[SCD-FORUM] 69E RE:心肺呼吸骤停及心脏猝死――Perez Riera医师

[SCD INFO]

69E RE:心肺呼吸骤停及心脏猝死――Perez Riera医师
尊敬的Miguel Angel Sanchez Verduzco医师（来自墨西哥Guadalajara 
Jalisco）。来自巴西圣保罗市的Andrés Ricardo Pérez Riera医师将对您的问题 
作出解答。猝死的定义为自然或非自然原因引起的非预料的突然死亡。虽然国际上 
对于猝死的突发性没有统一的界定，但国际卫生组织规定症状出现后24小时内的死 
亡为猝死。
    心脏猝死的定义为，非预料心源性自然死亡，其前驱症状为先前无致命性疾病 
的患者在症状出现1小时内突发意识丧失（1）。心脏猝死是心脏功能的突然丧失 
（例如，心脏停搏），可发生在既往诊断有或无心脏病者身上。死亡的时间及模式 
都是非预料的，发生在症状出现后即刻或不久。院外心脏猝死是死亡的常见原因。 
尽管医疗手段不断进步，此类患者幸存率仍然很低。最近，德国柏林急救医疗系统 
的Muller等人通过调查问卷的方式获得了许多有关院外心脏猝死病例的信息 
（2）。旁观者调查由急诊内科医师在病人被宣布死亡或复苏成功后即刻完成。在 
5831次急救任务中，406人推测发生心脏停搏，其中66％的患者既往有心脏病， 
72％的停搏发生在家中，67％的发作有目击者。在406位病人中有80％的人其心脏 
停搏前的症状信息是可以获得的。在274例有目击者的停搏患者中，25％的病人有 
典型心绞痛发作，平均持续时间为120分钟；33％的病人症状持续不足1小时。因 
此，作者的结论是：心脏猝死多发生在亲属在场的情况下，且发作前有持续较长时 
间的典型症状作为预兆。尽管，已有的几项调查均证实广泛使用的体外除颤是很受 
欢迎的急救措施，但目前的问题是，是否要对有猝死危险的病人及其亲属优先制定 
有关方面知识的培训措施或目标培训计划。
心脏猝死被看作是（且通常是）心脏原因引起的突发性和/或自发性死亡，可能由 
运动诱发。心脏猝死的机制如下：1）室颤；2）室速和室扑继发室颤；3）尖端扭 
转性室速继发室颤；4）缓慢性心律失常；5）心脏骤停。其主要危险因素为冠心病 
及易于发生心脏猝死的各种器质性或功能性心脏病。心脏猝死（也称作心脏骤停 
SCA或心血管衰竭）是源于心功能突然丧失的死亡。死亡的时间及模式均不可预 
料。猝死在既往未曾患有危及生命的疾病患者，其症状出现后60分钟内发生，这些 
人可有或无心脏病。最常见的引起心脏骤停导致猝死的原因为冠心病。大约一半的 
心脏死亡可归类为心脏猝死。在许多院外发生心脏骤停的病人中，心脏猝死可能是 
心脏病的首次表现。评价心脏猝死危险性的非创伤性检查有动态心电图、心超、运 
动试验、信号平均心电图，但创伤性PES 检查通常是必须的。治疗以药物为基础 
（主要是β受体阻滞剂及胺碘酮），还包括冠状动脉重建术、导管消融技术及植入 
埋藏式心室除颤器（ICD）。后者可能是最有希望的治疗措施（3）。
心律失常性猝死综合征（SADS）每20个心脏猝死病人中约有1个死因不明，即使在 
心脏病理专家对死者心脏作出检查后仍难找出死因。这种情况下发生的死亡就被称 
为心律失常性猝死综合征或 SADS。（过去也被称为成年猝死综合征或猝死综合 
征，但是因为这种情况也累及儿童，所以现在称为心律失常性猝死综合征。）人们 
认为婴儿暴亡症（婴儿猝死综合征或者SIDS）可能也与引起SADS的病因有关。
SADS是心脏电系统功能紊乱，它能导致健康人无预警性死亡。病因是离子通道功能 
障碍。这些离子通道控制着诸如Ca2+, Na+ 和 K+等离子的流动。这些离子在细胞 
的流入和流出引起了心脏的电活动。这些通道的异常可以是先天性的也可以是后天 
性的。后天性的异常可由特定的药物引起或发生在某些病理生理状态下。
参考文献：
1)       Zheng ZJ, Croft JB, Giles WH, et al. Sudden cardiac death in  
the United States, 1989 to 1998. Circulation. 2001; 104: 2158–2163.
2)       Muller D, Agrawal R, Arntz HR. How sudden is sudden cardiac  
death? Circulation. 2006; 114:1146-1150.
3)       Evequoz D, Zuber M, Erne P.Sudden cardiac death: definition,  
mechanisms and risk factors Synonyms and related keyword: sudden  
arrest: Schweiz Rundsch Med Prax. 1996; 85:188-196.
All the best
Andrés Ricardo Pérez Riera
Chief of Electro-Vectocardiology Sector of the Discipline of   
Cardiology, ABC Faculty of Medicine (FMABC), Foundation of ABC  
(FUABC) - Santo André -  Sao Paulo - Brazil. Rua Sebastiao Afonso   
885 - Zip Code: 044417-100- Jardim Miriam   S.P  Brazil
--
Sergio Dubner 博士
科委会主席
Edgardo Schapachnik博士
组委会主席
张欣译 王玲洁校

69E RE: Cardiorespiratory arrest and sudden cardiac death. Dr. Perez Riera
Dear Miguel Angel Sanchez Verduzco from Guadalajara Jalisco Mexico.  
Here Andrés Ricardo Pérez Riera from Sao Paulo Brazil answer.
Sudden death (SD) is defined as a death that occurs suddenly,  
develops during an unpredictable course, and is due to natural or  
unnatural causes. Although there is no universally standardized  
definition on how "sudden" a SD is, WHO defines SD as a death that  
occurs within 24 hours after the onset of symptoms.

Sudden Cardiac Death (SCD) is defined as unexpected natural death due  
to cardiac causes, heralded by abrupt loss of consciousness within  
one hour after the onset of symptoms in a person without any prior  
condition that would appear fatal(1). SCD is the sudden, abrupt loss  
of heart function (ie, cardiac arrest) in a person who may or may not  
have been diagnosed with heart disease. The time and mode of death  
are unexpected. It occurs instantly or shortly after the onset of  
symptoms. Out-of-hospital SCD is a frequent cause of death. Survival  
rates remain low despite increasing efforts in medical care. Recently  
information on cases of out-of-hospital SCD was collected in the  
Berlin, Germany, and emergency medical system via a questionnaire by  
Muller et al.(2) Bystander interviews were performed by the  
emergency physician on scene immediately after declaration of death  
or return of circulation. Of 5831 rescue missions, 406 involved  
patients with presumed cardiac arrest. 66% had a known cardiac  
disease. In 72%, the arrest occurred at home, and in 67%, it occurred  
in the presence of an eyewitness. Information on symptoms immediately  
preceding the arrest was available in 80% of all 406 patients.  
Typical angina was present for a median of 120 minutes in 25% of the  
274 patients with witnessed arrest and in 33% with a symptom duration  
of less than 1 hour. The authors conclude that SCD occurs most often  
at home in the presence of relatives and after a longer period of  
typical warning symptoms. Although the much-hailed use of public  
access external defibrillation is supported by several studies, the  
present results raise the question of whether educational measures  
and targeted educational programs tailored for patients at risk and  
their relatives should have a higher priority.
  SCD is a dramatic and/or spontaneous death that is thought to be  
(and usually is) caused by a heart condition and may have been  
brought on by exercise.
The mechanisms of SCD are the following: 1)       VF; 2)       VT and  
ventricular flutter with subsequent VF; 3)       TdP followed by VF;  
4)       Bradyarrhythmias and 5)       Asystolic arrest.
White the main risk factor is the presence of coronary artery disease
(CAD), any organic or functional disease of the heart can predispose  
for SCD.
SCD (also called sudden cardiac arrest (SCA) or cardiovascular  
collapse,) is death resulting from an abrupt loss of heart function.  
The victim may or may not have diagnosed heart disease. The time and  
mode of death are unexpected. It occurs within 60 minutes after  
symptoms appear in a person with known or unknown cardiac disease in  
whom no previously diagnosed fatal condition is apparent. The most  
common underlying reason for patients to die suddenly from SCA  is CHD.
Approximately half of all cardiac deaths can be classified as SCDs.
SCD occurs as the first expression of cardiac disease in many  
individuals presenting as out-of-hospital patients with SCA.
To evaluate the risk of SCD noninvasive (Holter, echocardiography,  
exercise test, SA-ECG, MTWA, and often invasive PES tests are necessary.
The therapy is based on drugs (mainly beta blockers and amiodarone),  
coronary revascularization, catheter ablation techniques and the  
implantation of a CDI. The latter appears to be the most promising  
approach(3).
Sudden Arrhythmia Death Syndrome (SADS) In about 1 in every 20 cases  
of SCD, no definite cause of death can be found, even after the heart  
has been examined by an expert cardiac pathologist. This is then  
called Sudden Arrhythmic Death Syndrome or SADS. (In the past it has  
also been called Sudden Adult Death Syndrome or Sudden Death Syndrome  
but, because it affects children too, the term Sudden Arrhythmic  
Death Syndrome is now used.) It is thought that cot death (Sudden  
Infant Death Syndrome, or SIDS) may be partly due to the same causes  
responsible for SADS.
SADS is a disorder of the electrical system of the heart that can  
lead to the death of apparently healthy people without any warning.  
The condition is caused by dysfunction ion channels.  These channels  
control the flow of ions like Ca++, Na+ and K+. The flow of these  
ions in and out of the cells produces the electrical activity of the  
heart.  Abnormalities of these channels can be acquired or  
inherited.  The acquired form is caused by certain medications or  
physiopatological conditions.
References

1)       Zheng ZJ, Croft JB, Giles WH, et al. Sudden cardiac death in  
the United States, 1989 to 1998. Circulation. 2001; 104: 2158–2163.
2)       Muller D, Agrawal R, Arntz HR. How sudden is sudden cardiac  
death? Circulation. 2006; 114:1146-1150.
3)       Evequoz D, Zuber M, Erne P.Sudden cardiac death: definition,  
mechanisms and risk factors Synonyms and related keyword: sudden  
arrest: Schweiz Rundsch Med Prax. 1996; 85:188-196.
All the best
Andrés Ricardo Pérez Riera
Chief of Electro-Vectocardiology Sector of the Discipline of   
Cardiology, ABC Faculty of Medicine (FMABC), Foundation of ABC  
(FUABC) - Santo André -  Sao Paulo - Brazil. Rua Sebastiao Afonso   
885 - Zip Code: 044417-100- Jardim Miriam   S.P  Brazil


--
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee

篮色斜体不用翻译

 > I can't see hardly any complication, not even semantic, in what we  
 > consider cardiac arrest or better, cardiorespiratory arrest,  
 > whichever the cause. We may simply consider that any patient that  
 > requires cardiorespiratory reanimation is because he/she has: lack  
 > of effective cardiac output.
 >
 > Dr. Miguel Angel Sanchez Verduzco
 > medicina intensiva. Guadalajara jalisco México
 >>
 >> From a certain point of view, cardiac arrest is the time of death,  
 >> although we all know there is a margin between brain death,  
 >> legally considered in many countries as "death" proper, and  
 >> cardiac arrest or else, tachyarrythmias that condition low output.  
 >> It would be necessary to differentiate also VT/VF from electrical  
 >> activity with no pulse, or asystole as cause of death. We know  
 >> that on many occasions, they are a continuum that we attempt to  
 >> stop with different interventions that are variably successful  
 >> according to the opportunity and efficacy.
 >> From my personal point of view, the difference may be more  
 >> semantic than practical, due to the great amount of variables to  
 >> take into account: do we consider cardiac arrest as the  
 >> disappearance of pulse? However, many times there is VT or VF, why  
 >> can we start CPR even when there are still slow pulses (escape  
 >> rhythms or AV blocks in ECG)? Again we are involved in a  
 >> discussion of terms very hard to define because of the number of  
 >> pathophysiological concepts and mostly, due to the "dynamics" of  
 >> events and their sequences. What do experts think?
 >>
 >> Enrique Asensio L.
 >> México
 >>
 >>
 >>>
 >>> Dear colleagues,
 >>> I am writing to this list because I would to have some concepts  
 >>> clarified to me regarding the subject of discussion.
 >>> I have looked through several articles, books and journals, and  
 >>> they are not clear in this sense. For instance: the Spanish  
 >>> guidelines for CPR mention that there is a very narrow and  
 >>> arbitrary limit between the concepts of cardiorespiratory arrest  
 >>> and sudden cardiac death, leaving one for statistic limits, and  
 >>> the cardiorespiratory arrest as a clinical approach of the problem.
 >>> My question for the experts:
 >>> Is there some way of defining both concepts, or do they overlap  
 >>> in such a way that they can be used without distinction in  
 >>> related studies and papers?
 >>> Other authors point out “reanimation from sudden cardiac death”.
 >>> Could it be reanimation from a cardiac arrest? Is it not death  
 >>> precisely that, “death”?
 >>>
 >>> I hope you can clarify this dilemma for me, and thanking you in  
 >>> advance,
 >>>
 >>> Dr. Oscar Ruiz Ropero
 >>> Intensivista
 >>> Hospital General Docente. Guantanamo. Cuba.