2014植入型心律转复除颤器治疗的中国专家共识

1例恶性心律失常患者植入埋藏式自动转复除颤器的护理随着医学科技的飞速发展，近几年自埋藏式自动心脏复律除颤器(ICD)开发以来，已逐渐被引用于临床。

持续性室性心动过速、心室扑动、心室颤动是心脏性猝死常见的病因，约占心脏猝死的87%。

植入ICD是治疗恶性心律失常的首先措施。

临床资料表明，ICD降低致命性室性心律失常病死率的效果明显优于抗心律失常药物。

我科已成功为一名患者植入了埋藏式自动转复除颤器(ICD)，效果满意，现将护理体会总结如下：1临床资料男，71岁，间断性头晕、乏力、心悸三天既往有冠心病陈旧性广泛前壁心肌梗塞并室壁瘤形成，心功能2级、动态心电图示频发室性早搏、短阵室速连续7跳。

2护理2.1术前护理2.1.1心理护理：植入ICD是一种新疗法且费用高，患者多数在思想上有一定的压力，尤其是在清醒状态下被电击除颤过的患者，感到恐惧不安，术前向患者及家属介绍有关ICD系统的基本知识，手术指征和治疗效果，介绍手术方法，小切口，出血少，手术安全可靠，局部麻醉，患者清醒状态下完成手术，解除病人及家属的思想负担，让家属主动配合，共同做好心理疏导工作，使病人保持良好的情绪和精神状态，积极配合治疗。

2.1.2术前患者的准备：术前停用抗凝药物一周可减少切口出血，常规术前备皮，药物过敏试验，协助患者做相关检查，保持静脉通畅，术前禁食4-6小时，术前30分钟可给镇静剂。

2.2术中护理2.2.1导管室房间的准备：ICD的植入技术必须在无菌技术条件下进行，护士要在术前4小时导管室内环境清洁消毒，用500毫克／Ｌ含氯消毒液擦抹桌子、手术台、手术床和拖地，空气循环消毒机进行空气消毒。

2.2.2抢救物品准备：监护仪，体外除颤仪，起搏器分析仪，必须具有ICD功能及能程控ICD 参数的程控仪，心电图机，微量泵，吸痰器等。

2.2.3药物准备：如胺碘酮、阿托品、利多卡因、阿拉明、多巴胺等，护士术前抽好药物，标明药名。

2.2.4术中配合：植入一枚BD留置针保持静脉输液通畅，术中密切观察心电监护、血压、血氧饱和度，患者神志及倾听患者主诉，如发现异常，立即通知术者处理或暂停手术。

《心脏介入诊疗术中电击除颤护理专家共识》（2024）要点1 心脏电击除颤定义心脏电击除颤是指在严重快速型心律失常时，用外加的高能量脉冲电流通过心脏，使全部或大部分心肌细胞在瞬间同时除极，造成心脏短暂的电活动停止，然后由最高自律性的起搏点（通常为窦房结）重新主导心脏节律的治疗过程。

1.1 心脏电击除颤原理除颤仪的电压变换器将直流低压变换成脉冲高压，经高压整流后向储能电容C充电，在电容中储存一定的能量。

除颤治疗时，控制高压继电器动作，将储能电容C、电感L及人体（负荷）串联接通，使之构成RLC（R为人体电阻、导线本身电阻、人体与电极的接触电阻三者之和）串联谐振衰减振荡电路，在几秒钟内通过电极板向胸壁或直接向心脏放电，使颤动的心脏全部除极。

由于窦房结产生的信号最强，因此将重新支配心脏的收缩，从而将各种室上性或室性快速性心律失常（VT/ VF）转复为正常窦性心律。

1.2 心脏电击除颤适应证（1）心室颤动是电复律的绝对指征；（2）心室扑动；（3）心房颤动或新房扑动；（4）阵发性室上性心动过速，常规治疗无效而伴有明显血液动力学障碍者。

1.3 心脏电击除颤禁忌症（1）检查发现心房内血栓；（2）风湿活动期或者心肌炎急性期；（3）未能有效控制或纠正心房颤动的病因或诱因（例如甲状腺功能亢进、心肌梗死、肺炎等）；（4）合并洋地黄中毒或电解质紊乱，特别是低钾血症；（5）合并高度或完全性房室阻滞，或病态窦房结综合征（已安装起搏器者除外）。

2 心脏介入诊疗术中除颤规范2.1 除颤仪的准备2.1.1 推荐意见1 除颤仪应放于易取用的位置，定点放置，标识明显，电量充足，处于备用状态。

具体位置可以根据导管室的布局和手术团队的需求确定（强推荐）。

推荐依据：2.1.2 推荐意见2 心脏除颤仪的质量检测：除颤仪的检测环境温度为20℃±10℃，相对湿度为30%～60%，供电电源电压为（220±22）V，频率为（50±10）Hz，周围无影响校准系统正常工作的机械振动和电磁干扰（强推荐）。

皮下植入式心律转复除颤器的现状及展望（完整版）心源性猝死（Sudden cardiac death，SCD）是一种常见而凶险的心血管疾病，患者在病情基本稳定的情况下突然发生严重心律失常导致迅速死亡。

据国家心血管中心统计，我国每年心源性猝死者高达55万，居全球之首。

近30年来，大陆SCD平均年发病率为40.7人/10万人，约50-70%的SCD与快速性室性心律失常有关。

及时有效地除颤是预防SCD 的关键，大量临床研究试验已证实植入式心脏复律除颤器(ICD)应用于猝死高危患者的一级预防及二级预防，效果优于现有的药物治疗，可降低长期死亡率。

但传统经静脉植入心律转复除颤器（TV-ICD）的围手术期和长期并发症发生率较高，且多数是由植入式电极引起的，如静脉血栓、气胸、血胸、感染、心脏穿孔、电极断裂、心包填塞、三尖瓣损伤等。

部分患者由于心脏结构及解剖异常，如先天性心脏病、机械瓣及其他少见原因，以及ICD植入后感染并发静脉闭塞，而面临TV-ICD植入困难的问题。

为满足临床需求，填补TV-ICD的缺陷和不足，皮下植入式心律转复除颤器(S-ICD)应运而生。

其无需植入心内电极，简化了手术过程，避免了TV-ICD 电极相关并发症，活动限制少，为SCD高危患者提供了新的治疗选择。

本文旨在阐述S-ICD的工作原理及临床应用。

一、S-ICD的组成及工作原理S-ICD主要由脉冲发生器和皮下电极导线构成。

其植入以体表解剖标志为参照，不需要X线照射。

脉冲发生器植入患者胸部左外侧第6肋水平腋前线和腋中线之间的皮下组织囊袋中。

皮下电极导线长45cm，两端有两个感知电极，两者中间有一直径3mm、长8cm的除颤线圈电极，电极经皮下隧道置于胸骨左缘1-2cm，近端位于剑突，远端位于胸骨柄。

导线自第6肋水平行至左侧腋前线，与脉冲发生器相连，组成三个感知向量，S-ICD可自动选择最佳的感知向量，用于心脏节律分析及室性心律失常检测。

与TV-ICD的腔内心电图不同，S-ICD获得的皮下心电信号类似于体表心电图，具有更高的分辨率，从而有利于通过形态学匹配来识别心脏节律。

植入式心律转复除颤器术后焦虑研究的进展孙天恒　张疆华　汤宝鹏（新疆医科大学第一附属医院心脏中心起搏电生理科新疆心电生理与心脏重塑重点实验室，新疆乌鲁木齐８３００５４）【摘要】目前，植入式心律转复除颤器是防治心源性猝死的有效措施。

尽管它提高了患者的生存效益，但由于心理及生物等各种因素，部分患者出现了焦虑症状，尤其是经历电击的患者。

焦虑症状与不良心脏结局相关，降低了患者的生活质量，并增加再入院率和医疗费用，从而降低了植入式心律转复除颤器的治疗效益。

此外焦虑也是除颤器电击治疗的触发因素，电击、焦虑互为因果形成恶性循环。

尽管认知行为疗法治疗植入除颤器患者的焦虑症状有效，但临床依从性差，而网络干预途径有望成为新趋势，但尚未完善。

因此心内科医师有必要对植入除颤器患者术后的焦虑症状进行筛查，并详细记录他们的心脏病史及除颤器随访记录，以便分析植入除颤器后焦虑相关的因素并进行干预，提高植入除颤器患者的治疗效益。

【关键词】植入型心律转复除颤器；焦虑；心理干预【ＤＯＩ】１０ １６８０６／ｊ．ｃｎｋｉ．ｉｓｓｎ．１００４ ３９３４ ２０２３ １２ ００４ＳｔｕｄｙｏｆＰｏｓｔｏｐｅｒａｔｉｖｅＡｎｘｉｅｔｙｗｉｔｈＩｍｐｌａｎｔａｂｌｅＣａｒｄｉｏｖｅｒｔｅｒＤｅｆｉｂｒｉｌｌａｔｏｒＳＵＮＴｉａｎｈｅｎｇ，ＺＨＡＮＧＪｉａｎｇｈｕａ，ＴＡＮＧＢａｏｐｅｎｇ（ＤｅｐａｒｔｍｅｎｔｏｆＰａｃｉｎｇａｎｄＥｌｅｃｔｒｏｐｈｙｓｉｏｌｏｇｙ，ＤｅｐａｒｔｍｅｎｔｏｆＣａｒｄｉａｃＥｌｅｃｔｒｏｐｈｙｓｉｏｌｏｇｙａｎｄＲｅｍｏｄｅｌｉｎｇ，ＴｈｅＦｉｒｓｔＡｆｆｉｌｉａｔｅｄＨｏｓｐｉｔａｌｏｆＸｉｎｊｉａｎｇＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ，Ｕｒｕｍｑｉ８３００５４，Ｘｉｎｊｉａｎｇ，Ｃｈｉｎａ）【Ａｂｓｔｒａｃｔ】Ｃｕｒｒｅｎｔｌｙ，ｉｍｐｌａｎｔａｂｌｅｃａｒｄｉｏｖｅｒｔｅｒｄｅｆｉｂｒｉｌｌａｔｏｒｉｓａｎｅｆｆｅｃｔｉｖｅｍｅａｓｕｒｅｔｏｐｒｅｖｅｎｔｓｕｄｄｅｎｃａｒｄｉａｃｄｅａｔｈ．Ａｌｔｈｏｕｇｈｉｔｉｍｐｒｏｖｅｓｔｈｅｓｕｒｖｉｖａｌｂｅｎｅｆｉｔｏｆｐａｔｉｅｎｔｓ，ｓｏｍｅｐａｔｉｅｎｔｓｅｘｐｅｒｉｅｎｃｅａｎｘｉｅｔｙｓｙｍｐｔｏｍｓ，ｅｓｐｅｃｉａｌｌｙｔｈｏｓｅｗｈｏｅｘｐｅｒｉｅｎｃｅｅｌｅｃｔｒｉｃｓｈｏｃｋｓ，ｄｕｅｔｏｖａｒｉｏｕｓｐｓｙｃｈｏｌｏｇｉｃａｌａｎｄｂｉｏｌｏｇｉｃａｌｆａｃｔｏｒｓ．Ａｎｘｉｅｔｙｓｙｍｐｔｏｍｓａｒｅａｓｓｏｃｉａｔｅｄｗｉｔｈｐｏｏｒｃａｒｄｉａｃｏｕｔｃｏｍｅｓ，ｒｅｄｕｃｉｎｇｔｈｅｑｕａｌｉｔｙｏｆｌｉｆｅｏｆｐａｔｉｅｎｔｓａｎｄｉｎｃｒｅａｓｉｎｇｒｅａｄｍｉｓｓｉｏｎｒａｔｅｓａｎｄｈｅａｌｔｈｃａｒｅｃｏｓｔｓ，ｔｈｅｒｅｂｙｒｅｄｕｃｉｎｇｔｈｅｔｈｅｒａｐｅｕｔｉｃｂｅｎｅｆｉｔｏｆｉｍｐｌａｎｔａｂｌｅｃａｒｄｉｏｖｅｒｔｅｒｄｅｆｉｂｒｉｌｌａｔｏｒ．Ｉｎａｄｄｉｔｉｏｎ，ａｎｘｉｅｔｙｉｓａｔｒｉｇｇｅｒｆｏｒｄｅｆｉｂｒｉｌｌａｔｏｒｓｈｏｃｋｔｈｅｒａｐｙ，ａｎｄｓｈｏｃｋａｎｄａｎｘｉｅｔｙａｒｅｍｕｔｕａｌｌｙｒｅｉｎｆｏｒｃｉｎｇｉｎａｖｉｃｉｏｕｓｃｙｃｌｅ．Ａｌｔｈｏｕｇｈｃｏｇｎｉｔｉｖｅｂｅｈａｖｉｏｒａｌｔｈｅｒａｐｙｉｓｅｆｆｅｃｔｉｖｅｉｎｔｒｅａｔｉｎｇａｎｘｉｅｔｙｉｎｐａｔｉｅｎｔｓｗｉｔｈｉｍｐｌａｎｔｅｄｄｅｆｉｂｒｉｌｌａｔｏｒｓ，ｃｌｉｎｉｃａｌａｄｈｅｒｅｎｃｅｉｓｐｏｏｒ，ａｎｄｗｅｂ ｂａｓｅｄｉｎｔｅｒｖｅｎｔｉｏｎｉｓａｐｒｏｍｉｓｉｎｇｎｅｗｔｒｅｎｄｔｈａｔｈａｓｎｏｔｙｅｔｂｅｅｎｐｅｒｆｅｃｔｅｄ．Ｔｈｅｒｅｆｏｒｅ，ｉｔｉｓｎｅｃｅｓｓａｒｙｆｏｒｃａｒｄｉｏｌｏｇｉｓｔｓｔｏｓｃｒｅｅｎｄｅｆｉｂｒｉｌｌａｔｏｒｉｍｐｌａｎｔａｔｉｏｎｐａｔｉｅｎｔｓｆｏｒｐｏｓｔｏｐｅｒａｔｉｖｅａｎｘｉｅｔｙｓｙｍｐｔｏｍｓａｎｄｒｅｃｏｒｄｔｈｅｉｒｃａｒｄｉａｃｈｉｓｔｏｒｙａｎｄｄｅｆｉｂｒｉｌｌａｔｏｒｆｏｌｌｏｗ ｕｐｒｅｃｏｒｄｓｉｎｏｒｄｅｒｔｏａｎａｌｙｓｅｔｈｅｆａｃｔｏｒｓｒｅｌａｔｅｄｔｏａｎｘｉｅｔｙａｆｔｅｒｄｅｆｉｂｒｉｌｌａｔｏｒｉｍｐｌａｎｔａｔｉｏｎａｎｄｉｎｔｅｒｖｅｎｅｉｎｏｒｄｅｒｔｏｉｍｐｒｏｖｅｔｈｅｂｅｎｅｆｉｔｓｏｆｔｒｅａｔｍｅｎｔｆｏｒｄｅｆｉｂｒｉｌｌａｔｏｒｉｍｐｌａｎｔａｔｉｏｎｐａｔｉｅｎｔｓ．【Ｋｅｙｗｏｒｄｓ】Ｉｍｐｌａｎｔａｂｌｅｃａｒｄｉｏｖｅｒｔｅｒｄｅｆｉｂｒｉｌｌａｔｏｒ；Ａｎｘｉｅｔｙ；Ｐｓｙｃｈｏｌｏｇｉｃａｌｉｎｔｅｒｖｅｎｔｉｏｎ 目前植入型心律转复除颤器（ｉｍｐｌａｎｔａｂｌｅｃａｒｄｉｏｖｅｒｔｅｒｄｅｆｉｂｒｉｌｌａｔｏｒ，ＩＣＤ）是防治心源性猝死（ｓｕｄｄｅｎｃａｒｄｉａｃｄｅａｔｈ，ＳＣＤ）最有效的措施［１］。

万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据万方数据植入型心律转复除颤器治疗的中国专家共识作者：中华医学会心电生理和起搏分会， 中华医学会心血管病学分会， 中国医师协会心律学专业委员会植入型心律转复除颤器治作者单位：刊名：中华心律失常学杂志英文刊名：Chinese Journal of Cardiac Arrhythmias年，卷(期)：2014,18(4)1.de Vreede-Swaemakwes JJ;Gorgels AP;Dubois-Arbouw WI Out-of-hospital cardiac arrest in the 1990's:a population-based study in the Maastricht area on incidence,characteristics and survival 19972.胡大一;丁荣晶推动自动体外除颤器应用提高院外心脏骤停患者生存率 20083.王方正;张澍;任自文植入型心律转复除颤器治疗的适应证 20024.Priori SG;Aliot E;Blomstrom-Lundqvist C Task Force on Sudden Cardiac Death of the European Society of Cardiology 20015.Lloyd-Jones D;Adams R J;Brown TM Heart disease and stroke statistics-2010 update:a report from the American Heart Association 20126.Kong MH;Fonarow GC;Peterson ED Systematic review of the incidence of sudden cardiac death in the United States 20117.Dudas K;Lappas G;Stewart S Trends in out-of-hospital deaths due to coronary heart disease in Sweden(1991 to 2006) 20118.Gerber Y;Jacobsen S J;Frye RL Sevular trends 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American Association for Thoracic surgery 200829.Zipes DP;Camm AJ;Borggrefe M ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 200630.Tracy CM;Epstein AE;Darbar D2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.[corrected] 201231.梁义秀;宿燕岗;柏瑾心脏性猝死一级与二级预防植入型心律转变除颤器患者临床特征单中心分析 201232.宿燕岗;吴妍;柏瑾ICD适应证患者及主管医生的问卷调查 201033.程中伟;朱孔博;陈太波植入型心律转复除颤器在一级预防心力衰竭患者中的应用 201134.Softeriades ES;Evans JC;Larson MG Incidence and prognosis of syncope 200235.Olshansky B;Poole JE;Johnson G Syncope Predicts the outcome of cardiomyopathy patients:analysis of the SCD-HeFT study 200836.deSousa MR;Morillo CA;Rabelo FT Non-sustained ventricular tachycardia as a predictor of sudden cardiac deathin patients with left ventricular 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patients who are not included or not well represented in clinical trials 201442.Newby LK;Jesse RL;Babb JD ACC 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations:a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents 201243.Hohnloser SH;Kuck KH;Dorian P Prophylactic use of an implantable cardioverter-defibrillator after acutemyocardial infarction 200444.Steinbeck G;Andresen D;Seidl K for the IRIS Investigators.Defbrillator implantation early after myocardial infarction 200945.Volpi A;Cavalli A;Santoro L Incidence and prognosis of early primary ventricular fibrillation in acute myocardial infarction:results of the Gruppo Italiano per lo Studio della Sopravvivenza nell' Infarto Miocardico (GISSI-2) database 199846.Newby KH;Thompson T;Stebbins A Sustained ventricular arrhythmias in patients receiving thrombolytictherapy:incidence and outcomes.The GUSTO Investigators 199847.Mehta RH;Starr AZ;Lopes RD Incidence of and outcomes associated with ventricular tachycardia or fbrillation in patients undergoing primary percutaneous coronary intervention 200948.The PURSUIT Trial Investigators Inhibition of platelet glycoprotein Ⅱ b/Ⅲa with eptifbatide in patients with acute coronary syndromes 199849.Piccini JP;White JA;Mehta RH Sustained ventricular tachycardia and ventricular fibrillation complicating non-ST-segmentelevation acute coronary syndromes 201250.Bigger JT Jr Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery.Coronary Artery Bypass Graft (CABG) Patch Trial Investigators 199751.Barsheshet A;Goldenberg I;Moss AJ Effect of elapsed time from coronary revasculariza-tion to implantation of a cardioverter defibrillator on long-term survival in the MADIT-Ⅱ trial 201152.Goldenberg I;Moss A J;McNitt S Time dependence of defbrillator beneft after coro-nary revascularization in the multicenter automatic defibrillator implanta-tion trial(MADIT)-Ⅱ 200653.Nageh MF;Kim JJ;Chung J The role of implantable cardioverter defibrillators in high-risk CABG patients identified early post-cardiac surgery 201154.John JM;Hussein A;Imran N Underutilization of implantable cardioverter defibrillators post coronary artery bypass grafting in patients with systolic dysfunction 201055.Cook JR;Rizo-Patron C;Curtis AB Effect of surgical revascularization in patients with coronary artery disease and ventricular tachycardia or fibrillation in the Antiarrhythmics Versus ImplantableDefibrillators(AVID)registry 200256.Kadish A;Schaechter A;Subacius H Levine J.Patients with recently diagnosed nonischemic cardiomyopathy beneftfrom implantable cardioverter-defibrillators 200657.McNamara DM;Starling RC;Cooper LT for the IMAC Investigators.Clinical and demographic predictors of outcomesin recent onset dilated cardiomyopathy:results of the IMAC (Intervention in Myocarditis and Acute Cardiomyopathy)-2 study 201158.Zecchin M;Merlo M;Pivetta A How can optimization of medical treatment avoid unnecessary implantable cardioverter-defibrillator implantations in patients with idiopathic dilated cardiomyopathy presenting with "SCD-HeFT criteria?" 201259.Meyer C;Schueller P;Rodenbeck A Primary and secondary prevention of ventricular arrhythmias in dilated cardiomyopathy:nonsustained,sustained,and incessant 200960.Matlock DD;Peterson PN;Wang Y Variation in use of dualchamber implantable cardioverter-defibrillators:results from the national cardiovascular data registry 201261.Gregoratos G;Abrams J;Epstein AE ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices:summary article:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines) 200262.Friedman PA;Bradley D;Koestler C A prospective randomized trial of single-or dual-chamber implantable cardioverter-defibrillators to minimize inappropriate shock risk in primary sudden cardiac death prevention 2014 63.Wilkoff BL;Cook JR;Epstein AE for the Investigators VV ⅡDT.Dual chamber pacing or ventricular backup pacingin patients with an implantable defbrillator:the Dual-chamber and VVI Implantable Defbrillator (DAVID) trial 2002 64.Peleska B;Blazek Z Effect of serial inductivity in condenser defibrillators on the defibrillation threshold of the heart and proposals for a modification of the earlier prema type defibrillator 196365.Pires L;Johnson KM Intraoperative testing of the implantable cardioverter-defibrillator:how much Is enough 200666.Strickberger SA;Klein GJ Is defi rillation testing required for defibrillator implantation 200467.Brignole M;Occhetta E;Bongiorni MG Clinical evaluation of defibrillation testing in an unselected populationof 2,120 consecutive patients undergoing first implantable cardioverterdefibrillator implant 201268.Birnie D;Tung S;Simpson C Complications associated with defibrillation threshold testing:The Canadian experience 200869.Healey JS;Hohnloser SH;Glikson M The rationale and design of the Shockless IMPLant Evaluation (SIMPLE) trial:a randomized,controlled trial of defibrillation testing at the time of defibrillator implantation 201270.陈泗林;林纯莹;费洪文心脏再同步治疗起搏参数优化对血流动力学的影响及随访 200971.陈柯萍减少植入型心律转复除颤器放电是临床医生必须重视的问题 201272.张澍;陈柯萍;黄德嘉心血管植入型电子器械术后随访的专家共识 201273.华伟;丁立刚;张澍远程家庭监测功能在心脏再同步治疗中的应用 201074.Varma N;Epstein AE;Irimpen A Efficacy and safety of automatic remote monitoring for implantable cardioverter-defibrillator follow-up:the Lumos-t Safely Reduces Routine Office Device Follow-up (TRUST) trial 201075.Crossley GH;Boyle A;Vitense H The CONNECT (Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision) trial:The value of wireless remote monitoring with automatic clinician alerts 201176.Wathen M;Sweeney MO;De Groot PJ Shock reduction using antitachycardia pacing for 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of long-detection interval vs standard-detection interval for implantable cardioverter-defibrillators on antitachycardia pacing and shock delivery:the ADVANCE Ⅲ randomized clinical trial 201381.Wilkoff BL;Williamson BD;Stern RS Strategic programming of detection and therapy parameters in implantable cardioverterdefibrillators reduces shocks in primary prevention patients results from the PREPARE(Primary Prevention Parameters Evaluation)study 200882.Wilkoff BW;Ousdigian KT;Sterns LD A comparison of empiric to physician-tailored programming of implantable cardioverter-defibrillators results from the prospective randomized multicenter EMPIRIC trial 2006引用本文格式：中华医学会心电生理和起搏分会.中华医学会心血管病学分会.中国医师协会心律学专业委员会植入型心律转复除颤器治植入型心律转复除颤器治疗的中国专家共识[期刊论文]-中华心律失常学杂志 2014(4)。

心力衰竭生物标志物临床应用中国专家共识目前全球心力衰竭（心衰）患者估计6 430万人。

我国心衰流行病学的最新调查结果显示，35岁及以上的居民患病率为1.3%，估计现有心衰患者约为890万人。

在过去20余年，已发现多种反映心衰时神经内分泌激活、心肌牵拉、心肌损伤、心脏基质重构、炎症、氧化应激及肾功能不全等病理生理改变的生物标志物，这些生物标志物的应用有助于心衰的预防、诊断和治疗，其重要性日益受到关注。

01心衰生物标志物的种类及其在临床中的应用（一）心脏负荷/室壁张力相关生物标志物利钠肽家族中的A型利钠肽（A-type natriuretic peptide,ANP）和B型利钠肽（B-type natriuretic peptide,BNP）是反映心脏负荷/室壁张力的主要生物标志物。

临床检验科检测和具有临床数据的利钠肽种类包括BNP、N 末端B型利钠肽原（N terminal pro-B type natriuretic peptide，NT-proBNP）和心房利钠肽原中间片段（mid-regional pro-atrial natriuretic peptide，MR-proANP），其中ANP又称心房利钠肽，BNP又称脑钠肽。

ANP和BNP是膜结合型鸟苷酸环化酶受体的天然配体，与这些受体结合后通过增加细胞内第二信使——环磷酸鸟苷（cyclic guanosine monophosphate，cGMP）浓度来介导利钠肽的生物学功能。

1. BNP/NT-proBNP：利钠肽家族中的BNP和NT-proBNP 是目前临床检验科常规开展的项目，在心衰所有生物标志物中推荐类别最高，现已成为心衰高危人群识别、诊断及预后评估的最主要的生物标志物。

（1）利钠肽在心衰中的病理生理机制：70% 以上的BNP 释放来自心室，心脏容量和/或压力负荷超负荷时导致室壁张力增加，其他如缺血、缺氧等因素均可刺激心肌的BNP基因表达增加，初始产物为pre-proBNP1-134，被快速酶切割后成为激素原proBNP1-108，随后被蛋白水解酶分解为等摩尔的两部分：一部分为含76个氨基酸的NT-proBNP 1-76，另一部分为含32个氨基酸的BNP1-32。

AHA穿戴式心脏除颤仪（WCD）指南解读尽管多项临床研究证实植入式心律转复除颤器（Implantable Cardioverter Defibrillator, ICD）可以降低高危患者的死亡，但美国每年发生心源性猝死（Sudden Cardiac Death，SCD）的30万人中，大多数并不符合目前植入ICD的适应证，而这些患者很可能会从自动除颤仪中获益。

主要包括两类患者：一类是明知有心脏猝死的风险，如冠状动脉重建术后、新诊断的急性心肌梗死或缺血性心脏病等，但并未达到ICD的适应证；第二类是有明确的ICD使用指征，但同时也存在植入ICD的禁忌证的患者，如活动性感染或预后不明等。

穿戴式心脏除颤仪（Wearable Cardioverter Defibrillator, WCD）主要适用于那些有心脏猝死发生危险、但由于各种原因而未能立即植入ICD的患者。

由于WCD的使用率不断提高、以及临床心血管病医生对WCD的使用指征知之甚少，美国心脏病协会（American Heart Association，AHA）制定了这份科学指南，对WCD的独特工艺、临床定位以及可替代疗法三个方面进行了描述。

但由于支持WCD应用的前瞻性研究证据尚少，尤其是已发表的、随机性临床试验的缺少，因此这份指南仅提供了临床治疗建议。

WCD的应用由患者和医生共同决定，医患双方均应认识到WCD在有效性和安全性方面的不确定性，需要医患双方针对风险与获益的深入沟通。

SCD的预防与流行病学非住院病人发生的心脏停搏约三分之一是由于室性心动过速或室颤导致的。

快速电复律可以救命，但大部分室速和室颤的病人并未得到及时的电复律。

从致命性心律失常发生到电击复律所需的等待时间，是室速和室颤能否成功复苏的关键因素。

如未及时进行心肺复苏，由室速和室颤引起的停搏，每耽搁1分钟除颤，生存率就会下降7％～10％；即便进行了心外按压，等待电复律所需的每分钟也会使生存率下降3％～4％。