今日の臨床サポート

持続性心室頻拍

著者: 庭野慎一 北里大学病院 循環器内科

監修: 山下武志 心臓血管研究所付属病院

著者校正/監修レビュー済:2019/11/21
参考ガイドライン:
日本循環器学会、日本小児循環器学会、日本心臓病学会、日本心電学会、日本不整脈学会:不整脈薬物治療に関するガイドライン(2009年改訂版)
患者向け説明資料

概要・推奨   

  1. Wide QRS tachycardia(頻拍)に遭遇したときは、安易に心室頻拍と思い込まず、上室頻拍の変行伝導との鑑別を常に心掛けることが推奨される(推奨度1)
  1. 頻拍中のQRS波形からある程度、その起源や原因となる心疾患も推定できる。これらの所見をもとに検査治療方針を決定することが推奨される(推奨度2)
  1. 血行動態(血圧や意識状態)悪化時には、頻拍への緊急対応を行うことが強く推奨される(推奨度2)
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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:
庭野慎一 : 原稿料(第一三共),奨学(奨励)寄付など(日本ベーリンガーインゲルハイム)[2021年]
監修:山下武志 : 講演料(第一三共,ブリストル・マイヤーズスクイブ,バイエル,小野薬品,トーアエイヨー,ノバルティス),原稿料(第一三共,バイエル),研究費・助成金など(第一三共,ブリストルマイヤーズスクイブ)[2021年]

改訂のポイント:
  1. 最近の薬物使用の実情に鑑み、使用頻度の低い薬物の順位を下げるないし削除等の修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 心室頻拍の診断は心電図でなされ、頻拍(脈拍>100/分)時の心電図で幅の広いQRSが記録される。
  1. 上室頻拍の変行伝導との鑑別が重要である。
  1. 心室頻拍はその持続時間から持続性と非持続性に、QRSの形態から単形性と多形性に分類され、これらの組み合わせで表現される(例:持続性単形性心室頻拍、非持続性多形性心室頻拍)。
  1. 30秒以上続くもの、あるいは停止に人的介入(薬剤投与や電気ショック)が必要なものを持続性と称する。
  1. 多形性心室頻拍が持続した場合は心室細動に分類される。本稿で解説する持続性心室頻拍は、持続性単形性心室頻拍を指す。
病歴・診察のポイント  
  1. 頻拍が持続している場合、まず意識状態とバイタルをチェックする。

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文献 

著者: R B Stewart, G H Bardy, H L Greene
雑誌名: Ann Intern Med. 1986 Jun;104(6):766-71.
Abstract/Text The extent and consequence of misdiagnosis of wide complex tachycardia (QRS, 120 ms or more; heart rate, 100 or more beats/min) presenting emergently were assessed. Forty-six consecutive episodes of wide complex tachycardia were reviewed and their tachycardia mechanisms subsequently established. All 8 episodes of supraventricular tachycardia with aberrant conduction were correctly diagnosed, whereas 15 of 38 episodes of ventricular tachycardia (39%) were misdiagnosed as supraventricular tachycardia at the time initial therapy was given. Ventriculoatrial dissociation was evident in 11 (73%) of the electrocardiograms of misdiagnosed ventricular tachycardia. Patients with misdiagnosed episodes had poorer outcomes than those with episodes correctly diagnosed (p = 0.0003). Verapamil was administered to patients in 13 of the 15 episodes of misdiagnosed ventricular tachycardia; hemodynamic deterioration occurred in all 13 episodes. Wide complex tachycardia is often incorrectly diagnosed as supraventricular tachycardia when, in fact, the 12-lead electrocardiogram strongly suggests ventricular tachycardia. Verapamil is commonly administered in these circumstances and is frequently associated with a poor outcome.

PMID 3706928  Ann Intern Med. 1986 Jun;104(6):766-71.
著者: M Akhtar, M Shenasa, M Jazayeri, J Caceres, P J Tchou
雑誌名: Ann Intern Med. 1988 Dec 1;109(11):905-12.
Abstract/Text BACKGROUND AND PURPOSE: Despite available criteria, diagnosis of the mechanisms of wide complex tachycardia is often incorrect. We aimed in this study to identify reasons for misdiagnoses and the value and limitations of clinical and surface electrocardiographic criteria.
DATA IDENTIFICATION: The analyzed data of 150 consecutive patients with wide QRS tachycardia from this study and a literature search of key papers in English since 1960 on clinical and surface electrocardiographic criteria form the basis of this report. The final correct diagnosis was made with intracardiac electrograms.
DATA EXTRACTION AND ANALYSIS: Among the 150 patients, 122 had ventricular tachycardia, 21 had supraventricular tachycardia with aberrant conduction, and 7 had accessory pathway conduction. Only 39 of 122 patients with ventricular tachycardia were correctly diagnosed initially. In others, the diagnoses were supraventricular tachycardia with aberrant conduction (43 of 122) or simply a wide QRS tachycardia (40 of 122). Misdiagnosis in patients with aberrant or accessory pathway conduction was also common. Standard electrocardiographic criteria for ventricular tachycardia had unacceptable sensitivity, poor specificity, or both. Collectively such criteria allowed a correct diagnosis of ventricular tachycardia in 92% of cases. Diagnosis of ventricular tachycardia was also suggested by its association with structural heart disease. Criteria suggestive of ventricular tachycardia included atrioventricular dissociation, positive QRS concordance, axis less than -90 deg to +/- 180 deg, combination of left bundle branch block and right axis, QRS duration of greater than 140 ms with right bundle branch block and greater than 160 ms with left bundle branch block and, a different QRS during tachycardia compared to baseline preexisting bundle branch block.
CONCLUSIONS: Ventricular tachycardia is the commonest underlying mechanism for wide QRS tachycardia. A correct diagnosis can usually be made from clinical and surface electrocardiographic criteria.

PMID 3190044  Ann Intern Med. 1988 Dec 1;109(11):905-12.
著者: A K Gupta, R K Thakur
雑誌名: Med Clin North Am. 2001 Mar;85(2):245-66, ix-x.
Abstract/Text Wide QRS complex tachycardia is a common clinical occurrence and presents a diagnostic challenge for the physician. History, physical examination, chest radiographs, and electrocardiographic analysis are important in making the correct diagnosis. Diagnosis of ventricular tachycardia is supported by history of prior myocardial infarction or congestive heart failure, physical examination showing cannon A-waves in the jugular venous pulsation or variable heart sounds, chest radiograph showing cardiomegaly or evidence of prior cardiac surgery, and characteristic ECG features: AV dissociation, fusion/capture beats, QRS concordance or typical morphologic features in leads V1 and V6. In this article, a clinical approach to wide QRS complex tachycardias is presented.

PMID 11233948  Med Clin North Am. 2001 Mar;85(2):245-66, ix-x.
著者: P Tchou, P Young, R Mahmud, S Denker, M Jazayeri, M Akhtar
雑誌名: Am J Med. 1988 Jan;84(1):53-6.
Abstract/Text Misdiagnosis occurs upon initial presentation to medical attention in a considerable number of patients referred for evaluation of wide QRS tachycardia. In order to improve diagnostic accuracy (ventricular versus supraventricular tachycardia), the answers to two key bedside questions were prospectively evaluated: (1) Had the patient experienced a prior myocardial infarction? (2) Did symptoms of tachyarrhythmia start only after the infarction? A patient presenting with a wide QRS tachycardia was considered to have ventricular tachycardia if he or she answered in the affirmative to both of these questions. Of 31 consecutive patients referred with electrocardiographically documented sustained wide QRS tachycardia that was reproduced in the electrophysiology laboratory, the diagnoses made when the patients first presented to medical attention were ventricular tachycardias in 17 patients and supraventricular tachycardias in 14 patients. Following electrophysiologic evaluation, 29 were diagnosed as having ventricular tachycardia and two as supraventricular tachycardia. If the diagnoses were made solely on the basis of responses to the bedside questions mentioned earlier, 28 of the 29 patients having a final diagnosis of ventricular tachycardia would have been correctly identified. It is concluded that the use of these two questions can be very helpful in improving the clinical diagnosis of ventricular tachycardia.

PMID 3337132  Am J Med. 1988 Jan;84(1):53-6.
著者: R Brooks, J H Burgess
雑誌名: Medicine (Baltimore). 1988 Sep;67(5):271-94.
Abstract/Text Idiopathic or unexplained VT occurs in a small but important subset of patients without clinically evident heart disease. The majority of these patients appear to have a structurally normal heart. The cause of the arrhythmias in these individuals is unclear and may never be recognized. Other patients with this condition may have minor abnormalities not sufficient to impair overall cardiac function. The significance of these abnormalities to the genesis of the arrhythmia is uncertain. Whether patients with minor abnormalities are more likely to harbor covert heart disease such as myocarditis or a focal defect is not known, nor is it resolved whether such patients warrant a more aggressive search for a structural cause. The question that remains in any patient not subjected to surgical or pathological exploration is whether undetermined heart disease is responsible for the arrhythmia. Continued correlation between functional (electrophysiological) and structural (pathological) data will provide meaningful information concerning the pathophysiology (substrate) of these arrhythmias. Because of the preservation of normal cardiac function, these arrhythmias are generally well-tolerated. Although the condition is usually associated with a favorable prognosis, the occasional deaths reported in patients with apparently idiopathic ventricular arrhythmias may not permit calling this condition benign. It would be important to know the extent to which unrecognized abnormalities play a role in the genesis of these tachycardias, and whether such patients are more predisposed to fatal arrhythmias or have a different natural history. If cases involving undetermined or covert heart disease were excluded from consideration, then a relatively homogeneous disease-free group may be identified with a truly benign condition and a uniformly favorable prognosis. In these cases, a primary electrical abnormality may prove to be the basis for the arrhythmia. These issues remain to be elucidated in future studies.

PMID 3045477  Medicine (Baltimore). 1988 Sep;67(5):271-94.
著者: T Ohe, N Aihara, S Kamakura, T Kurita, W Shimizu, K Shimomura
雑誌名: J Am Coll Cardiol. 1995 Jan;25(1):54-8.
Abstract/Text OBJECTIVES: This study attempted to determine the long-term outcome of verapamil-sensitive sustained left ventricular tachycardia in patients without apparent structural heart disease.
BACKGROUND: Several types of idiopathic ventricular tachycardia have been reported, and their clinical, electrophysiologic and electropharmacologic characteristics are different. It is possible that the prognosis of each type of ventricular tachycardia might also be different.
METHODS: We studied mortality and morbidity in 37 consecutive patients (27 male, 10 female; mean [+/- SD] age 33 +/- 14 years) with verapamil-sensitive sustained left ventricular tachycardia who had no apparent structural heart disease. Patients were followed up for 1 to 13 years (mean 5.8). Verapamil repeatedly terminated ventricular tachycardia in all patients. Ventricular tachycardia originated from the inferior and inferoseptal regions of the left ventricle in 33 patients and the superior and superioseptal regions in 4. Severity of ventricular tachycardia was classified according to the extent to which symptoms limited daily activities. Ventricular tachycardia was mild (minimal limitation) in 14 patients, moderate (some limitation) in 17 and severe (severe limitation) in 6.
RESULTS: Fourteen patients with mild ventricular tachycardia were followed up without any drug therapy, and the ventricular tachycardia remained mild in all patients. Antiarrhythmic therapy was initiated empirically in the 23 patients with moderate and severe ventricular tachycardia (verapamil in 20, propranolol in 2, digoxin in 1). Moderate ventricular tachycardia became mild ventricular tachycardia after drug therapy in all patients, but the six patients with severe ventricular tachycardia showed no improvement. The six patients with severe ventricular tachycardia had nonpharmacologic therapy (cryosurgery in one, catheter ablation in four, antitachycardia pacing device in one). During the follow-up period, all patients remained alive except for one who died suddenly after implantation of an antitachycardia pacing device.
CONCLUSIONS: 1) The long-term prognosis of verapamil-sensitive sustained left ventricular tachycardia in patients without apparent structural heart disease is good. 2) Verapamil is the drug of choice for alleviating symptoms, but nonpharmacologic therapy is necessary in some patients.

PMID 7798526  J Am Coll Cardiol. 1995 Jan;25(1):54-8.
著者:
雑誌名: N Engl J Med. 1997 Nov 27;337(22):1576-83. doi: 10.1056/NEJM199711273372202.
Abstract/Text BACKGROUND: Patients who survive life-threatening ventricular arrhythmias are at risk for recurrent arrhythmias. They can be treated with either an implantable cardioverter-defibrillator or antiarrhythmic drugs, but the relative efficacy of these two treatment strategies is unknown.
METHODS: To address this issue, we conducted a randomized comparison of these two treatment strategies in patients who had been resuscitated from near-fatal ventricular fibrillation or who had undergone cardioversion from sustained ventricular tachycardia. Patients with ventricular tachycardia also had either syncope or other serious cardiac symptoms, along with a left ventricular ejection fraction of 0.40 or less. One group of patients was treated with implantation of a cardioverter-defibrillator; the other received class III antiarrhythmic drugs, primarily amiodarone at empirically determined doses. Fifty-six clinical centers screened all patients who presented with ventricular tachycardia or ventricular fibrillation during a period of nearly four years. Of 1016 patients (45 percent of whom had ventricular fibrillation, and 55 percent ventricular tachycardia), 507 were randomly assigned to treatment with implantable cardioverter-defibrillators and 509 to antiarrhythmic-drug therapy. The primary end point was overall mortality.
RESULTS: Follow-up was complete for 1013 patients (99.7 percent). Overall survival was greater with the implantable defibrillator, with unadjusted estimates of 89.3 percent, as compared with 82.3 percent in the antiarrhythmic-drug group at one year, 81.6 percent versus 74.7 percent at two years, and 75.4 percent versus 64.1 percent at three years (P<0.02). The corresponding reductions in mortality (with 95 percent confidence limits) with the implantable defibrillator were 39+/-20 percent, 27+/-21 percent, and 31+/-21 percent
CONCLUSIONS: Among survivors of ventricular fibrillation or sustained ventricular tachycardia causing severe symptoms, the implantable cardioverter-defibrillator is superior to antiarrhythmic drugs for increasing overall survival.

PMID 9411221  N Engl J Med. 1997 Nov 27;337(22):1576-83. doi: 10.1056・・・
著者: S J Connolly, A P Hallstrom, R Cappato, E B Schron, K H Kuck, D P Zipes, H L Greene, S Boczor, M Domanski, D Follmann, M Gent, R S Roberts
雑誌名: Eur Heart J. 2000 Dec;21(24):2071-8. doi: 10.1053/euhj.2000.2476.
Abstract/Text AIMS: Three randomized trials of implantable cardioverter defibrillator (ICD) therapy vs medical treatment for the prevention of death in survivors of ventricular fibrillation or sustained ventricular tachycardia have been reported with what might appear to be different results. The present analysis was performed to obtain the most precise estimate of the efficacy of the ICD, compared to amiodarone, for prolonging survival in patients with malignant ventricular arrhythmia.
METHODS AND RESULTS: Individual patient data from the Antiarrhythmics vs Implantable Defibrillator (AVID) study, the Cardiac Arrest Study Hamburg (CASH) and the Canadian Implantable Defibrillator Study (CIDS) were merged into a master database according to a pre-specified protocol. Proportional hazard modelling of individual patient data was used to estimate hazard ratios and to investigate subgroup interactions. Fixed effect meta-analysis techniques were also used to evaluate treatment effects and to assess heterogeneity across studies. The classic fixed effects meta-analysis showed that the estimates of ICD benefit from the three studies were consistent with each other (P heterogeneity=0.306). It also showed a significant reduction in death from any cause with the ICD; with a summary hazard ratio (ICD:amiodarone) of 0.72 (95% confidence interval 0.60, 0.87;P=0.0006). For the outcome of arrhythmic death, the hazard ratio was 0.50 (95% confidence interval 0.37, 0.67;P<0.0001). Survival was extended by a mean of 4.4 months by the ICD over a follow-up period of 6 years. Patients with left ventricular ejection fraction < or = 35% derived significantly more benefit from ICD therapy than those with better preserved left ventricular function. Patients treated before the availability of non-thoracotomy ICD implants derived significantly less benefit from ICD therapy than those treated in the non-thoracotomy era.
CONCLUSION: Results from the three trials of the ICD vs amiodarone are consistent with each other. There is a 28% reduction in the relative risk of death with the ICD that is due almost entirely to a 50% reduction in arrhythmic death.

Copyright 2000 The European Society of Cardiology.
PMID 11102258  Eur Heart J. 2000 Dec;21(24):2071-8. doi: 10.1053/euhj.・・・

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