儿童房性心动过速药物治疗研究及致心肌损害预警分析

发布时间：2018-05-25 15:09

本文选题：房性心动过速 + 儿童　；参考：《清华大学》2015年博士论文

【摘要】：房性心动过速(房速)为儿童常见室上性心动过速的一种,可见于各年龄组儿童,尤其婴儿中很常见,多表现为持续无休止性。频繁或持续的心动过速发作易导致心动过速性心肌病,严重出现猝死。由于儿童血管径小、射频消融操作难度大等原因,儿童房速治疗首选抗心律失常药物,但目前关于房速药物治疗缺乏规范统一的公认指南,只有少数小样本回顾性的儿童药物治疗研究,治疗有效率仅54%~75%。本课题分析2009年1月至2014年4月本院住院接受治疗的房速患儿144例,对患儿进行随访,每1~2月行动态心电图检查,酌情评估心功能。详细记录患儿的临床表现、房速特点、抗心律失常药物治疗效果,以血清NT-proBNP、超声心动图及组织多普勒评估心功能。对儿童房速进行临床特点、抗心律失常药物治疗效果影响因素、致心动过速性心肌病高危因素、早期心功能损害识别的研究。结果发现,儿童房速起病年龄呈正偏态分布,3岁以内达54.9%,临床症状不典型,持续无休止性发作类型高达36.1%。以索他洛尔联合普罗帕酮方案为主的抗心律失常药物治疗房速,总体有效率为88.7%。药物治疗效果不佳者,射频消融即刻成功率为91.8%,射频复发者多源于心耳位置。首次诊断年龄、发作类型、病程、索他洛尔对儿童房速抗心律失常药物治疗效果的影响有统计学意义。儿童房速心动过速性心肌病发生率为18.1%,持续无休止发作患儿心肌病发病率(46.1%)显著高于短阵性发作患儿心肌病发病率(2.6%)。心律失常控制后,左室射血分数在25±25(2~94)d恢复正常。相比左室射血分数,TDI-MPI和E/E′与异常升高的血清NT-proBNP有显著相关性。在左室射血分数基础上,联合间隔E/E′及侧壁TDI-MPI诊断异常升高NT-proBNP,敏感率为91.7%。因此,本研究认为:(1)儿童房速发病年龄早,临床症状不典型,漏诊风险高,持续无休止性发作多(36.1%)。(2)索他洛尔联合普罗帕酮的方案治疗儿童房速疗效理想。(3)首次诊断年龄小,病程短,短阵发作的患儿抗心律失常药物治疗效果好。年长、持续无休止性发作房速患儿,抗心律失常药物治疗效果欠理想,推荐射频消融治疗。(4)儿童房速心动过速性心肌病发病率为18.1%,持续无休止性发作是关键高危因素。(5)相比左室射血分数,组织多普勒参数E/E′、TDI-MPI对早期心功能损害的识别有更好的应用前景。本文国内首次大样本对儿童房速临床特点、药物治疗及致心功能损害进行长期随访和全面分析,研究结果对制定儿童房速的临床诊治方案有较好的参考价值。
[Abstract]:Atrial tachycardia (atrial tachycardia) is one of the most common supraventricular tachycardia in children. Frequent or sustained tachycardia attacks may lead to tachycardia cardiomyopathy, severe sudden death. Because of the small diameter of children's blood vessels and the difficulty of radiofrequency ablation, children's atrial tachycardia therapy is the first choice of antiarrhythmic drugs, but at present there is a lack of standardized and uniform guidelines for the treatment of atrial tachycardia drugs. Only a small sample of retrospective child drug therapy studies, the effective rate of treatment is only 54 / 7575. From January 2009 to April 2014, 144 hospitalized patients with atrial velocity were analyzed. The patients were followed up, and ambulatory electrocardiogram was performed every 1 ~ 2 months to evaluate cardiac function. The clinical manifestations, atrial tachycardia, antiarrhythmic effect, serum NT-proBNPs, echocardiography and tissue Doppler were used to evaluate cardiac function. The clinical characteristics of children with atrial tachycardia, the influencing factors of antiarrhythmic drug therapy, the risk factors of cardiomyopathy, and the recognition of early cardiac function damage were studied. The results showed that the age of children with rapid onset was positively skewed to 54.9 years old, the clinical symptoms were atypical, and the type of persistent restless attack was as high as 36.1%. The total effective rate of atrial tachycardia treated with sotalol combined with propafenone was 88. 7%. The immediate success rate of radiofrequency ablation was 91.8 for the patients with poor drug therapy, and most of the patients with radiofrequency recurrence originated from the auricular position. The effect of sotalol on the efficacy of antiarrhythmic drugs in children's atrial tachycardia was statistically significant in the first diagnosis of age, type of attack, course of disease. The incidence of cardiomyopathy in children with atrial tachycardia was 18.1.The incidence of cardiomyopathy in children with persistent restless attack was significantly higher than that in children with short duration attack (46.1%). After arrhythmia control, left ventricular ejection fraction (LVEF) returned to normal at 25 卤25 d. Compared with left ventricular ejection fraction (LVEF), TDI-MPI and E / E 'were significantly correlated with elevated serum NT-proBNP. On the basis of left ventricular ejection fraction (LVEF) combined with septal E / E 'and lateral wall TDI-MPI the diagnosis of NT-proBNPs was abnormal and the sensitivity rate was 91.7%. Therefore, this study suggests that the children's atrial tachycardia onset age is early, the clinical symptoms are atypical, the risk of missed diagnosis is high, the duration of restless seizures is much more than 36.1%, and the therapeutic effect of sotalol combined with propafenone is ideal. 3) the first diagnosis age is young. The short course of disease, short-array attack of children with anti-arrhythmia drug treatment effect is good. The effect of antiarrhythmic drugs on atrial tachycardia was not satisfactory in the elderly and children with persistent restless atrial tachycardia. Recommended radiofrequency catheter ablation (RFA). 4) the incidence of tachycardia cardiomyopathy in children is 18.1.The persistent restless attack is the key risk factor. 5) compared with left ventricular ejection fraction (LVEF). TDI-MPI has a better application prospect in the recognition of early cardiac function damage. For the first time in China, a large sample of children was followed up and comprehensively analyzed for the clinical characteristics, drug therapy and cardiac function damage. The results of the study have a good reference value for the clinical diagnosis and treatment of children's atrial velocity.
【学位授予单位】：清华大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R725.4

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