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Ïîäðîáíî. ×àñòü 9.
Ëå÷åíèå. Îêîí÷àíèå. 6. Àíòèàðèòìèêè äðóãèõ ãðóïï – ïîìíèòü ïðî íå íàâðåäè! Ñàìûõ ïðîàðèòìîãåííûõ (ñîòàëîë, äðîíåäàðîí) ëó÷øå âñÿ÷åñêè èçáåãàòü! Ïîìíèòü î ãëîáàëüíîé öåëè ëå÷åíèÿ (ïðîäëåíèå êà÷åñòâåííîé æèçíè), ò.å. áåçîïàñíîñòü âî ãëàâå óãëà. Ïðåçóìïöèÿ âèíîâíîñòè: íåèçó÷åííûé àíòèàðèòìèê ñ÷èòàòü ïîòåíöèàëüíî îïàñíûì ïîêà íå äîêàçàíû åãî áåçîïàñíîñòü è ýôôåêòèâíîñòü. Ïðèìåíåíèå àíòèàðèòìè÷åñêèõ ïðåïàðàòîâ (íàïðèìåð, ôëåêàèíèäà è äðóãèõ àíòèàðèòìè÷åñêèõ ïðåïàðàòîâ êëàññà IÑ) ïðè ÆÝ íå ðåêîìåíäîâàíî, ò.ê. ìíîãèå èç íèõ ñâÿçàíû ñ ïîâûøåííîé ñìåðòíîñòüþ èç-çà ïðîàðèòìèè ïðè íàçíà÷åíèè ïàöèåíòàì ñ ïðåäøåñòâóþùèì ÈÌ [Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991; 324:781; Siebels J, Cappato R, Rüppel R, Schneider MA, Kuck KH. Preliminary results {there was a significantly higher total mortality and cardiac arrest recurrence in patients randomized to propafenone} of the Cardiac Arrest Study Hamburg (CASH). CASH Investigators. Am J Cardiol. 1993 Nov 26;72(16):109F-113F. doi: 10.1016/0002-9149(93)90973-g. PMID: 8237823; Waldo AL, Camm AJ, deRuyter H, et al. Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol. Lancet 1996; 348:7]. Ïðîàðèòìèÿ ïðè ïðèìåíåíèè ýòèõ ïðåïàðàòîâ ïðàêòè÷åñêè íå âûçûâàåò áåñïîêîéñòâà ó ïàöèåíòîâ áåç îñíîâíîãî çàáîëåâàíèÿ ñåðäöà [Podrid PJ, Lampert S, Graboys TB, et al. Aggravation of arrhythmia by antiarrhythmic drugs--incidence and predictors. Am J Cardiol 1987; 59:38E]. a. Ïàöèåíòû áåç ÿâíûõ ñòðóêòóðíûõ çàáîëåâàíèé ñåðäöà (òðåáóåòñÿ îäíîçíà÷íîå èñêëþ÷åíèå ÈÁÑ ìåòîäîì ñòðåññ-ÝõîÊÃ)*:7. Ð×À – äàííûõ äëÿ ïîíèìàíèÿ ïðîãíîñòè÷åñêîé ïîëüçû íåäîñòàòî÷íî. a. Ð×À ïðè ÍÆÝ ïðè äîêàçàííîé ïðîâîöèðóåìîñòè ÔÏ. b. Ð×À ïðè ÆÝ. Åñëè áåòà-áëîêàòîðû è / èëè íåäèãèäðîïèðèäèíîâûå áëîêàòîðû êàëüöèåâûõ êàíàëîâ íåýôôåêòèâíû èëè íåæåëàòåëüíû, à òàêæå äëÿ ïàöèåíòîâ, ó êîòîðûõ ñîõðàíÿþòñÿ ñèìïòîìû, ñâÿçàííûå ñ ÆÝ, íåñìîòðÿ íà àíòèàðèòìè÷åñêóþ ëåêàðñòâåííóþ òåðàïèþ, èëè êîòîðûå ïðåäïî÷èòàþò íå ïðèíèìàòü àíòèàðèòìè÷åñêóþ ëåêàðñòâåííóþ òåðàïèþ, êàòåòåðíàÿ àáëÿöèÿ ÿâëÿåòñÿ ýôôåêòèâíûì âàðèàíòîì äëÿ óìåíüøåíèÿ èëè óñòðàíåíèÿ ÆÝ [Marcus GM. Evaluation and Management of Premature Ventricular Complexes. Circulation 2020; 141:1404; Hasdemir C, Ulucan C, Yavuzgil O, et al. Tachycardia-induced cardiomyopathy in patients with idiopathic ventricular arrhythmias: the incidence, clinical and electrophysiologic characteristics, and the predictors. J Cardiovasc Electrophysiol 2011; 22:663; Baman TS, Lange DC, Ilg KJ, et al. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm 2010; 7:865; Takemoto M, Yoshimura H, Ohba Y, et al. Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract improves left ventricular dilation and clinical status in patients without structural heart disease. J Am Coll Cardiol 2005; 45:1259; Zhong L, Lee YH, Huang XM, et al. Relative efficacy of catheter ablation vs antiarrhythmic drugs in treating premature ventricular contractions: a single-center retrospective study. Heart Rhythm 2014; 11:187; Wijnmaalen AP, Delgado V, Schalij MJ, et al. Beneficial effects of catheter ablation on left ventricular and right ventricular function in patients with frequent premature ventricular contractions and preserved ejection fraction. Heart 2010; 96:1275; Yarlagadda RK, Iwai S, Stein KM, et al. Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract. Circulation 2005; 112:1092; Yokokawa M, Good E, Crawford T, et al. Recovery from left ventricular dysfunction after ablation of frequent premature ventricular complexes. Heart Rhythm 2013; 10:172]. Ïàöèåíòàì ñ ïîäîçðåíèåì íà ÆÝ-èíäóöèðîâàííóþ êàðäèîìèîïàòèþ è ñíèæåííûì ÔÂËÆ (< 50%) ñëåäóåò ïðåäëîæèòü êàòåòåðíóþ àáëÿöèþ, äàæå äëÿ ïàöèåíòîâ ñ èìïëàíòèðîâàííûì êàðäèîâåðòåðîì-äåôèáðèëëÿòîðîì, ñ öåëüþ óëó÷øåíèÿ è, âîçìîæíî, íîðìàëèçàöèè ôóíêöèè ËÆ. Ðåøåíèå ðåêîìåíäîâàòü àíòèàðèòìè÷åñêèå ïðåïàðàòû èëè ðàäèî÷àñòîòíóþ êàòåòåðíóþ àáëÿöèþ êîíêðåòíîìó ïàöèåíòó áóäåò çàâèñåòü îò ìíîãèõ êëèíè÷åñêèõ ôàêòîðîâ, à òàêæå ïðåäïî÷òåíèé ïàöèåíòà. Êëèíè÷åñêèå ïåðåìåííûå, êîòîðûå èäåíòèôèöèðóþò ïàöèåíòà, êîòîðûé, ñêîðåå âñåãî, ïîëîæèòåëüíî îòâåòèò íà êàòåòåðíóþ àáëÿöèþ, âêëþ÷àþò [Lip GYH, Coca A, Kahan T, et al. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2017; 19:891.]: i. Ìîíîôîêóñíûå ÆÝ.Õîòÿ ìîíîôîêóñíûå ÆÝ ñ ìîðôîëîãèåé áëîêàäû ïðàâîé íîæêè ïó÷êà Ãèñà òàêæå ïîääàþòñÿ êàòåòåðíîé àáëÿöèè, äëÿ ýòîãî îáû÷íî òðåáóåòñÿ àáëÿöèÿ ËÆ è/èëè êîðíÿ àîðòû, ÷òî ÿâëÿåòñÿ íåñêîëüêî áîëåå ñëîæíîé ïðîöåäóðîé êàòåòåðíîé àáëÿöèè, ïîñêîëüêó íåîáõîäèì òðàíñåïòàëüíûé èëè ðåòðîãðàäíûé äîñòóï ê àîðòå.  ìåòà-àíàëèçå íåáîëüøèõ íåðàíäîìèçèðîâàííûõ èññëåäîâàíèé 2014 ãîäà ðàäèî÷àñòîòíîé àáëÿöèè äëÿ ëå÷åíèÿ èäèîïàòè÷åñêèõ ÆÝ, ïðîèñõîäÿùèõ èç âûâîäíîãî òðàêòà ïðàâîãî æåëóäî÷êà, êàòåòåðíàÿ àáëÿöèÿ áûëà ñâÿçàíà ñî çíà÷èòåëüíûì ñíèæåíèåì äîëè ÆÝ (ñðåäíåå ñíèæåíèå ïîñëå àáëÿöèè íà 97%) íàðÿäó ñî çíà÷èòåëüíûì óëó÷øåíèåì ÔÂËÆ (ñðåäíåå óâåëè÷åíèå íà 10%), õîòÿ ìåòà-àíàëèç áûë îãðàíè÷åí çíà÷èòåëüíîé íåîäíîðîäíîñòüþ ñðåäè èññëåäîâàíèé [Lamba J, Redfearn DP, Michael KA, et al. Radiofrequency catheter ablation for the treatment of idiopathic premature ventricular contractions originating from the right ventricular outflow tract: a systematic review and meta-analysis. Pacing Clin Electrophysiol 2014; 37:73]. Ïðè öèòèðîâàíèè ïðîñüáà ññûëàòüñÿ íà àâòîðà. Êîðçóí À.È., Ýêñòðàñèñòîëû, ïðîãíîç è ëå÷åíèå. ÿíâàðü 2023 Àâòîð ïðèçíàòåëåí äðóãó è ïñèõîòåðàïåâòó Ñåêàöêîìó Êèðèëëó Èâàíîâè÷ó çà ïîìîùü â ðàçäåëå "ñíèæåíèå ñåíñèòèâíîñòè".
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |