心动过速通常指心率不低于100次/min,它可以是一种正常的生理反应,也可以是潜在疾病的表现。[1]Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016 Apr 5;67(13):e27-115.
https://www.sciencedirect.com/science/article/pii/S0735109715058404?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/26409259?tool=bestpractice.com
[2]Katritsis DG, Boriani G, Cosio FG, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace. 2017 Mar 1;19(3):465-511.
https://academic.oup.com/europace/article/19/3/465/2631183
http://www.ncbi.nlm.nih.gov/pubmed/27856540?tool=bestpractice.com
正常情况下,心率随年龄增长而变化。 婴儿正常窦房结频率每分钟处于110次至150次之间,并随年龄增长而逐渐变慢。[3]Bjerregaard P. Mean 24 hour heart rate, minimal heart rate and pauses in healthy subjects 40-79 years of age. Eur Heart J. 1983 Jan;4(1):44-51.
http://www.ncbi.nlm.nih.gov/pubmed/6339245?tool=bestpractice.com
快速性心律失常分类
目前一些快速性心律失常的分类方法有助于心动过速的管理和评估。 这些分类包括:窦性和非窦性;房性和室性心律失常;窄和宽QRS复合波心动过速;规律和不规律的心律失常;以及根据心律失常的起源点分类。[1]Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016 Apr 5;67(13):e27-115.
https://www.sciencedirect.com/science/article/pii/S0735109715058404?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/26409259?tool=bestpractice.com
窦性与非窦性原因
房性与室性心律失常
窄与宽QRS波群
规则与不规则心律
起源点:
按照起源部位不同,快速性心律失常可分为房性、交界区性和室性心律失常。
心房波是心房初始去极化的标志。 来源于房内单一起源点的如窦性心动过速或房性心动过速;围绕解剖学障壁的巨大折返如典型房扑;或源于多发折返波如房颤。
起源于房室交界区(房室结和/或希氏束近端)的心律失常以心室除极和逆行性心房活动(如存在)为特点,如房室结折返性心动过速或交界区异位心动过速,表现为逆行P波。
起自心室的心律失常可来源于希氏-浦肯野系统远端或心肌。 心室内起源点可进一步确定某些心律失常。 示例如右室流出道室性心动过速和束支折返性室性心动过速。 在鉴别房性和室性心律失常方面,血流动力学稳定性并不可靠。 某些室性心动过速病例开始时血流动力学稳定,耐受良好。 误诊和处理不当(如应用钙通道阻滞剂)可带来灾难性后果。
当评估一例宽QRS波心动过速的患者而不能确定诊断时,重要的是先按照室性心动过速处理,直到诊断明确为其他心律失常为止。
流行病学
窦性心动过速是心动过速最常见的类型,通常是对心理或躯体刺激的正常生理反应。
房颤是临床实践中最常见的心律失常,一般人群中估测的患病率是0.4%到1%,并随年龄增长而升高。[4]Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001 May 9;285(18):2370-5.
http://jama.ama-assn.org/cgi/reprint/285/18/2370
http://www.ncbi.nlm.nih.gov/pubmed/11343485?tool=bestpractice.com
年龄在80岁以上的患者心房颤动的患病率高达9%。[4]Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001 May 9;285(18):2370-5.
http://jama.ama-assn.org/cgi/reprint/285/18/2370
http://www.ncbi.nlm.nih.gov/pubmed/11343485?tool=bestpractice.com
随着人口老龄化趋势,房颤患病数量将明显增加。
房扑的发病率是88/100 000人年。 男性较多见,并常见于心力衰竭或COPD患者。 房扑也随年龄增长而上升。[5]Granada J, Uribe W, Chyou P, et al. Incidence and predictors of atrial flutter in the general population. J Am Coll Cardiol. 2000 Dec;36(7):2242-6.
http://www.ncbi.nlm.nih.gov/pubmed/11127467?tool=bestpractice.com
据估测,其患病率高出阵发性室上性心动过速(PSVT)2.5倍。
PSVT是间歇性室上性心动过速(房室结折返性心动过速,房室折返性心动过速,或房性心动过速),发病率为36例/100 000人年,患病率是2.29例/1000人。[6]Orejarena L, Vidaillet HJ, DeStefano F, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Cardiol. 1998 Jan;31(1):150-7.
http://www.ncbi.nlm.nih.gov/pubmed/9426034?tool=bestpractice.com
女性的 PSVT 患病率为女性的两倍,而 65 岁以上人群的发病率为更年轻人群的 5 倍。绝大多数室上速患者属于房室结折返性心动过速(占 60%),其余为房室折返性心动过速(30%)和房性心动过速(10%)。[7]Trohman RG. Supraventricular tachycardia: implications for the intensivist. Crit Care Med. 2000 Oct;28(10 Suppl):N129-35.
http://www.ncbi.nlm.nih.gov/pubmed/11055681?tool=bestpractice.com
不适当窦性心动过速的患病率并不十分清楚,其基本发病机制很可能是多因素参与,但患者通常年龄偏轻(15~50岁),女性常见,医务人员多发。[1]Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016 Apr 5;67(13):e27-115.
https://www.sciencedirect.com/science/article/pii/S0735109715058404?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/26409259?tool=bestpractice.com
[2]Katritsis DG, Boriani G, Cosio FG, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace. 2017 Mar 1;19(3):465-511.
https://academic.oup.com/europace/article/19/3/465/2631183
http://www.ncbi.nlm.nih.gov/pubmed/27856540?tool=bestpractice.com
[8]Brady PA, Low PA, Shen WK. Inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome, and overlapping syndromes. Pacing Clin Electrophysiol. 2005 Oct;28(10):1112-21.
http://www.ncbi.nlm.nih.gov/pubmed/16221272?tool=bestpractice.com
室性心动过速的患病率高度依赖其类型和间期。 既往有心肌梗死史的患者中,持续性单形性室速的发病率取决于梗死面积和整体左室功能。