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Желудочковые аритмии при хронической сердечной недостаточности: особенности лечения и возможности улучшения прогноза
Желудочковые аритмии при хронической сердечной недостаточности: особенности лечения и возможности улучшения прогноза
Бунин Ю.А., Золозова Е.А. Желудочковые аритмии при хронической сердечной недостаточности: особенности лечения и возможности улучшения прогноза. Consilium Medicum. 2019; 21 (5): 57–61. DOI: 10.26442/20751753.2019.5.190419
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Аннотация
Желудочковые нарушения ритма сердца часто осложняют течение хронической сердечной недостаточности (ХСН) и являются одной из основных причин внезапной сердечной смерти (ВСС). В статье представлены современные данные по ведению больных с ХСН с «потенциально опасными» желудочковыми аритмиями, медикаментозные и немедикаментозные методы первичной профилактики ВСС, включая применение имплантируемых кардиовертеров-дефибрилляторов (ИКД) и кардиальной ресинхронизирующей терапии. Важное место в представленной работе отведено лечению устойчивой желудочковой тахикардии (ЖТ) и улучшению прогноза при жизнеопасных желудочковых аритмиях (ЖТ/фибрилляция желудочков – ФЖ): показания к использованию антиаритмиков III класса, ИКД и катетерной аблации. Отмечено, что для больных с ХСН, имеющих устойчивую ЖТ или выживших после остановки кровообращения (ФЖ), оптимальным лечением является имплантация КД, а не фармакотерапия. В основе изложенного материала лежат данные современных международных рекомендаций (ESC, AHA/ACC/HRS) по лечению ХСН, желудочковых нарушений ритма сердца и профилактике ВСС, а также результаты ряда контролируемых исследований и собственный клинический опыт лечения аритмий.
Ключевые слова: хроническая сердечная недостаточность, желудочковая тахикардия, фибрилляция желудочков, антиаритмические препараты, имплантируемые кардиовертеры-дефибрилляторы, кардиальная ресинхронизирующая терапия, радиочастотная катетерная аблация.
Ключевые слова: хроническая сердечная недостаточность, желудочковая тахикардия, фибрилляция желудочков, антиаритмические препараты, имплантируемые кардиовертеры-дефибрилляторы, кардиальная ресинхронизирующая терапия, радиочастотная катетерная аблация.
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Ventricular arrhythmias often complicate the course of chronic heart failure (CHF) and are one of the main causes of sudden cardiac death (VSS). The article presents current data on the management of patients with CHF with "potentially dangerous" ventricular arrhythmias, drug and non-drug methods of primary prevention of VSS, including the use of implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT). An important place in the presented work is devoted to the treatment of stable VT and improvement of the prognosis for life-threatening ventricular arrhythmias (VT/VF): indications for use of class III antiarrhythmic, ICD and catheter ablation. It was noted that for patients with CHF who have sustained VT or who survived after circulatory arrest (VF), the optimal treatment is CD implantation, rather than pharmacotherapy. The presented material is based on data from modern international guidelines (ESC, AHA/ACC/HRS) for the treatment of CHF, ventricular arrhythmias and SCD prevention, as well as the results of a number of controlled studies and own clinical experience in the treatment of arrhythmias.
Key words: chronic heart failure, ventricular tachycardia, ventricular fibrillation, antiarrhythmic drugs, implantable cardioverter-defibrillators, cardiac resynchronization therapy, radiofrequency catheter ablation.
Key words: chronic heart failure, ventricular tachycardia, ventricular fibrillation, antiarrhythmic drugs, implantable cardioverter-defibrillators, cardiac resynchronization therapy, radiofrequency catheter ablation.
Полный текст
Список литературы
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2. Meta-analysis Global Group in Chronic Heart Failure (MAGGIC). The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction. Eur Heart J 2012; 33: 1750–7.
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13. Velazquez EJ, Lee KL, Deja MA et al. STICH investigators. Coronary-artery bypass surgery in patients with ventricular dysfunction. N Engl J Med 2011; 364: 1607–16.
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17. Desai AS, Fang JC, Maisel WH, Baughman KL. Implantable defibrillators for the prevention of mortality in patients with nonischemic cardiomyopathy: a meta-analysis of randomized controlled trials. JAMA 2004; 292: 2874–9.
18. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. JACC DOI: 10.1016/J.Jacc.2017.10.054
19. Bristow MR, Saxon LA, Boehmer J et al. Comparison of medical therapy, pacing and defibrillator in heart failure (COMPANION) investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–50.
20. Cleland JG, Daubert JC, Erdmann E. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539–49.
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22. Connolly SJ, Hallstrom AP, Cappato R et al. Meta-analysis of the implantable cardioverter-defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Eur Heart J 2000; 21: 2071–8.
23. Connoly SJ, Dorian P, Roberts RS et al. Comparison of beta-blockers, amiodarone plusbeta-blockers or sotalol for prevention of shocks from implantable cardioverter-defibrillators. The OPTIC study. JAMA 2006; 295: 165–71.
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2. Meta-analysis Global Group in Chronic Heart Failure (MAGGIC). The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction. Eur Heart J 2012; 33: 1750–7.
3. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J 2012; 33: 1787–847.
4. Maggioni AP, Zuanetti G, Franzosi MG et al. Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era. GISSI-2 results. Circulation 1993; 87: 312–22.
5. Deyell MW, Park KM, Han Y et al. Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm 2012; 9: 1465–72.
6. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2015. DOI: 10.1093eurheartj/ehv316
7. Desai AS, Mc Murray JJ, Packer M et al. Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of death in heart failure patients. Eur Heart J 2015; 36: 1990–7.
8. Kotecha D, Holmes J, Krum H et al. Beta-blockers in heart failure collaborative group. Efficacy of beta-blockers in patients with heart failure plus atrial fibrillation. Lancet 2014; 384: 2235–43.
9. Bapoje SR, Bahia A, Hokanson JE et al. Effect of mineralocorticoid receptor antagonists on the risk of sudden cardiac death in patients with left ventricular systolic dysfunction: a meta-analysis of randomized controlled trials. Circ Heart Fail 2013; 6: 166–73.
10. Piccini JP, Berger JS, O’Connor CM. Amiodarone for the prevention of sudden cardiac death: a meta-analysis of randomized controlled trials. Eur Heart J 2009; 30 (10): 1245–53.
11. Boutitie F, Boissel J-P, Connolly SJ. Amiodarone interaction with beta-blockers: analysis of the merged EMIAT and CAMIAT databases. The EMIAT and CAMIAT investigators. Circulation 1999; 99 (17): 2268–75.
12. Bardy GH, Lee KL, Mark DB et al. Amiodarone or implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352 (2): 225–37.
13. Velazquez EJ, Lee KL, Deja MA et al. STICH investigators. Coronary-artery bypass surgery in patients with ventricular dysfunction. N Engl J Med 2011; 364: 1607–16.
14. Carson P, Wertheimer J, Miller A et al. The STICH trial: mode-of-death results. JACC Heart Fail 2013; 1: 400–8.
15. NanthaKumar K, Epstein AE, Kay GN et al. Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction. J Am Coll Cardiol 2004; 44 (11): 2166–72.
16. Kadish A, Dyer A, Daubert JP et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004; 350: 2151–8.
17. Desai AS, Fang JC, Maisel WH, Baughman KL. Implantable defibrillators for the prevention of mortality in patients with nonischemic cardiomyopathy: a meta-analysis of randomized controlled trials. JAMA 2004; 292: 2874–9.
18. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. JACC DOI: 10.1016/J.Jacc.2017.10.054
19. Bristow MR, Saxon LA, Boehmer J et al. Comparison of medical therapy, pacing and defibrillator in heart failure (COMPANION) investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–50.
20. Cleland JG, Daubert JC, Erdmann E. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539–49.
21. Gasparini M, Leclercq C, Lunati M et al. Cardiac resynchronization therapy in patients with atrial fibrillation: the CERTIFY study. JACC Heart Fail 2013; 1: 500–7.
22. Connolly SJ, Hallstrom AP, Cappato R et al. Meta-analysis of the implantable cardioverter-defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Eur Heart J 2000; 21: 2071–8.
23. Connoly SJ, Dorian P, Roberts RS et al. Comparison of beta-blockers, amiodarone plusbeta-blockers or sotalol for prevention of shocks from implantable cardioverter-defibrillators. The OPTIC study. JAMA 2006; 295: 165–71.
24. Tanner H, Hindricks G, Volkmer M et al. Catheter ablation of recurrent scar-related ventricular tachycardia using electroanatomical mapping and irrigated ablation technology: results of the prospective multicenter Euro-VT-study. J Cardiovasc Electrophysiol 2010; 21: 47–53.
2. Meta-analysis Global Group in Chronic Heart Failure (MAGGIC). The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction. Eur Heart J 2012; 33: 1750–7.
3. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J 2012; 33: 1787–847.
4. Maggioni AP, Zuanetti G, Franzosi MG et al. Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era. GISSI-2 results. Circulation 1993; 87: 312–22.
5. Deyell MW, Park KM, Han Y et al. Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm 2012; 9: 1465–72.
6. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2015. DOI: 10.1093eurheartj/ehv316
7. Desai AS, Mc Murray JJ, Packer M et al. Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of death in heart failure patients. Eur Heart J 2015; 36: 1990–7.
8. Kotecha D, Holmes J, Krum H et al. Beta-blockers in heart failure collaborative group. Efficacy of beta-blockers in patients with heart failure plus atrial fibrillation. Lancet 2014; 384: 2235–43.
9. Bapoje SR, Bahia A, Hokanson JE et al. Effect of mineralocorticoid receptor antagonists on the risk of sudden cardiac death in patients with left ventricular systolic dysfunction: a meta-analysis of randomized controlled trials. Circ Heart Fail 2013; 6: 166–73.
10. Piccini JP, Berger JS, O’Connor CM. Amiodarone for the prevention of sudden cardiac death: a meta-analysis of randomized controlled trials. Eur Heart J 2009; 30 (10): 1245–53.
11. Boutitie F, Boissel J-P, Connolly SJ. Amiodarone interaction with beta-blockers: analysis of the merged EMIAT and CAMIAT databases. The EMIAT and CAMIAT investigators. Circulation 1999; 99 (17): 2268–75.
12. Bardy GH, Lee KL, Mark DB et al. Amiodarone or implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352 (2): 225–37.
13. Velazquez EJ, Lee KL, Deja MA et al. STICH investigators. Coronary-artery bypass surgery in patients with ventricular dysfunction. N Engl J Med 2011; 364: 1607–16.
14. Carson P, Wertheimer J, Miller A et al. The STICH trial: mode-of-death results. JACC Heart Fail 2013; 1: 400–8.
15. NanthaKumar K, Epstein AE, Kay GN et al. Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction. J Am Coll Cardiol 2004; 44 (11): 2166–72.
16. Kadish A, Dyer A, Daubert JP et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004; 350: 2151–8.
17. Desai AS, Fang JC, Maisel WH, Baughman KL. Implantable defibrillators for the prevention of mortality in patients with nonischemic cardiomyopathy: a meta-analysis of randomized controlled trials. JAMA 2004; 292: 2874–9.
18. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. JACC DOI: 10.1016/J.Jacc.2017.10.054
19. Bristow MR, Saxon LA, Boehmer J et al. Comparison of medical therapy, pacing and defibrillator in heart failure (COMPANION) investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–50.
20. Cleland JG, Daubert JC, Erdmann E. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539–49.
21. Gasparini M, Leclercq C, Lunati M et al. Cardiac resynchronization therapy in patients with atrial fibrillation: the CERTIFY study. JACC Heart Fail 2013; 1: 500–7.
22. Connolly SJ, Hallstrom AP, Cappato R et al. Meta-analysis of the implantable cardioverter-defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Eur Heart J 2000; 21: 2071–8.
23. Connoly SJ, Dorian P, Roberts RS et al. Comparison of beta-blockers, amiodarone plusbeta-blockers or sotalol for prevention of shocks from implantable cardioverter-defibrillators. The OPTIC study. JAMA 2006; 295: 165–71.
24. Tanner H, Hindricks G, Volkmer M et al. Catheter ablation of recurrent scar-related ventricular tachycardia using electroanatomical mapping and irrigated ablation technology: results of the prospective multicenter Euro-VT-study. J Cardiovasc Electrophysiol 2010; 21: 47–53.
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2. Meta-analysis Global Group in Chronic Heart Failure (MAGGIC). The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction. Eur Heart J 2012; 33: 1750–7.
3. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J 2012; 33: 1787–847.
4. Maggioni AP, Zuanetti G, Franzosi MG et al. Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era. GISSI-2 results. Circulation 1993; 87: 312–22.
5. Deyell MW, Park KM, Han Y et al. Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm 2012; 9: 1465–72.
6. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2015. DOI: 10.1093eurheartj/ehv316
7. Desai AS, Mc Murray JJ, Packer M et al. Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of death in heart failure patients. Eur Heart J 2015; 36: 1990–7.
8. Kotecha D, Holmes J, Krum H et al. Beta-blockers in heart failure collaborative group. Efficacy of beta-blockers in patients with heart failure plus atrial fibrillation. Lancet 2014; 384: 2235–43.
9. Bapoje SR, Bahia A, Hokanson JE et al. Effect of mineralocorticoid receptor antagonists on the risk of sudden cardiac death in patients with left ventricular systolic dysfunction: a meta-analysis of randomized controlled trials. Circ Heart Fail 2013; 6: 166–73.
10. Piccini JP, Berger JS, O’Connor CM. Amiodarone for the prevention of sudden cardiac death: a meta-analysis of randomized controlled trials. Eur Heart J 2009; 30 (10): 1245–53.
11. Boutitie F, Boissel J-P, Connolly SJ. Amiodarone interaction with beta-blockers: analysis of the merged EMIAT and CAMIAT databases. The EMIAT and CAMIAT investigators. Circulation 1999; 99 (17): 2268–75.
12. Bardy GH, Lee KL, Mark DB et al. Amiodarone or implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352 (2): 225–37.
13. Velazquez EJ, Lee KL, Deja MA et al. STICH investigators. Coronary-artery bypass surgery in patients with ventricular dysfunction. N Engl J Med 2011; 364: 1607–16.
14. Carson P, Wertheimer J, Miller A et al. The STICH trial: mode-of-death results. JACC Heart Fail 2013; 1: 400–8.
15. NanthaKumar K, Epstein AE, Kay GN et al. Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction. J Am Coll Cardiol 2004; 44 (11): 2166–72.
16. Kadish A, Dyer A, Daubert JP et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004; 350: 2151–8.
17. Desai AS, Fang JC, Maisel WH, Baughman KL. Implantable defibrillators for the prevention of mortality in patients with nonischemic cardiomyopathy: a meta-analysis of randomized controlled trials. JAMA 2004; 292: 2874–9.
18. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. JACC DOI: 10.1016/J.Jacc.2017.10.054
19. Bristow MR, Saxon LA, Boehmer J et al. Comparison of medical therapy, pacing and defibrillator in heart failure (COMPANION) investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–50.
20. Cleland JG, Daubert JC, Erdmann E. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539–49.
21. Gasparini M, Leclercq C, Lunati M et al. Cardiac resynchronization therapy in patients with atrial fibrillation: the CERTIFY study. JACC Heart Fail 2013; 1: 500–7.
22. Connolly SJ, Hallstrom AP, Cappato R et al. Meta-analysis of the implantable cardioverter-defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Eur Heart J 2000; 21: 2071–8.
23. Connoly SJ, Dorian P, Roberts RS et al. Comparison of beta-blockers, amiodarone plusbeta-blockers or sotalol for prevention of shocks from implantable cardioverter-defibrillators. The OPTIC study. JAMA 2006; 295: 165–71.
24. Tanner H, Hindricks G, Volkmer M et al. Catheter ablation of recurrent scar-related ventricular tachycardia using electroanatomical mapping and irrigated ablation technology: results of the prospective multicenter Euro-VT-study. J Cardiovasc Electrophysiol 2010; 21: 47–53.
Авторы
Ю.А. Бунин, Е.А. Золозова*
ФГБОУ ДПО «Российская медицинская академия непрерывного последипломного образования» Минздрава России, Москва, Россия
*ezolozova@mail.ru
ФГБОУ ДПО «Российская медицинская академия непрерывного последипломного образования» Минздрава России, Москва, Россия
*ezolozova@mail.ru
________________________________________________
Yuriy A. Bunin, Elena А. Zolozova*
Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*ezolozova@mail.ru
Russian Medical Academy of Continuous Professional Education, Moscow, Russia
*ezolozova@mail.ru
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