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（钱安斌 胡申江）
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内科学新进展 第三节 心脏性猝死与心电信息改变
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摘 要 心脏性猝死是影响全球公众健康的重大问题。心脏性猝死发病复杂，常发生于以往有基础心脏疾病患者，但也见于无器质性心脏疾病患者。猝死患者最常见的基础疾病是冠状动脉粥样硬化性心脏病。发生心脏骤停患者最有效的抢救措施是及时呼叫急救系统，早期心肺复苏，早期除颤和早期高级生命支持。然而院外复苏的成功率不高，美国低于30％，我国低于10％。尽管随着诊断和治疗技术的迅速发展，对心脏性猝死高危因素进行检测和分级，并在其指导下选择有效的预防性措施，可减少恶性心律失常事件或心脏性猝死的发生。一些无创技术如心电生理检查对恶性室性心律失常和心脏性猝死的预测有较肯定的价值。而把这些无创性检查技术结合使用，则有更高的临床价值。
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Abstract Sudden cardiac death is a major globle public health problem. SCD is a heterogeneous condition and may be caused in patients with structural abnormalities of the heart usually as coronary artery disease. Less commonly, SCD happens in patients who may not have apparent structural heart disease. People are more likely to survive cardiac arrest when activation of the Emergency Medical Service（EMS）system, basic cardiopulmonary resuscitation（CPR), defibrillation and advanced care occur as rapidly as possible. But survival after out-of-hospital cardiac arrest remains poor, as less than 30% in America and 10% in our country. However, major developments in risk stratification and therapy have now made it possible to identify many of those at risk and to provide effective prophylactic treatment and reduce the incidence of fatal ventricular tachyarrhythmias or SCD. Several ninvasive risk stratification techniques has been proven to identify fatal ventricular tachyarrhythmias or SCD from total mortality, and it is important to combine and use these techniques in clinical practice.
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一、心脏性猝死
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心脏骤停（cardiac arrest）系指心脏泵血功能的突然停止。虽偶有自发恢复，通常会导致死亡。心脏性猝死（sudden cardiac death, SCD）系指由于心脏原因所致的无法预测的自然死亡。可发生于原有或无已知心脏病的病人中。在急性症状出现后1h内（亦有规定为24h，但以1h最为常见）发生心脏骤停，导致脑血流的突然中断，出现意识丧失，病人如经及时救治可获存活，否则将发生所有生物学功能的不可逆性停止。
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（一）病 因
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心脏性猝死者常有基础的心脏结构异常，包括以下几个方面：
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（1）冠状动脉异常 在西方国家，心脏性猝死中至少80％由冠心病及其并发症所致。25％冠心病者以心脏性猝死为首发临床表现。
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（2）心肌疾病 如肥厚性心肌病、扩张性心肌病、左心室肥厚、心肌炎、高血压、致心律失常性右心室发育不良、心脏瓣膜病、先天性心脏病等。
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（3）心电异常 如长QT综合征、Brugada综合征、心室预激综合征、特发性室性心动过速／心室颤动、电解质紊乱、药物尤其抗心律失常药物的致心律失常作用等。
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（4）其他病变 如主动脉夹层分离、急性肺动脉栓塞、急性心脏压塞等。
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心脏性猝死常由以下因素诱发：心肌缺血、冠状动脉痉挛、血小板聚集、心电不稳定、自主神经系统不稳定、过度劳累、情绪压抑、电解质紊乱及某些抗心律失常药物使用等。
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（二）病 理
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病理解剖发现，81％心脏性猝死的病因是冠心病。常见的病理改变为广泛的多支冠状动脉粥样硬化。急性冠状动脉内血栓形成，作为心脏性猝死的促发因素，在单支血管病、尸解发现的急性心肌梗死和有前驱症状的猝死病者中起作用。偶尔，冠状动脉痉挛引起急性缺血，也可导致心脏性猝死。
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病理研究还表明：左室肥厚本身易发生心脏骤停，如以往有心肌梗死史则发生心脏骤停的危险性更大；细胞凋亡也参与了SCD者心律失常或传导系统异常的发生和病理改变。
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