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伍伟锋2010.12.4
院内获得性尖端扭转型室速防治 --AHA/ACC 院内获得性 TdP 防治专家共识临床
要点
尖端扭转型室速( torsade de pointes,TdP )
TdP 定义• TdP 一词也能用描述少数 QT 间期不延长的多形性室
速,因为部分患者伴有隐匿性长 QT 综合征• 但最好用来描述 QT 间期显著延长( >500ms ),
伴 T- U 波畸形的多形性室速,因为这类室速有着不同的发生机制和治疗方法
问题的提出• 药物引起的获得性长 QT 综合征 (LQTS) 伴
TdP 发作心脏骤停恶性事件极罕见• 与院外服用同一种药物患者相比,住院患者
药物 LQTS 伴 TdP 发生可能性明显增高• 住院患者还其它心律失常促发因素– 老年人:有心脏病基础、肝肾功能受损– 电解质紊乱– 心动过缓– 静脉用药
内容• The ECG characteristics of TdP
• Premonitory ECG Signs of TdP
• Drugs That Cause TdP
• TdP Risk Factors
• Management of Drug-Induced QT Prolongation
• Management of Drug-Induced TdP
一、 Characteristic Pattern of TdP
typical feature
• 1 、 twisting of the QRS complexes around the isoelectric line– not be evident in all ECG leads
• 2 、 short-long-short pattern of R-R cycles– R-on-T PVC
• 3 、 warm-up phenomenon– The rate ofTdP:160-240 beats/minute
• 4 、 frequently terminates spontaneously– Some cases degenerates into VF
• VF 与 TdP 的区别–R-on-T PVC : short coupling interval
–The rate of VF:250~500 beats/minute
–does not terminate without defibrillation
二、 Premonitory ECG Signs of TdP
• QT-interval prolongation :–male QTc>470ms , female>480ms
–QTc >500 ms
• T-U deformity
• macroscopic T-wave alternans
Circulation.2010,121:1049
三、 Drugs That Cause TdP
• Antiarrhythmic :– Procainamide 、 Quinidine 、 Sotalol 、 Disopyramide 、
Ibutilide 、• Antibiotic :– Erythromycin (红霉
素)、 Clarithromycin 、 Sparfloxacin• pain control :– Methadone (美沙酮)
• Antipsychotic :– Chlorpromazine (氯丙嗪)、 Thioridazine( 硫利达嗪 )
• Gastrointestinal stimulant :– Cisapride( 西沙比利 )
• Cancer/leukemia :– Arsenic trioxide( 三氧化二砷 )
四、 TdP Risk Factors
• 1 、 QTc >500 ms
• 2 、 Use of QT-prolonging drugs
– Concurrent use of more than 1 QT-prolonging drug
– Rapid infusion by intravenous route
• 3 、 Heart disease– Congestive heart failure
– Myocardial infarction
• 4 、 Advanced age
• 5 、 Female sex
• 6 、 Hypokalemia
• 7 、 Hypomagnesemia
• 8 、 Hypocalcemia
• 9 、 Treatment with diuretics
• 10 、 Impaired hepatic drug metabolism (hepatic dysfunction or drug-drug interactions)
• 11 、 Bradycardia
– Sinus bradycardia, heart block, incomplete heart block with pauses
• 12 、 Premature complexes leading to short-long-short cycles
五、 Management of Drug-Induced QT Prolongation
• 1 、 Continuous QTc monitoring
–QTc>500 ms or increase>60ms
• accompanied by Premonitory ECG Signs of TdP
• 2 、 Appropriate actions include– discontinuation of the culprit drug
– Bradyarrhythmias 、 electrolyte abnormalities
– the ready availability of an external defibrillator
– highest possible ECG monitoring surveillance :• Patients should not be transported from the unit for
diagnostic or therapeutic procedures
– Intravenous Magnesium sulfate 2 g
(Class IIa, Level of Evidence: B)
六、 Management of Drug-Induced TdP
• directcurrent cardioversion
–Sustained TdP• does not terminate spontaneously
• degenerates into ventricular fibrillation
• intravenous magnesium sulfate
–Magnesium sulfate 2 g
(Class IIa, Level of Evidence: B)
–repeat infusions of magnesium sulfate 2 g
•TdP persist
• temporary transvenous pacing–Atrial or ventricular
–at rates 70 beats/minute
• Repletionof potassium– levels of 4.5 to 5 mmol/L
–Class IIb, Level of Evidence: C
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