallas,Tex.:

AmericanHeartAssociation;2002.AdaptedfromHeikkietal.NEnglJMed,Vol.345,No.20,2001.MyerbergRJ.HeartDisease,ATextbookofCardiovascularMedicine.6thed.P.895.ArrhythmicCauseofSCDAlbertCM.Circulation.2003;107:

2096-2101.12%OtherCardiacCause88%ArrhythmicCauseBradycardia16.5%VF62.4%PrimaryVT8.3%TorsadesdePointes12.7%BaysdeLunaA.AmHeartJ.1989;117:

151-159.ApplicationofICDinChina200544,000“Eventhewealthiestnationscannotaffordtopaytouseeverymedicaladvanceinanypatientwhomightbenefit.”ThomasBigger,Lancet,2001RolesofDrugsinSCDPreventionRolesofDrugsinSCDPreventionValueofAntiarrhythmicDrugsClassIantiarrhythmicsBetaBlockersAmiodaroneSotalolValueofNon-antiarrhythmicDrugsElectrolytesACEinhibitors,ARBsandaldosteroneblockersAntithromboticandantiplateletagentsStatinsn-3FattyacidsSCDPreventionbyAntiarrhythmicDrugsAll-causemortalityDaysafterrandomization050100150200250300350400450500859095100Survival（%）Placebo（n=725）Encainideorflecainide（n=730）:

406CASTInvestigators.NEnglJMed1989;32112.P=0.000380RolesofClassIantiarrhythmicsinSCDPreventionCAST:

CardiacArrhythmiaSuppressionTrialCASTII:

CardiacArrhythmiaSuppressionTrialIIAswiththeantiarrhythmicagentsusedinCAST-I,theuseofmoricizineinCAST-IItosuppressasymptomaticormildlysymptomaticventricularprematuredepolarizationstotrytoreducemortalityaftermyocardialinfarctionisnotonlyineffectivebutalsoharmful.RolesofBetaBlockersinSCDPreventionStudyBHATNorwegianCOPERNICUSCIBIS-IICAPRICORNMERIT-HFPublished1981FollowupTargetDosage（mg/day）Patientsmild/moderateHFPost-MILVDPost-MILVDPost-MILVDmoderate/severeHFsevereHFDrugPropranoloTimololmetoprololcarvedilolbisoprololcarvedilol200qd25bid10bid18024025bid10qd25m17m15m2.4y1.3y10.4m19822000199919992001NorwegianMulticentreStudyGroup.NEnglJMed.1981;304:

801-807.36333027242118151296300.000.050.100.150.200.25TimololPlaceboMonthCumulativeMortalityRaten=945n=939P0.0005OverviewofNorwegianTimololTrialandBHAT（Beta-BlockerHeartAttack）Trial（Post-MILVDpatients）39%ReducedmortalityPlacebon=1921061824303612024681012N=383737063647395921631310406CumulativeMortality（%）MonthsofFollow-upPropranololn=1916P0.00526%DecreasedmortalityBeta-BlockerHeartAttackTrialResearchGroup.JAMA.1982;247:

1707-1714.BHATNorwegianAverageincidenceofSCDinlongtermtrialscomparingblockerswithplaceboafterMINuttallSL,ToescuV,KendallMJ.BMJ.2000;320:

581.Averageincidenceofsuddendeathinlongtermtrialscomparing-blockerswithplaceboaftermyocardialinfarctionPlacebotreatmentBlockertreatmentTotalNoofpatientsTotalNoofdeathsNo（%）ofsuddendeathsTotalNoofpatientsTotalNoofdeathsNo（%）ofsuddendeathsNorwegiantimololtrial93915295（63）9459847（48）Blockerheartattacktrial192118889（47）191613864（46）PlaceboCarvedilolHazardRatio（95%CI）CardiovascularDeath1391040.75（0.58-0.96）SuddenDeath69510.74（0.51-1.06）DeathDuetoPumpFailure30180.60（0.33-1.07）CAPRICORN:

CarvedilolPost-InfarctSurvivalControlinLVDysfunction-TRIALRESULTS-DargieHJetal.EurJHeartFail.2000;2:

325-332.CIBISII:

CardiacInsufficiencyBisoprololStudyII-RESULTS-PPrimaryendpointAll-causemortalitySecondaryendpointsAll-causehospitaladmissionAllcardiovasculardeathsCombinedendpoint