暈厥的診斷思路與治療策略

1、暈厥的診斷思路與治療策略北京大學(xué)人民醫(yī)院郭繼鴻,第一部分暈厥的發(fā)生率及其影響,70歲人群*,15%20-25%16-19%23%,暈厥是一種常見的嚴(yán)重疾病,*10年隨訪,Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.,暈厥的重要性,美國(guó)每年新發(fā)暈厥50萬例 517萬例反復(fù)發(fā)作暈厥 67萬例反復(fù)發(fā)作、原因不明

2、 1-4,原因明確: 53%～62%,不常發(fā)作、原因不明: 38%～47% 1-4,1 Kapoor W, Med. 1990;69:160-175.2 Silverstein M, et al. JAMA. 1982;248:1185-1189.3 Martin G, et al. Ann Emerg. Med. 1984;12:499-504.,4 Kapoor W, et al. N Eng J Med. 1983;30

3、9:197-204.5 National Disease and Therapeutic Index, IMS America, Syncope and Collapse #780.2; Jan 1997-Dec 1997.6 Kapoor W, et al. Am J Med. 1987;83:700-708.,1 Day SC, et al. Am J of Med 1982;73:15-23.2 Kapoor W. Me

4、dicine 1990;69:160-175.3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189.4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.,暈厥的死亡率較高,暈厥嚴(yán)重影響生活質(zhì)量,1Linzer, J Clin Epidemiol, 1991.2Linzer, J Gen

5、Int Med, 1994.,焦慮／抑郁,日?；顒?dòng)改變,限制駕駛,改換工作,73% 1,71% 2,60% 2,37% 2,患者百分?jǐn)?shù),暈厥的病因,Orthostatic,CardiacArrhythmia,StructuralCardio-Pulmonary,,,,,,,,,*,,,1VasovagalCarotid Sinus?SituationalCoughPost- micturition,2Drug

6、 Induced? ANSFailurePrimarySecondary,3BradySick sinusAV block?TachyVTSVTLong QT Syndrome,4 Aortic StenosisHOCM? PulmonaryHypertension,5Psychogenic?Metabolice.g. hyper-ventilationNeurological,No

7、n-Cardio-vascular,Neurally-Mediated,Unknown Cause = 34%,24%,11%,14%,4%,12%,DG Benditt, UM Cardiac Arrhythmia Center,第二部分暈厥的診斷思路,初步評(píng)估,詳盡的病史 體格檢查 12導(dǎo)聯(lián)ECG和24小時(shí)動(dòng)態(tài)心電圖 超聲心動(dòng)圖,頸動(dòng)脈竇按摩,方法：先左后右，5～10秒（非阻斷）結(jié)果判斷：3秒以上停搏和／或收縮壓下

8、降50 mmHg以上，伴癥狀，稱為Carotid Sinus Syndrome (CSS)禁忌證：頸動(dòng)脈雜音，已知頸動(dòng)脈疾病，既往腦血管疾病，3月以內(nèi)心肌梗死風(fēng)險(xiǎn)： TIA －1/5000,,直立傾斜試驗(yàn),直立傾斜試驗(yàn),,DG Benditt, UM Cardiac Arrhythmia Center,腦電圖,有助于除外癲癇兩次發(fā)作之間腦電圖不正常提示癲癇,事件捕捉儀,Linzer M. Am J Cardiol. 199

9、0;66:214-219.,Patient Activator,Reveal® Plus ILR,9790 Programmer,植入性Holter,植入性Holter,,心臟電生理檢查,對(duì)于器質(zhì)性心臟病患者更有用心臟病患者…..…50-80%非心臟病患者……18-50%有助于檢出心律失常性暈厥,Brignole M, Alboni P, Benditt DG, et al. Eur Heart Journal 200

10、1; 22: 1256-1306.,暈厥的診斷思路,History and Physical Exam Surface ECG,Neurological Testing Head CT Scan Carotid Doppler MRI Skull Films Brain Scan EEG,CV Syncope Workup Holter ELR or ILR Tilt Table Echo EPS,Other

11、CV Testing Angiogram Exercise Test SAECG,Psychological Evaluation,ENT Evaluation,Endocrine Evaluation,,,,,,,,Adapted from: W.Kapoor.An overview of the evaluation and management of syncope. From Grubb B, Olshansky B

12、(eds) Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing Co., Inc.1998.,第三部分神經(jīng)介導(dǎo)性暈厥,神經(jīng)介導(dǎo)性暈厥,血管迷走性暈厥頸動(dòng)脈竇綜合征特定情形暈厥排尿性暈厥咳嗽性暈厥吞咽性暈厥排便性暈厥抽血時(shí)暈厥etc.,神經(jīng)介導(dǎo)性暈厥的機(jī)制,Benditt DG, Lurie KG, Adler SW, et al. P

13、athophysiology of vasovagal syncope. In: Neurally mediated syncope: Pathophysiology, investigations and treatment. Blanc JJ, Benditt D, Sutton R. Bakken Research Center Series, v. 10. Armonk, NY: Futura, 1996,血管迷走性暈厥的發(fā)生率

14、,發(fā)生率：8%～37% (平均18%)患者特點(diǎn)：比頸動(dòng)脈竇綜合征患者年輕多伴面色蒼白、惡心、出汗、心悸,,DG Benditt, UM Cardiac Arrhythmia Center,,,,16.3,sec,Continuous Tracing,,,1 sec,,一例自然發(fā)生的血管迷走性暈厥,血管迷走性暈厥的治療策略,尚存在爭(zhēng)議一般治療患者教育、 使其放心、指導(dǎo)措施增加液體、食鹽攝入傾斜脫敏訓(xùn)練彈力長(zhǎng)統(tǒng)襪藥物治療

15、起搏治療,血管迷走性暈厥的藥物治療,β受體阻滯劑雙異丙吡胺(Disopyramide)選擇性5羥色胺再吸收抑制劑(SSRIs)血管收縮劑：甲氧胺福林(midodrine),甲氧胺福林治療血管迷走性暈厥,Journal of Cardiovascular Electrophysiology Vol. 12, No. 8, Perez-Lugones, et al.,起搏治療血管迷走性暈厥的現(xiàn)狀,循證醫(yī)學(xué)研究表明起搏治療有效VPS

16、IVASIS SYDITVPS II –Phase IROME VVS Trial,1Gregoratos G, et al. ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmic Devices. Circulation. 1998; 97: 1325-1335.,頻率驟降檢測(cè),,,,,,,,,,,,,,,,,,,,,,,

17、,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40,50,60,70,80,90,100,110,Ventricular Rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Drop Size=25 bpm,Drop Rate,Peak Rate=90 bpm,,,,2 consecutive beats

18、,<,Drop,Size and Drop Rate,,,Rate Drop Detection in Medtronic Kappa® Series Pacemakers,VPS-IVasovagal Pacemaker Study I,Connolly S, et al. J Am Coll Cardiol 1999; 33: 16-20.,研究設(shè)計(jì)54例患者隨機(jī)分組27例植入帶頻率驟降功能的DDD起搏器2

19、7例不植入起搏器入選標(biāo)準(zhǔn)≧6次暈厥事件直立傾斜試驗(yàn)（ + ）相對(duì)心動(dòng)過緩：基礎(chǔ)心率2μg/min心率仍<80/min,VPS- I,Connolly S, et al. J Am Coll Cardiol 1999; 33: 16-20.,*2p = 0.000022,VPS- I,Connolly S, et al. J Am Coll Cardiol 1999; 33: 16-20.,,,,,,,,,,,,,,,

20、,,,,,累積暈厥風(fēng)險(xiǎn)(%),100,90,80,70,60,50,40,30,20,10,0,15,12,9,6,3,0,對(duì)照組,2P=0.000022,起搏器組,時(shí)間（月）,NumberAt Risk,C2794210P27211712118,,VASIS Vasovagal Syncope International Study,Sutton, R, et al. Circulation

21、. 2000; 102:294-299.,研究設(shè)計(jì)42例患者隨機(jī)分組19例DDI起搏器(80 bpm)，頻率滯后(45 bpm)開啟23例不植入起搏器入組標(biāo)準(zhǔn)2年內(nèi)暈厥發(fā)作 >3次，最后一次發(fā)作在入組時(shí)半年以內(nèi)直立傾斜試驗(yàn)（ + ）年齡 >40歲，或 < 40歲但藥物治療無效,VASIS,Sutton, R, et al. Circulation. 2000; 102:294-299.,*P= 0

22、.0006,VASIS,,,,,,,,,,,,,,,,,,,,起搏器組,對(duì)照組,p=0.0004,（年）,無暈厥發(fā)作患者的百分?jǐn)?shù),100,80,60,40,20,0,2,3,4,5,6,Sutton, R, et al. Circulation. 2000; 102:294-299.,SYDIT Syncope Diagnosis and Treatment Study,研究設(shè)計(jì)93例患者隨機(jī)分組46例植入帶頻率驟降功能的DD

23、D起搏器47例口服阿替洛爾100mg/日入組標(biāo)準(zhǔn) > 55 yrs 2年內(nèi)暈厥 > 3次 直立傾斜試驗(yàn)（＋）伴相對(duì)性心動(dòng)過緩,Ammirati F, et al. Circulation. 2001; 104:52-57.,SYDIT,*P=0.004,Ammirati, et al. Circulation. 2001; 104:52-57.,,Ammirati F, et al. Circulation.

24、 2001; 104:52-57.,SYDIT,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100,時(shí)間（天）,100,90,80,70,60,200,300,400,500,600,700,800,900,1000,0,P = 0.0032,,,藥物組,起搏器組,,無暈厥發(fā)作患者的百分?jǐn)?shù),VPS-II: Phase IVasovagal Pacemaker Study

25、-II,研究設(shè)計(jì)100 例患者均植入DDD起搏器，隨機(jī)分組50例頻率驟降功能打開(DDD起搏模式)50例頻率驟降功能關(guān)閉(ODO起搏模式)入選標(biāo)準(zhǔn)既往暈厥發(fā)作> 6次，或2年內(nèi) > 3次，或半年內(nèi) > 1次直立傾斜試驗(yàn)（＋）,Presented at the 23rd Annual Scientific Sessions of the North American Society of Pacing and

26、 Electrophysiology. Late Breaking Clinical Trials, May 11, 2002.,VPS-II: Phase I,*P=0.153,,Presented at the 23rd Annual Scientific Sessions of the North American Society of Pacing and Electrophysiology. Late Breaking Cl

27、inical Trials, May 11, 2002.,,,,,,,,,,,,,,,,,,,,0.4,0.3,0.2,ODO,DDD,P = 0.153 (one-sided),Number at Risk,ODO403735323121DDD393634333317,0,1,2,3,4,5,6,0.1,0.0,Presented at the 23rd Annual Scientific Sessions

28、 of the North American Society of Pacing and Electrophysiology. Late Breaking Clinical Trials, May 11, 2002.,VPS-II: Phase I,累積暈厥風(fēng)險(xiǎn)(%),頸動(dòng)脈竇綜合征的起搏治療,SAFE PACE 研究,,Accident and Emergency Attendees > 50 Yrs,,Falls

29、 or Syncope,,Non-accidental Fall,,CSM Performed,,Cardioinhibitory or Mixed CSH,,n=175,,,,,,,Control (n=88),,Pacemaker(n=87),,,Kenny RA, J Am Coll Cardiol 2001; 38:1491-1496.,頻率驟降,隨機(jī),SAFE PACE 結(jié)果,50% [OR 0.53; 95%CI 0

30、.23; 1.20 ns],Kenny RA, J Am Coll Cardiol 2001; 38:000-000.,,SAFE PACE 結(jié)果,70%,Kenny RA, J Am Coll Cardiol 2001; 38:1491-1496.,,頸動(dòng)脈竇綜合征的起搏治療,Brignole et. Al. Diagnosis, natural history and treatment. Eur JCPE. 1992; 4:247

31、-254,57%,%6,復(fù)發(fā)率,I類適應(yīng)證:心臟抑制型混合型DDD/DDI優(yōu)于VVI,隨訪時(shí)間：6個(gè)月,第四部分心原性暈厥,引致暈厥的常見器質(zhì)性心臟病,急性心肌梗死肥厚型梗阻性心肌病急性主動(dòng)脈夾層急性心包填塞肺動(dòng)脈栓塞／肺動(dòng)脈高壓瓣膜性心臟病：主動(dòng)脈瓣狹窄左房粘液瘤,引致暈厥的常見心律失常,心動(dòng)過緩竇性停搏，竇房阻滯急性高度或完全性房室阻滯心動(dòng)過速心房顫(撲)動(dòng)伴快速心室反應(yīng)：如預(yù)激伴房顫或心房撲動(dòng)1：1

32、下傳陣發(fā)性室上性或室性心動(dòng)過速尖端扭轉(zhuǎn)型室速心室撲動(dòng)／顫動(dòng),反復(fù)暈厥患者的心律分布,Krahn A, et al. Circulation. 1999; 99: 406-410,Normal Sinus Rhythm58%,Normal Sinus Rhythm58%,Bradycardia36%,Tachyarrhythmia6%,起搏器,,心動(dòng)過速暈厥的治療,房性快速心律失常AVRT：導(dǎo)管射頻消融AVNRT：導(dǎo)管射