1、晕厥的诊断思路与治疗策略北京大学人民医院郭继鸿,第一部分晕厥的发生率及其影响,70岁人群*,15%20-25%16-19%23%,晕厥是一种常见的严重疾病,*10年随访,Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.,晕厥的重要性,美国每年新发晕厥50万例 517万例反复发作晕厥 67万例反复发作、原因不明 1-4,原因明确: 53%62%,不常发作、原因不明: 38%47% 1-4,1 Kapoor W, Med. 1990;69:160-175.2 Silverstein M, et al
2、. 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;309:197-204.5 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
3、 Med 1982;73:15-23.2 Kapoor W. Medicine 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.,晕厥的死亡率较高,晕厥严重影响生活质量,1Linzer, J Clin Epidemiol, 1991.2Linzer, J Gen Int Med, 1994.,焦虑抑郁,日常活动改变,限制驾驶,改换工作,73% 1,71% 2,60%
4、2,37% 2,患者百分数,晕厥的病因,Orthostatic,CardiacArrhythmia,StructuralCardio-Pulmonary,*,1VasovagalCarotid SinusSituationalCoughPost- micturition,2Drug Induced ANSFailurePrimarySecondary,3BradySick sinusAV blockTachyVTSVTLong QT Syndrome,4 Aortic StenosisHOCM PulmonaryHypertension,5PsychogenicMetabolice.g. hy
5、per-ventilationNeurological,Non-Cardio-vascular,Neurally-Mediated,Unknown Cause = 34%,24%,11%,14%,4%,12%,DG Benditt, UM Cardiac Arrhythmia Center,第二部分晕厥的诊断思路,初步评估,详尽的病史 体格检查 12导联ECG和24小时动态心电图 超声心动图,颈动脉窦按摩,方法：先左后右，510秒（非阻断）结果判断：3秒以上停搏和或收缩压下降50 mmHg以上，伴症状，称为Carotid Sinus Syndrome (CSS)禁忌证：颈动脉杂音，已知颈动脉疾
6、病，既往脑血管疾病，3月以内心肌梗死风险： TIA 1/5000,直立倾斜试验,直立倾斜试验,DG Benditt, UM Cardiac Arrhythmia Center,脑电图,有助于除外癫痫两次发作之间脑电图不正常提示癫痫,事件捕捉仪,Linzer M. Am J Cardiol. 1990;66:214-219.,Patient Activator,Reveal Plus ILR,9790 Programmer,植入性Holter,植入性Holter,心脏电生理检查,对于器质性心脏病患者更有用心脏病患者.50-80%非心脏病患者18-50%有助于检出心律失常性晕厥,Brignole
7、M, Alboni P, Benditt DG, et al. Eur Heart Journal 2001; 22: 1256-1306.,晕厥的诊断思路,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 CV Testing Angiogram Exercise Test SAECG
8、,Psychological Evaluation,ENT Evaluation,Endocrine Evaluation,Adapted from: W.Kapoor.An overview of the evaluation and management of syncope. From Grubb B, Olshansky B (eds) Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing Co., Inc.1998.,第三部分神经介导性晕厥,神经介导性晕厥,血管迷走性晕厥颈动脉窦综合征特定情形晕厥排尿性晕厥
9、咳嗽性晕厥吞咽性晕厥排便性晕厥抽血时晕厥etc.,神经介导性晕厥的机制,Benditt DG, Lurie KG, Adler SW, et al. Pathophysiology 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,血管迷走性晕厥的发生率,发生率
10、：8%37% (平均18%)患者特点：比颈动脉窦综合征患者年轻多伴面色苍白、恶心、出汗、心悸,DG Benditt, UM Cardiac Arrhythmia Center,16.3,sec,Continuous Tracing,1 sec,一例自然发生的血管迷走性晕厥,血管迷走性晕厥的治疗策略,尚存在争议一般治疗患者教育、 使其放心、指导措施增加液体、食盐摄入倾斜脱敏训练弹力长统袜药物治疗起搏治疗,血管迷走性晕厥的药物治疗,受体阻滞剂双异丙吡胺(Disopyramide)选择性5羟色胺再吸收抑制剂(SSRIs)血管收缩剂：甲氧胺福林(midodrine),甲氧胺福林治疗血管迷走性晕厥,Jo
11、urnal of Cardiovascular Electrophysiology Vol. 12, No. 8, Perez-Lugones, et al.,起搏治疗血管迷走性晕厥的现状,循证医学研究表明起搏治疗有效VPS 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.,频率骤降
12、检测,40,50,60,70,80,90,100,110,Ventricular Rate,Drop Size=25 bpm,Drop Rate,Peak Rate=90 bpm,2 consecutive beats,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.,研究设计54例患者随机分组27例植入带频率骤
13、降功能的DDD起搏器27例不植入起搏器入选标准6次晕厥事件直立倾斜试验（ + ）相对心动过缓：基础心率2g/min心率仍3次，最后一次发作在入组时半年以内直立倾斜试验（ + ）年龄 40岁，或 55 yrs 2年内晕厥 3次 直立倾斜试验（）伴相对性心动过缓,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. 2001; 104:52-57.,SYDIT,100,
14、时间（天）,100,90,80,70,60,200,300,400,500,600,700,800,900,1000,0,P = 0.0032,药物组,起搏器组,无晕厥发作患者的百分数,VPS-II: Phase IVasovagal Pacemaker Study-II,研究设计100 例患者均植入DDD起搏器，随机分组50例频率骤降功能打开(DDD起搏模式)50例频率骤降功能关闭(ODO起搏模式)入选标准既往晕厥发作 6次，或2年内 3次，或半年内 1次直立倾斜试验（）,Presented at the 23rd Annual Scientific Sessions of the Nort
15、h American Society of Pacing and 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 Clinical Trials, May 11, 2002.,0.4,0.3,0.2,ODO,DDD,P
16、 = 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 of the North American Society of Pacing and Electrophysiology. Late Breaking Clinical Trials, May 11, 2002.,VPS-II: Phase I,累积晕厥风险(%),颈动脉窦综合征的起搏治疗,SAFE PACE 研究,Ac
17、cident and Emergency Attendees 50 Yrs,Falls 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.,频率骤降,随机,SAFE PACE 结果,50% OR 0.53; 95%CI 0.23; 1.20 ns,Kenny RA, J Am Coll Cardiol 2001; 38:000-0
18、00.,SAFE PACE 结果,70%,Kenny RA, J Am Coll Cardiol 2001; 38:1491-1496.,颈动脉窦综合征的起搏治疗,Brignole et. Al. Diagnosis, natural history and treatment. Eur JCPE. 1992; 4:247-254,57%,%6,复发率,I类适应证:心脏抑制型混合型DDD/DDI优于VVI,随访时间：6个月,第四部分心原性晕厥,引致晕厥的常见器质性心脏病,急性心肌梗死肥厚型梗阻性心肌病急性主动脉夹层急性心包填塞肺动脉栓塞肺动脉高压瓣膜性心脏病：主动脉瓣狭窄左房粘液瘤,引致晕厥的
19、常见心律失常,心动过缓窦性停搏，窦房阻滞急性高度或完全性房室阻滞心动过速心房颤(扑)动伴快速心室反应：如预激伴房颤或心房扑动1：1下传阵发性室上性或室性心动过速尖端扭转型室速心室扑动颤动,反复晕厥患者的心律分布,Krahn A, et al. Circulation. 1999; 99: 406-410,Normal Sinus Rhythm58%,Normal Sinus Rhythm58%,Bradycardia36%,Tachyarrhythmia6%,起搏器,心动过速晕厥的治疗,房性快速心律失常AVRT：导管射频消融AVNRT：导管射频消融心房颤动：药物起搏消融ICD心房扑动：导管射频消融药物 室性快速心律失常室速：ICDablation药物室颤：ICD,谢谢！,
