не применительно к данному пациенту, просто, в поддержание разговора на тему ЭКС и бета-блокаторы. В исследовании DAPHNE изучали пациентов с фибрилляцией предсердий и с установленным двухкамерным водителем ритма по поводу синдрома слабости синусового узла на фоне терапии бета-блокаторами по сравнению с соталолом
Цитата:
The Drug And Pace Health cliNical Evaluation (DAPHNEstudy: A randomized trial comparing sotalol versus β-blockers to treat symptomatic atrial fibrillation in patients with brady-tachycardia syndrome implanted with an antitachycardia pacemaker
Background Atrial tachyarrhythmias (ATAs) are mainly treated by pharmacologic therapy for rate control or rhythm control. The aim of our study was to compare sotalol (S) versus β-blocking agents (BB) in terms of prevention of ATA, cardioversions (CVs), and cardiovascular hospitalizations (H) in patients paced for bradycardia-tachycardia form of sinus node disease (BT-SND).
Methods One hundred thirty-five patients (67 males, aged 73 ± 7 years) were enrolled in a prospective, parallel, randomized, single-blind, multicenter study. All patients received a dual chamber rate adaptive pacemaker; after 1 month, 66 patients were randomly assigned to BB (62 ± 26 and 104 ± 47 mg/d for atenolol and metoprolol, respectively) and 69 patients to S (167 ± 66 mg/d).
Results After an observation period of 12 months, the percentage of patients free from ATA recurrences was 29% in both BB and S group. Cardioversion and H were significantly (P b .01) fewer in the 12 months after implantation than in the 12 months before both in patients treated with S (CV 69.4% vs 22.2%, H 91.7% vs 33.3%) and in patients treated with BB (CV 58.5% vs 17.1%, H 82.9% vs 26.8%). Kaplan-Meier survival analysis showed a nonsignificant trend toward a lower incidence of the composite end point (CV + H) among BB patients.
Conclusions In the complex context of “hybrid therapy” in patients with BT-SND implanted with a modern dual chamber rate adaptive pacemaker device delivering atrial antitachycardia pacing, no differences were found between the use of β-blocker and the use of S, at the relatively low dose achieved after clinical titration, in terms of prevention of cardiovascular H or need for atrial CV. (Am Heart J 2008;156:373.e1-373.e8.)
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Еще есть симпатичная статья Beta-blocker induced bradycardia—should we pace? на тему необходима ли установка кардиостимулятора пациентам с сердечной недостаточностью при невозможности назначения бета-блокаторов или их титрации до полной дозы
Цитата:
The European Journal of Heart Failure 6 (2004) 449–451
- Patients who tolerate a minimal beta-blocker dose should be up-titrated guided by the individual patient’s tolerability and heart rate response. These patients should not be paced to achieve a higher beta-blocker dose.
– In patients not tolerating a minimal beta-blocker dose due to sinus node dysfunction, atrial pacing (i.e. AAI) might be considered in individual patients to initiate a beta-blocker therapy.
– Although development of significant AV block with the use of a beta-blocker suggests that there is disease of the conduction system, in patients not tolerating a minimal beta-blocker dose due to AV-block, right ventricular pacing should be avoided. Currently, no data are available supporting biventricular pacing or HISpacing to enable a beta-blocker therapy in this population.
– In patients not tolerating beta-blockers who have left bundle branch block (>130 ms) and severe heart failure, biventricular pacing should be considered.
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В настоящее время проходит рандомизированное исследование PACE-MI trial (см. статьи в приложении), оценивающее, имеет ли терапия бета-блокаторами при имплантации кардиостимулятора преимущества над отсутствием бета-блокаторов и кардиостимулятора у пациентов после инфаркта миокарда с противопоказанием к бета-блокаторам или симптоматической брадикардией на фоне приема бета-блокаторов.
25.07.2011, 20:55
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