今日の臨床サポート

緊急ペーシング

著者: 中井俊子 日本大学板橋病院循環器内科

監修: 今井靖 自治医科大学 薬理学講座臨床薬理学部門・内科学講座循環器内科学部門

著者校正/監修レビュー済:2021/08/11
患者向け説明資料

概要・推奨   

薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
中井俊子 : 講演料(日本メドトロニック,アボットメディカル,バイオトロニックジャパン),企業などが提供する寄付講座(バイオトロニックジャパン,アボットメディカル,日本メドトロニック,日本ライフライン,ボストンサイエンティフィック)[2021年]
監修:今井靖 : 講演料(第一三共株式会社)[2021年]

改訂のポイント:
  1. 定期レビューを行った。

まとめ・診察

手技のまとめ  
  1. 高度な徐脈、心拍停止により意識消失を来す状態において、血行動態改善のために緊急にペーシングを行う必要がある。
  1. 房室ブロック、洞不全症候群になる原因としては、心筋梗塞、心サルコイドーシスなどの心筋疾患によるもの、あるいは電解質異常など、さまざまである。
  1. 緊急ペーシングを必要とする場合に、時間的に余裕がない場合には経皮的ペーシングが有効であるが、これは痛みを伴うため、鎮痛が必要である。
  1. 継続してペーシング治療が必要な場合には、経皮ペーシングを行いつつ、経静脈的一時ペーシングの挿入の準備をする。
  1. 硫酸アトロピンやβ刺激薬の投与により心拍増加が見込める場合、あるいは、徐脈であっても血行動態が保たれている場合には、経静脈的一時ペーシングの挿入を行う。
 
  1. 典型的症例:発作性房室ブロック症例(76歳、男性)
  1. 病歴:散歩に出かけようと歩き出したところ、眼前暗黒感を感じ、その後失神し救急搬送された。
  1. 診察:来院時には意識は回復しており、バイタルも安定していた。脈拍80/分、整。
  1. 診断テストとその結果:精査のため入院。心拍モニターを装着し観察していたところ、経過中に眼前暗黒感の症状に一致して発作性の房室ブロックを認め、診断がついた。
  1. 治療:緊急一時ペーシングを施行、後日、永久ペースメーカ植込み術を施行した。
  1. 転帰:軽快し退院。
  1. コメント:発作性不整脈の診断には、発作時の心電図が重要である。
  1. 心拍モニターのトレース。2段目の2拍目から、P波のみとなりQRSが脱落している。
 
心拍モニターのトレース

2段目の2拍目から、P波のみとなりQRSが脱落している。

出典

img1:  著者提供
 
 
 
問診・診察のポイント  
  1. まずは、バイタルサインのチェックを優先し、緊急性を確認する。

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文献 

著者: Uffe Jakob Ortved Gang, Christian Jøns, Rikke Mørch Jørgensen, Steen Zabell Abildstrøm, Marc D Messier, Jens Haarbo, Heikki V Huikuri, Poul Erik Bloch Thomsen
雑誌名: Am Heart J. 2011 Sep;162(3):542-7. doi: 10.1016/j.ahj.2011.06.021. Epub 2011 Aug 11.
Abstract/Text BACKGROUND: High-degree atrioventricular block (HAVB) is a frequent complication in the acute stages of a myocardial infarction associated with an increased rate of mortality. However, the incidence and clinical significance of HAVB in late convalescent phases of an AMI is largely unknown. The aim of this study was to assess the incidence and prognostic value of late HAVB documented by continuous electrocardiogram (ECG) monitoring in post-AMI patients with reduced left ventricular function.
METHODS: The study included 286 patients from the CARISMA study with AMI and left ventricular ejection fraction of 40% or less. An insertable loop recorder was implanted 5 to 21 days after AMI for incessant arrhythmia surveillance. Furthermore, ECG documentation was supplemented by a 24-hour Holter monitoring conducted at week 6 post-AMI. The clinical significance of HAVB occurring more than 21 days after AMI was examined with respect to development of major heart failure events and major ventricular tachyarrhythmic events.
RESULTS: During a median follow-up of 1.9 years (interquartile range 0.9-2.0), late HAVB was documented in 30 patients. The risk of major heart failure events (hazard ratio [HR] 4.08 [1.38-12.09], P = .01) and major ventricular tachyarrhythmic events (HR = 5.41 [1.88-15.58], P = .002) were significantly increased in patients who developed late HAVB.
CONCLUSION: High-degree atrioventricular block documented by continuous ECG monitoring occurring more than 3 weeks after AMI is a frequent complication in post-AMI patients with left ventricular dysfunction. Furthermore, HAVB is associated with ominous prognostic implications of both potentially lethal arrhythmias and heart failure.

Copyright © 2011 Mosby, Inc. All rights reserved.
PMID 21884874  Am Heart J. 2011 Sep;162(3):542-7. doi: 10.1016/j.ahj.2・・・
著者: B J Scherlag, G Kabell, L Harrison, R Lazzara
雑誌名: Circulation. 1982 Jun;65(7):1429-34. doi: 10.1161/01.cir.65.7.1429.
Abstract/Text Experimental and clinical cases have been described in which bradycardia, i.e., heart rates below 60 beats/min or slowing of the heart rate, resulted in lethal ventricular arrhythmias during various stages of myocardial ischemia and infarction. The present study was designed to determine the relationship of lethal ventricular arrhythmias and slow heart rates. In 18 dogs anesthetized with sodium pentobarbital, the left anterior descending (LAD) coronary artery was ligated. Standard ECGs, His bundle electrograms and composite electrograms from intramural and epicardial areas in ischemic and normal zones were recorded during the first 3 hours of ischemia. Vagosympathetic trunk stimulation caused varying degrees of slowing and bradycardia. Of the 18 dogs, slowing of the heart rate or marked bradycardia induced ventricular ectopic beats coupled to the sinus beats in two, sustained ventricular tachycardia in two, and ventricular fibrillation in two. In another group of six dogs studied 17-25 days after LAD ligation, one dog showed sustained ventricular tachycardia in response to vagal-induced bradycardia. In all acute or chronic cases of arrhythmias after LAD ligation, continuous electrical activity was recorded on one or more of the electrograms within or overlying the ischemic or infarcted zones. This bridging electrical activation, which is indicative of slow conduction, provided strong presumptive evidence for reentry as the mechanism of lethal or potentially lethal ventricular arrhythmias triggered by bradycardia in the setting of myocardial infarction.

PMID 7074798  Circulation. 1982 Jun;65(7):1429-34. doi: 10.1161/01.ci・・・
著者: A Fitzpatrick, R Sutton
雑誌名: BMJ. 1992 Feb 8;304(6823):365-9. doi: 10.1136/bmj.304.6823.365.
Abstract/Text
PMID 1540737  BMJ. 1992 Feb 8;304(6823):365-9. doi: 10.1136/bmj.304.6・・・
著者: K Rajappan, K F Fox
雑誌名: QJM. 2003 Nov;96(11):783-5. doi: 10.1093/qjmed/hcg135.
Abstract/Text
PMID 14566033  QJM. 2003 Nov;96(11):783-5. doi: 10.1093/qjmed/hcg135.
著者: J I Sznajder, F R Zveibil, H Bitterman, P Weiner, S Bursztein
雑誌名: Arch Intern Med. 1986 Feb;146(2):259-61.
Abstract/Text We prospectively studied the results of 714 attempts at central venous catheterization during an eight-month period in our intensive care department. We compared the rates of failure of catheterization and early complications among three percutaneous approaches: subclavian, anterior jugular, and posterior jugular veins. The procedures were performed by experienced staff or resident physicians and inexperienced interns and residents under teaching supervision. Overall rates of failure and complication were similar for each percutaneous approach within each group of physicians. Overall failure rate was 10.1% for the experienced group and 19.4% for the inexperienced. The complication was 5.4% for experienced and 11% for inexperienced. Among inexperienced physicians, the success rate was 86.7% and the complication rate 7.6% in unconscious patients, whereas in conscious patients these rates were 70.5% and 13.8%, respectively. The inexperienced physicians caused fewer complications in mechanically ventilated than in spontaneously breathing patients. We suggest that inexperienced physicians should first attempt central vein catheterizations in unconscious and mechanically ventilated patients.

PMID 3947185  Arch Intern Med. 1986 Feb;146(2):259-61.
著者: J J Murphy
雑誌名: BMJ. 1996 May 4;312(7039):1134. doi: 10.1136/bmj.312.7039.1134.
Abstract/Text
PMID 8620131  BMJ. 1996 May 4;312(7039):1134. doi: 10.1136/bmj.312.70・・・
著者: S Toyonaga, T Nakatsu, T Murakami, S Kusachi, K Mashima, Y Tominaga, S Yamane, T Uesugi, H Kanai, T Tsuji
雑誌名: J Cardiovasc Pharmacol Ther. 2000 Jul;5(3):183-91.
Abstract/Text BACKGROUND: Heart-rate (HR) variability is an important predictor of mortality in patients with heart disease. We examined the effects of cilostazol, a quinolinone derivative, on HR and HR variability in patients with chronic atrial fibrillation associated with bradycardia episodes.
PATIENTS AND METHODS: Thirteen patients with chronic atrial fibrillation associated with bradycardia episodes (minimal HR <40/min and/or pauses, ie, episodes with an RR interval > 2.5 sec) received cilostazol (100 or 200 mg/day) orally for at least 2 months and 24-hour Holter electrocardiography was performed before and after the start of cilostazol administration.
RESULTS: Minimal HR was significantly increased, by an average of 14 beats/min (bpm), at 3.3 +/- 0.8 weeks (mean +/- SD) after the start of cilostazol treatment. The number of pauses was significantly decreased. As a consequence, mean HR was increased by an average of 18 bpm. Maximal HR was also increased by an average of 19 bpm. The circadian variation of the HR, determined by cosine fitting, was not changed by cilostazol treatment. The time-domain HR variabilities, ie, the SD of the mean RR interval and the SD of the 5-minute mean RR intervals, were also unchanged. New York Heart Association functional class was significantly improved and the plasma atrial natriuretic polypeptide level was significantly decreased after the initiation of cilostazol treatment.
CONCLUSION: Cilostazol improves the slow HR episodes associated with chronic atrial fibrillation and maintains the HR circadian variation and time-domain variability, indicating that cilostazol has therapeutic utility for the treatment of the slow HR associated with chronic atrial fibrillation.

PMID 11150407  J Cardiovasc Pharmacol Ther. 2000 Jul;5(3):183-91.
著者: Anne B Curtis, Seth J Worley, Eugene S Chung, Pei Li, Shelly A Christman, Martin St John Sutton
雑誌名: J Am Coll Cardiol. 2016 May 10;67(18):2148-2157. doi: 10.1016/j.jacc.2016.02.051.
Abstract/Text BACKGROUND: Sustained right ventricular (RV) apical pacing may lead to deterioration in ventricular function and an increased risk of heart failure, especially in patients with pre-existing systolic dysfunction. The BLOCK HF (Biventricular Versus Right Ventricular Pacing in Heart Failure Patients With Atrioventricular Block) trial demonstrated that biventricular-paced patients had a reduced incidence of a composite endpoint of death, heart failure-related urgent care, and adverse left ventricular remodeling.
OBJECTIVES: In a pre-specified analysis, this study examined clinical outcomes, including clinical composite score, quality of life (QOL), and change in New York Heart Association (NYHA) functional classification.
METHODS: The BLOCK HF trial randomized patients with atrioventricular block, NYHA symptom class I to III heart failure, and left ventricular ejection fraction ≤50% to biventricular or RV pacing. NYHA functional classification, QOL, and clinical composite score were assessed at 6, 12, 18, and 24 months. Bayesian statistical methods were used, with the pre-specified metric of benefit being a posterior probability ≥0.95.
RESULTS: Patients with biventricular pacing showed greater improvement in NYHA functional class at 12 months, with 19% improved, 61% unchanged, and 17% worsened, compared with 12%/62%/23% in the RV arm. QOL was improved through 12 months. At 6 months, clinical composite score was improved/unchanged/worsened in 53%/24%/24% in the biventricular arm compared with 39%/33%/28% in the RV arm. This improvement in clinical composite score was sustained through 24 months.
CONCLUSIONS: For patients with atrioventricular block and systolic dysfunction, biventricular pacing not only reduces the risk of mortality/morbidity, but also leads to better clinical outcomes, including improved QOL and heart failure status, compared with RV pacing. (Biventricular Versus Right Ventricular Pacing in Heart Failure Patients With Atrioventricular Block [BLOCK HF]; NCT00267098).

Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
PMID 27151347  J Am Coll Cardiol. 2016 May 10;67(18):2148-2157. doi: 1・・・
著者: Gareth J Padfield, Christian Steinberg, Matthew T Bennett, Santabhanu Chakrabarti, Marc W Deyell, Jamil Bashir, Andrew D Krahn
雑誌名: Heart Rhythm. 2015 Nov;12(11):2344-56. doi: 10.1016/j.hrthm.2015.06.043. Epub 2015 Jun 30.
Abstract/Text Cardiac implantable electronic devices (CIEDs) have dramatically improved clinical outcomes in patients with heart disease, and the number of CIED-related procedures being performed continues to grow. Unfortunately, the rate of device-related infection (DRI) is increasing disproportionately to the rate of implantation, with DRI rates of >2% in many series. This increase in DRI is a consequence of the increased number of patients with a higher burden of comorbidities, who are more susceptible to infection and are undergoing more complex device procedures. Identification of high-risk patients is an important component of procedural planning, and targeted therapy and surveillance may be beneficial in certain groups. An understanding of the pathophysiology of DRI has facilitated more effective and widespread use of prophylactic antibiotics; however, current guidelines for antibiotic prophylaxis are based on a relatively small evidence base. Clinical equipoise remains regarding the optimal prophylactic regimen, and we are continuing to learn how best to manage these patients. In this review, we discuss the epidemiology and pathophysiology of DRI and its clinical presentation, the risk factors for DRI, and the existing and emerging evidence supporting strategies to prevent DRI.

Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
PMID 26142295  Heart Rhythm. 2015 Nov;12(11):2344-56. doi: 10.1016/j.h・・・
著者: H Atarashi, Y Endoh, H Saitoh, H Kishida, H Hayakawa
雑誌名: J Cardiovasc Pharmacol. 1998 Apr;31(4):534-9.
Abstract/Text Whether phosphodiesterase inhibitors increase the heart rate in patients with bradyarrhythmias is not known. We attempted to determine whether the oral phosphodiesterase inhibitor cilostazol exhibits beneficial chronotropic effects in patients with symptomatic bradyarrhythmias. Twenty patients comprising eight with bradycardic atrial fibrillation, eight with sick sinus syndrome, and four with Wenckebach-type atrioventricular block, whose 24-h total heart-beat count was < or =70,000 beats and whose maximal RR interval was > or =2.5 s, were enrolled. Holter recordings (24-h) were made before and 2 weeks after oral daily administration of 200 mg of cilostazol. Cilostazol increased the 24-h total heart-beat count from 77,429 +/- 11,168 to 107,981 +/- 13,536 (95% confidence interval, 24,605-36,497; p < 0.0001), the minimal heart rate from 33 +/- 9 47 +/- 13 beats/min (95% confidence interval, 9-19 beats/min; p < 0.0001), and the maximal RR interval from 3,149 +/- 1,018 to 2,087 +/- 601 ms (95% confidence interval, -1,517 to -608 ms; p = 0.0001). Only two patients had headaches as adverse effects. In conclusion, cilostazol had a beneficial positive chronotropic effect in patients with bradyarrhythmias, especially with bradycardic atrial fibrillation and sick sinus syndrome.

PMID 9554801  J Cardiovasc Pharmacol. 1998 Apr;31(4):534-9.

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