心脏起搏器植入指南.ppt

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1、Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.p

2、df2002年年ACC/AHA/NASPE 心脏起搏器植入指南心脏起搏器植入指南Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/c

3、linical/guidelines/pacemaker/pacemaker.pdfACC/AHA 适应证分类适应证分类v I类:有明确证据或专家们一致认为起搏治疗对患者有益和有效。v II类:起搏治疗是否给患者带来益处/有效的研究结果不一致/专家们的意见有分歧。IIa类:证据/意见偏向有用/有效。IIb类:证据/意见不能说明有用/有效。Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report

4、of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfACC/AHA 适应证分类适应证分类vIII类:根据病情状况，专家们一致认为起搏治疗无效，某些情况下甚至对患者有害。Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantatio

5、n of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfLevel A为最有力的证据。结论源于包含大数量病例的多次随机临床试验。Level B从含有较少量病人的有限次试验得出的数据或从设计较好

6、的非随机研究分析得出的数据或登记观察的数据.Level C专家共识是建议的主要来源.ACC/AHA 临床证据分类临床证据分类Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Avai

7、lable at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfSection I-A:成人获得性房室阻滞的起搏治疗成人获得性房室阻滞的起搏治疗Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association T

8、ask Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdf I 类适应证类适应证:获得性房室阻滞的起搏治疗获得性房室阻滞的起搏治疗1.任何阻滞部位的三度和高度房室阻滞伴:a)房室阻滞伴可能由心动过缓所致的症状(包括心力衰竭)b)需要药物治疗其他心律失常或其他疾病，而所用药物治疗导致症状性心动过缓c)清醒状态下虽无症状，但证实心室停搏 3.0s或逸搏心律40 bpm,尤其是合并心肌病或左心室功能不全2.无症状的二度 II型房室阻滞，伴窄QRS波

9、。倘若QRS为宽大畸形则属I类适应证。Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pa

10、cemaker/pacemaker.pdfIIa 类适应证类适应证:获得性房室阻滞的起搏治疗获得性房室阻滞的起搏治疗3.无症状性二度 I 型房室阻滞，因其他原因电生理检查发现阻滞部位在希氏束内或以下水平。4.一度或二度房室阻滞伴有类似起搏器综合征的临床表现。Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/Ame

11、rican Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIIb 类适应证类适应证:获得性房室阻滞的起搏治疗获得性房室阻滞的起搏治疗1.显著一度房室阻滞(0.30 sec.)合并左室功能不全或充血性心力衰竭症状的，缩短AV间期可能降低左心房充盈压而改善心力衰竭症状者。2.神经肌源性疾病伴发的任何程度房室阻滞，无论是否有症状（因为无法预测AV传导病变加重）。Gregoratos G.et al.

12、ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIII 类适应证类适应证:获得性房

13、室阻滞的起搏治疗获得性房室阻滞的起搏治疗1.无症状的一度房室阻滞。2.无症状二度 I 型房室阻滞，发生于希氏束以上或不知道发生在内或下。3.房室阻滞预期可以恢复且不再复发(如药物中毒，莱姆疾病等)，或发生于无症状OSAS患者低氧时。Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart A

14、ssociation Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfSection I-B:慢性双分支和三分支阻滞的起搏治疗慢性双分支和三分支阻滞的起搏治疗Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the A

15、merican College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfI 类适应证类适应证:慢性双分支和三分支阻滞的起搏治疗慢性双分支和三分支阻滞的起搏治疗1.间歇性三度房室阻滞2.二度 II 型房室阻滞3.交替性双侧支阻滞Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for

16、implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIIa 类适应证类适应证:慢性双分支和三分支阻滞的起搏治疗慢性双分支和三分支阻滞的起搏治疗1.虽未证实晕厥由房室阻

17、滞引起，但可排除可能的其它原因，尤其是室性心动过速后。2.无临床症状，但电生理检查时偶然发现 HV100 ms 3.电生理检查时偶然发现心房起搏诱发希氏束以下非生理性阻滞Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practi

18、ce Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIIb 类适应证类适应证:慢性双分支和三分支阻滞的起搏治疗慢性双分支和三分支阻滞的起搏治疗神经肌源性疾病伴发任何程度的分支阻滞，无论是否有症状，因为传导阻滞可能随时加重。Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a repor

19、t of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIII 类适应证类适应证:慢性双分支和三分支阻滞的起搏治疗慢性双分支和三分支阻滞的起搏治疗1.分支阻滞不伴房室阻滞或无症状2.无症状的分支阻滞伴一度房室阻滞Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline

20、update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfSection I-C:与急性心肌梗死相关的房室阻滞的起搏治疗与急性心肌梗死相关的房室阻滞的

21、起搏治疗Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemak

22、er.pdfI 类适应证类适应证:急性心肌梗死后的起搏治疗急性心肌梗死后的起搏治疗1.持续希氏束系统二度房室阻滞伴双束支阻滞或希氏束系统内或以下三度房室阻滞2.房室结以下暂时性高度(二度-或三度)房室阻滞伴束支阻滞，如果阻滞部位不清楚则应进行电生理检查3.持续和有症状二度或三度房室阻滞Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of

23、Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIIa 类和类和IIb 类适应证类适应证:急性心肌梗死后的起搏治疗急性心肌梗死后的起搏治疗 IIa类:无 IIb类:房室结水平的持续性二度或三度房室阻滞Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of card

24、iac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIII 类适应证类适应证:急性心肌梗死后的起搏治疗急性心肌梗死后的起搏治疗1.不伴室内阻滞的短暂性房室阻滞2.伴左前分支阻滞的短暂性房室阻滞3.获得性左前

25、分支阻滞不伴房室阻滞4.持续性一度房室阻滞伴有慢性或发病时间不明的束支阻滞Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clin

26、ical/guidelines/pacemaker/pacemaker.pdfSection I-D:窦房结功能不良的起搏治疗窦房结功能不良的起搏治疗Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guideli

27、nes.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfI 类适应证类适应证:窦房结功能不良的起搏治疗窦房结功能不良的起搏治疗1.窦房结功能不全伴有症状性心动过缓,包括引起症状的频繁的窦性停搏部分患者的窦性心动过缓是由于必须进行某些治疗而又无其他可替代药物的结果2.有症状的变时功能不良Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhyt

28、hmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIIa 类适应证类适应证:窦房结功能不良的起搏治疗窦房结功能不良的起搏治疗1.自发或药物诱发的窦房结功能不良，心率 40 bpm,虽有心动过缓的症状，但未证实与所发生的心动过缓有关2.不明原因晕厥，电生理检查或激

29、发试验证实存在窦房结功能不良。Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacema

30、ker/pacemaker.pdfIIb 类适应证类适应证:窦房结功能不良的起搏治疗窦房结功能不良的起搏治疗清醒状态下心率长期 40 bpm,但症状轻微.Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guide

31、lines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIII 类适应证类适应证:窦房结功能不良的起搏治疗窦房结功能不良的起搏治疗1.无症状的患者，包括长期应用药物所致的明显窦性心动过缓(HR 3 s的心室停搏Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the America

32、n College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIIa 类适应证类适应证:颈动脉窦过敏和神经心脏性晕厥的起搏治疗颈动脉窦过敏和神经心脏性晕厥的起搏治疗1.诱因不明的反复发作的晕厥，伴有颈动脉窦高敏性心脏抑制反射2.症状明显的反复发作神经心脏性晕厥，记录或TTT时证实伴心动过缓Gregoratos G.et al.ACC/AHA/N

33、ASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfIIb 类和类和 III 类适应证类适应证:颈动脉窦

34、过敏和神经心脏性晕厥的起搏治疗颈动脉窦过敏和神经心脏性晕厥的起搏治疗IIb类:无III类:1.颈动脉窦刺激引起的高敏性心脏抑制反射，但无明显症状或仅有迷走刺激症状如头昏、眩晕2.反复发作晕厥、眩晕或头昏，但无颈动脉窦刺激引起的高敏心脏抑制反射 3.场景性血管迷走性晕厥，回避场景刺激晕厥不再发生Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College

35、 of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfSection I-G:儿童、青少年和先天性心脏病患儿童、青少年和先天性心脏病患者的起搏治疗者的起搏治疗Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and a

36、ntiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfI 类适应证类适应证:儿童、青少年、儿童、青少年、和先天性心脏病的起搏治疗和先天性心脏病的起搏治疗1.二或三度房室阻滞合并有症状的心动过缓、心功能不全或低心排量2.窦房结功能不良，表现为与年龄不

37、相称的心动过缓及其症状3.心脏手术后二或三度房室阻滞，预计不能恢复，或已持续 7 天Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org

38、/clinical/guidelines/pacemaker/pacemaker.pdfI 类适应证类适应证:儿童儿童,青少年青少年,和先天性心脏的起搏治疗和先天性心脏的起搏治疗 4.先天性三度房室阻滞合并宽QRS逸搏心律，复杂室性早搏或心功能不全5.婴儿先天性三度房室阻滞，心室率 50-55 bpm；或合并先天性心脏疾病，心室率 70 bpm6.心动过缓依赖的持续性VT，伴或不伴长QT，起搏治疗被证明有效Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers a

39、nd antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdf1.慢-快综合征，需抗心律失常药长期治疗（除地高辛）2.先天性三度房室阻滞,1岁以上,平均心率 50 bpm；或突然心室停搏，周长是基础心率2或3倍，或有与变时功能不良相关的症状3.长Q

40、T综合征合并 2:1 二度或三度房室阻滞.4.无症状窦性心动过缓合并复杂先天性心脏病，静息时心率 3 s长间歇.5.先天性心脏病患者，血液动力学由于心动过缓和房室不同步而受损.IIa 类适应证类适应证:儿童儿童,青少年青少年,和先天性心脏的起搏治疗和先天性心脏的起搏治疗 Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiol

41、ogy/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdf1.手术后一过性三度房室阻滞，恢复窦律后残留室内双束支阻滞2.先天性三度房室阻滞的婴儿和青少年患者，无症状，其心率可接受，窄 QRS 波，心功能正常3.先天性心脏病伴窦性心动过缓，静息时 HR 3 长间歇但患者无症状4.神经肌源性疾病伴发任何程度(包括一度)的房室阻滞，无论是否有症状，因为传导阻滞随时会加重IIb 类适应证

42、类适应证:儿童儿童,青少年青少年,和先天性心脏的起搏治疗和先天性心脏的起搏治疗 Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/c

43、linical/guidelines/pacemaker/pacemaker.pdf1.手术后暂时性房室阻滞，其传导已恢复2.无症状的手术后室内双束支阻滞，伴或不伴一度房室阻滞3.无症状的二度I型房室阻滞4.青少年无症状的窦性心动过缓，最长间歇 40 bpmIII 类适应证类适应证:儿童儿童,青少年青少年,和先天性心脏的起搏治疗和先天性心脏的起搏治疗 Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a

44、report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdfSection I-H:特殊情况的起搏治疗特殊情况的起搏治疗肥厚梗阻性心脏病肥厚梗阻性心脏病特发性扩张性心肌病特发性扩张性心肌病心脏移植心脏移植Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline u

45、pdate for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdf I类:1.窦房结功能不全或房室阻滞，如前述 I 类适应证的各种情况 IIa类:无 IIb类:

46、1.药物治疗困难伴有症状的肥厚性心肌病，在静息或应激情况下有明显流出道梗阻者I,IIa,和和 IIb 类适应证类适应证:肥厚梗阻性心肌病肥厚梗阻性心肌病Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidel

47、ines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdf1.无症状或经药物治疗可以控制2.虽有症状但无左心室流出道梗阻的证据III 类适应证类适应证:肥厚梗阻性心肌病肥厚梗阻性心肌病 Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of C

48、ardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdf I 类合并窦房结功能不全或房室阻滞的 I 类适应证情况见前述 IIa 类:药物难治的扩张型心肌病或缺血性心肌病，心功能 NYHA分级 III/IV，QRS 时限(130 msec),LVDD 55mm,LVEF 35%，可考虑双心室起搏治疗I 和和 IIa类适应证类适应证:特发性扩张型心肌病特发性扩张型心肌病

49、 Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.2002.Available at www.acc.org/clinical/guidelines/pacemaker/pacemaker.

50、pdfIIb类:无III类：无症状有症状但药物治疗有效有症状缺血性心肌病，介入或手术治疗可望缓解病情III 类和类和IIb类适应证类适应证:特发性扩张型心肌病特发性扩张型心肌病 Gregoratos G.et al.ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:a report of the American College of Cardiology/American Heart Association Task Force on Pr