今日の臨床サポート

洞不全症候群

概要・推奨   

  1. 洞不全症候群に伴う失神、めまいなどの症状にはペースメーカー植込みが唯一確立された治療法である(推奨度1)。
  1. 洞不全症候群に伴う失神やめまいに対する薬物治療の効果は限定的で、適応は何らかの理由でペースメーカー植込みが不可能な場合(患者の拒否、合併疾患の予後)に限定される(推奨度2)。
  1. ホルター心電図をはじめとする心電図記録で洞不全症候群が疑われた場合、有益な心電図記録を得るためには、繰り返し長時間の記録が必要である(推奨度1)。
  1. 洞不全症候群では多くの患者で主に心房細動を合併するため、抗凝固療法を考慮すべきである。心房細動診断時にはCHADS2やCHA2DS2-VASCに準じてリスクの層別化を行い、抗凝固療法の適応を判断すべきである(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
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:
西原崇創 : 未申告[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. 不整脈非薬物治療ガイドライン フォーカスアップデート版に基づき、リードレスペースメーカーについて加筆を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 洞不全症候群(sick sinus syndrome、SSS)とは、洞房結節の機能不全(洞房結節自身もしくはその周囲の線維化)が原因で、失神やめまい、ふらつき、倦怠感などの症状を来す疾患である。
  1. 洞不全症候群とは、失神やめまい、ふらつき、倦怠感など脳虚血症状と心電図所見との一致をみることで診断となる。
  1. 主に高齢者(平均70歳程度)で、女性にやや多く、他の合併疾患を有することが多い。
  1. 徐脈の存在と心電図所見とが必ずしも一致しないことがあり、非侵襲的検査(安静時心電図、ホルター心電図、トレッドミル、心エコー検査などの運動負荷検査)から始め、必要に応じて電気生理学的検査や植込み型ループレコーダーなどを行い、確定診断となる。
  1. 心房性頻脈性不整脈の合併頻度が高く、その主なものは心房細動と心房粗動である。
  1. 徐脈のみで確定診断はできない。徐脈に伴う症状を有することが、診断上必要である。
病歴・診察のポイント  
  1. 高齢者に認められる傾向が強く、他の合併疾患を伴うことも多い。そのため、失神やめまい、ふらつき、倦怠感などの症状が徐脈と関連しているかどうかを、可能なかぎり問診で確認する。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

詳しくはクリック
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: T C Gibson, M R Heitzman
雑誌名: Am J Cardiol. 1984 Apr 1;53(8):1013-7.
Abstract/Text The effectiveness of an open referral electrocardiographic monitoring service in identifying an arrhythmogenic cause for syncope was evaluated. Over 5 years, 7,364 patients of all ages underwent ambulatory 24-hour electrocardiographic (Holter) monitoring using a 2-channel recorder. Of these, 1,512 (20.5%) were referred because of syncope. During monitoring, 15 patients had syncope and 7 of the episodes were related to an arrhythmia, usually ventricular tachycardia. Presyncope was reported in 241 patients, with a related arrhythmia in 24. Thus, an arrhythmia-related symptom that could be diagnostic was present in only 2% of the patients monitored. However, syncope or presyncope without an associated arrhythmia might be considered a negative diagnostic clue and occurred in 225 (15%). High-grade atrioventricular block was present in 15 and ventricular tachycardia in 116; only 6 (5%) reported associated symptoms. An age-related incremental increase in atrial and ventricular arrhythmias was found. In 415 of the 1,004 patients (41%) aged 60 years or more, arrhythmias that are conventionally associated with sinoatrial disease were recorded. Using stringent diagnostic criteria, the sick sinus or tachybradycardia syndrome was present in 33 (3%). Many older patients (70%) were taking drugs that could be arrhythmogenic, hypotensive or both. It is concluded that an open referral 24-hour ambulatory monitoring service rarely results in identifying relevant symptom-related arrhythmias in patients with syncope. It records many asymptomatic arrhythmias that can compound rather than resolve the diagnostic problem in older patients, because the data obtained could lead to unnecessary therapy. An iatrogenic cause for syncope should always be considered.

PMID 6702676  Am J Cardiol. 1984 Apr 1;53(8):1013-7.
著者: Gervasio A Lamas, Kerry L Lee, Michael O Sweeney, Russell Silverman, Angel Leon, Raymond Yee, Roger A Marinchak, Greg Flaker, Eleanor Schron, E John Orav, Anne S Hellkamp, Stephen Greer, John McAnulty, Kenneth Ellenbogen, Frederick Ehlert, Roger A Freedman, N A Mark Estes, Arnold Greenspon, Lee Goldman, Mode Selection Trial in Sinus-Node Dysfunction
雑誌名: N Engl J Med. 2002 Jun 13;346(24):1854-62. doi: 10.1056/NEJMoa013040.
Abstract/Text BACKGROUND: Dual-chamber (atrioventricular) and single-chamber (ventricular) pacing are alternative treatment approaches for sinus-node dysfunction that causes clinically significant bradycardia. However, it is unknown which type of pacing results in the better outcome.
METHODS: We randomly assigned a total of 2010 patients with sinus-node dysfunction to dual-chamber pacing (1014 patients) or ventricular pacing (996 patients) and followed them for a median of 33.1 months. The primary end point was death from any cause or nonfatal stroke. Secondary end points included the composite of death, stroke, or hospitalization for heart failure; atrial fibrillation; heart-failure score; the pacemaker syndrome; and the quality of life.
RESULTS: The incidence of the primary end point did not differ significantly between the dual-chamber group (21.5 percent) and the ventricular-paced group (23.0 percent, P=0.48). In patients assigned to dual-chamber pacing, the risk of atrial fibrillation was lower (hazard ratio, 0.79; 95 percent confidence interval, 0.66 to 0.94; P=0.008), and heart-failure scores were better (P<0.001). The differences in the rates of hospitalization for heart failure and of death, stroke, or hospitalization for heart failure were not significant in unadjusted analyses but became marginally significant in adjusted analyses. Dual-chamber pacing resulted in a small but measurable increase in the quality of life, as compared with ventricular pacing.
CONCLUSIONS: In sinus-node dysfunction, dual-chamber pacing does not improve stroke-free survival, as compared with ventricular pacing. However, dual-chamber pacing reduces the risk of atrial fibrillation, reduces signs and symptoms of heart failure, and slightly improves the quality of life. Overall, dual-chamber pacing offers significant improvement as compared with ventricular pacing.

PMID 12063369  N Engl J Med. 2002 Jun 13;346(24):1854-62. doi: 10.1056・・・
著者: D Saito, K Matsubara, H Yamanari, N Obayashi, S Uchida, K Maekawa, T Sato, K Mizuo, H Kobayashi, S Haraoka
雑誌名: J Am Coll Cardiol. 1993 Apr;21(5):1199-204.
Abstract/Text OBJECTIVES: We sought to determine the effect of theophylline on cardiac pauses in sick sinus syndrome.
BACKGROUND: Sick sinus syndrome, a relatively benign condition, is usually treated with pacemaker implantation without any proved effectiveness. Thus, an appropriate pharmacologic therapy would be useful.
METHODS: Theophylline (200 to 400 mg/day for 1 month) was initially administered orally to 17 patients with sick sinus syndrome, which is manifested by sinus pauses of > 2.5 s. Eleven of the 17 patients subsequently received theophylline for an additional 8 to 37 months. Twenty-four-hour Holter recordings were obtained before treatment, at the end of 1 month of treatment and then at 6-month intervals.
RESULTS: Theophylline decreased the frequency of sinus pauses from 256 +/- 230 to 23 +/- 62 pauses per 24 h and decreased the duration of the longest pauses from 4.7 +/- 1.8 to 2.2 +/- 0.97 s after 1 month of treatment. Subjective symptoms associated with cardiac pauses disappeared in 16 of 17 patients. Ventricular premature beats increased in frequency but did not last longer than two beats. Three patients experienced adverse effects. Nine of the 11 patients receiving long-term treatment had a good outcome, but 2 patients required a pacemaker because of the reappearance of long sinus pauses.
CONCLUSIONS: The results suggest that oral theophylline may be beneficial for the treatment of patients with sick sinus syndrome.

PMID 8459077  J Am Coll Cardiol. 1993 Apr;21(5):1199-204.
著者: P Alboni, C Menozzi, M Brignole, N Paparella, G Gaggioli, G Lolli, R Cappato
雑誌名: Circulation. 1997 Jul 1;96(1):260-6.
Abstract/Text BACKGROUND: Pacemakers and theophylline are currently being used to relieve symptoms in patients with sick sinus syndrome (SSS). However, the impact of either therapy on the natural course of the disease is unknown. We conducted a randomized controlled trial to prospectively assess the effects of pacemakers and theophylline in patients with SSS.
METHODS AND RESULTS: One hundred seven patients with symptomatic SSS (age, 73 +/- 11 years) were randomized to no treatment (control group, n = 35), oral theophylline (n = 36), or dual-chamber rate-responsive pacemaker therapy (n = 36). They were followed for up to 48 months (mean, 19 +/- 14 months). During follow-up, the occurrence of syncope was lower in the pacemaker group than in the control group (P = .02) and tended to be lower than in the theophylline group (P = .07). Heart failure occurred less often in patients assigned to pacemaker therapy and theophylline than in control patients (both, P = .05), whereas the incidence of sustained paroxysmal tachyarrhythmias, permanent atrial fibrillation, and thromboembolic events did not show any apparent difference among the three groups. Heart rate was higher in the theophylline group than in the control group. Both pacemaker therapy and theophylline improved symptom scores after 3 months of treatment; however, a similar improvement was observed in the control group.
CONCLUSIONS: In patients with symptomatic SSS, therapy with theophylline or dual-chamber pacemaker is associated with a lower incidence of heart failure; pacemaker therapy is also associated with a lower incidence of syncope. The therapeutic benefits of pacemakers and theophylline on symptoms are partly a result of spontaneous improvement of the disease.

PMID 9236443  Circulation. 1997 Jul 1;96(1):260-6.
著者: Andrew E Epstein, John P Dimarco, Kenneth A Ellenbogen, N A Mark Estes, Roger A Freedman, Leonard S Gettes, A Marc Gillinov, Gabriel Gregoratos, Stephen C Hammill, David L Hayes, Mark A Hlatky, L Kristin Newby, Richard L Page, Mark H Schoenfeld, Michael J Silka, Lynne Warner Stevenson, Michael O Sweeney, American College of Cardiology, American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, Society of Thoracic Surgeons
雑誌名: Heart Rhythm. 2008 Jun;5(6):e1-62. doi: 10.1016/j.hrthm.2008.04.014. Epub 2008 May 21.
Abstract/Text
PMID 18534360  Heart Rhythm. 2008 Jun;5(6):e1-62. doi: 10.1016/j.hrthm・・・
著者: Jeffrey S Healey, William D Toff, Gervasio A Lamas, Henning R Andersen, Kevin E Thorpe, Kenneth A Ellenbogen, Kerry L Lee, Allan M Skene, Eleanor B Schron, J Douglas Skehan, Lee Goldman, Robin S Roberts, A John Camm, Salim Yusuf, Stuart J Connolly
雑誌名: Circulation. 2006 Jul 4;114(1):11-7. doi: 10.1161/CIRCULATIONAHA.105.610303. Epub 2006 Jun 26.
Abstract/Text BACKGROUND: Several randomized trials have compared atrial-based (dual-chamber or atrial) pacing with ventricular pacing in patients with bradycardia. No trial has shown a mortality reduction, and only 1 small trial suggested a reduction in stroke. The goal of this review was to determine whether atrial-based pacing prevents major cardiovascular events.
METHODS AND RESULTS: A systematic review was performed of publications since 1980. For inclusion, trials had to compare an atrial-based with a ventricular-based pacing mode; use a randomized, controlled, parallel design; and have data on mortality, stroke, heart failure, or atrial fibrillation. Individual patient data were obtained from 5 of the 8 identified studies, representing 95% of patients in the 8 trials, and a total of 35 000 patient-years of follow-up. There was no significant heterogeneity among the results of the individual trials. There was no significant reduction in mortality (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.87 to 1.03; P=0.19) or heart failure (HR, 0.89; 95% CI, 0.77 to 1.03; P=0.15) with atrial-based pacing. There was a significant reduction in atrial fibrillation (HR, 0.80; 95% CI, 0.72 to 0.89; P=0.00003) and a reduction in stroke that was of borderline significance (HR, 0.81; 95% CI, 0.67 to 0.99; P=0.035). There was no convincing evidence that any patient subgroup received special benefit from atrial-based pacing.
CONCLUSIONS: Compared with ventricular pacing, the use of atrial-based pacing does not improve survival or reduce heart failure or cardiovascular death. However, atrial-based pacing reduces the incidence of atrial fibrillation and may modestly reduce stroke.

PMID 16801463  Circulation. 2006 Jul 4;114(1):11-7. doi: 10.1161/CIRCU・・・
著者: H R Andersen, J C Nielsen, P E Thomsen, L Thuesen, P T Mortensen, T Vesterlund, A K Pedersen
雑誌名: Lancet. 1997 Oct 25;350(9086):1210-6. doi: 10.1016/S0140-6736(97)03425-9.
Abstract/Text BACKGROUND: In a previous study of 225 patients with sick-sinus syndrome randomised to either single-chamber atrial pacing (n=110) or single-chamber ventricular pacing (n=115), we found that after a mean follow-up of 3.3 years, atrial pacing was associated with significantly less atrial fibrillation and thromboembolism whereas there was no significant difference in mortality and heart failure between the two groups. We aimed to find out whether this beneficial effect of atrial pacing is maintained during extended follow-up of up to 8 years.
METHODS: Follow-up visits for all patients were at 3 months, 12 months, then once a year at which patients had a physical examination, ECG recording, and pacemaker check-up. Endpoints were mortality, cardiovascular death, atrial fibrillation, thromboembolic events, heart failure, and atrioventricular block. Data was analysed on Dec 31, 1996.
FINDINGS: At long-term follow-up, 39 patients from the atrial group had died versus 57 from the ventricular group (relative risk 0.66 [95% CI 0.44-0.99]; p=0.045). 19 patients from the atrial group and 39 patients from the ventricular group died from a cardiovascular cause (0.47 [0.27-0.82]; p=0.0065). The cumulative incidences of atrial fibrillation and chronic atrial fibrillation were also significantly lower in the atrial group than in the ventricular group (0.54 [0.33-0.89], p=0.012 and 0.35 [0.16-0.76], p=0.004, respectively). Thromboembolic events occurred in 13 patients in the atrial group and 26 in the ventricular group (0.47 [0.24-0.92], p=0.023). Heart failure was less severe in the atrial group than in the ventricular group (p<0.05). In multivariate analysis, atrial pacing was significantly associated with freedom from thromboembolic events (0.47 [0.24-0.92], p=0.028) and survival from cardiovascular death (0.52 [0.30-0.91], p=0.022), but no longer with overall survival (0.71 [0.46-1.08], p=0.11) or chronic atrial fibrillation (0.45 [0.20-1.05], p=0.063). Atrioventricular block occurred in four patients in the atrial group (0.6% annual risk).
INTERPRETATION: The beneficial effect of atrial pacing found in our previous study is enhanced substantially over time. Patients with sick-sinus syndrome should be treated with an atrial rather than ventricular-pacing system because after long-term follow-up, atrial pacing is associated with a significantly higher survival, less atrial fibrillation, fewer thromboembolic complications, less heart failure, and a low-risk of atrioventricular block.

PMID 9652562  Lancet. 1997 Oct 25;350(9086):1210-6. doi: 10.1016/S014・・・
著者: G A Lamas, E J Orav, B S Stambler, K A Ellenbogen, E B Sgarbossa, S K Huang, R A Marinchak, N A Estes, G F Mitchell, E H Lieberman, C M Mangione, L Goldman
雑誌名: N Engl J Med. 1998 Apr 16;338(16):1097-104. doi: 10.1056/NEJM199804163381602.
Abstract/Text BACKGROUND: Standard clinical practice permits the use of either single-chamber ventricular pacemakers or dual-chamber pacemakers for most patients who require cardiac pacing. Ventricular pacemakers are less expensive, but dual-chamber pacemakers are believed to be more physiologic. However, it is not known whether either type of pacemaker results in superior clinical outcomes.
METHODS: The Pacemaker Selection in the Elderly study was a 30-month, single-blind, randomized, controlled comparison of ventricular pacing and dual-chamber pacing in 407 patients 65 years of age or older in 29 centers. Patients received a dual-chamber pacemaker that had been randomly programmed to either ventricular pacing or dual-chamber pacing. The primary end point was health-related quality of life as measured by the 36-item Medical Outcomes Study Short-Form General Health Survey.
RESULT: The average age of the patients was 76 years (range, 65 to 96), and 60 percent were men. Quality of life improved significantly after pacemaker implantation (P<0.001), but there were no differences between the two pacing modes in either the quality of life or prespecified clinical outcomes (including cardiovascular events or death). However, 53 patients assigned to ventricular pacing (26 percent) were crossed over to dual-chamber pacing because of symptoms related to the pacemaker syndrome. Patients with sinus-node dysfunction, but not those with atrioventricular block, had moderately better quality of life and cardiovascular functional status with dual-chamber pacing than with ventricular pacing. Trends of borderline statistical significance in clinical end points favoring dual-chamber pacing were observed in patients with sinus-node dysfunction, but not in those with atrioventricular block.
CONCLUSION: The implantation of a permanent pacemaker improves health-related quality of life. However, the quality-of-life benefits associated with dual-chamber pacing as compared with ventricular pacing are observed principally in the subgroup of patients with sinus-node dysfunction.

PMID 9545357  N Engl J Med. 1998 Apr 16;338(16):1097-104. doi: 10.105・・・
著者: S J Connolly, C R Kerr, M Gent, R S Roberts, S Yusuf, A M Gillis, M H Sami, M Talajic, A S Tang, G J Klein, C Lau, D M Newman
雑誌名: N Engl J Med. 2000 May 11;342(19):1385-91. doi: 10.1056/NEJM200005113421902.
Abstract/Text BACKGROUND: Evidence suggests that physiologic pacing (dual-chamber or atrial) may be superior to single-chamber (ventricular) pacing because it is associated with lower risks of atrial fibrillation, stroke, and death. These benefits have not been evaluated in a large, randomized, controlled trial.
METHODS: At 32 Canadian centers, patients without chronic atrial fibrillation who were scheduled for a first implantation of a pacemaker to treat symptomatic bradycardia were eligible for enrollment. We randomly assigned patients to receive either a ventricular pacemaker or a physiologic pacemaker and followed them for an average of three years. The primary outcome was stroke or death due to cardiovascular causes. Secondary outcomes were death from any cause, atrial fibrillation, and hospitalization for heart failure.
RESULTS: A total of 1474 patients were randomly assigned to receive a ventricular pacemaker and 1094 to receive a physiologic pacemaker. The annual rate of stroke or death due to cardiovascular causes was 5.5 percent with ventricular pacing, as compared with 4.9 percent with physiologic pacing (reduction in relative risk, 9.4 percent; 95 percent confidence interval, -10.5 to 25.7 percent [the negative value indicates an increase in risk]; P=0.33). The annual rate of atrial fibrillation was significantly lower among the patients in the physiologic-pacing group (5.3 percent) than among those in the ventricular-pacing group (6.6 percent), for a reduction in relative risk of 18.0 percent (95 percent confidence interval, 0.3 to 32.6 percent; P=0.05). The effect on the rate of atrial fibrillation was not apparent until two years after implantation. The observed annual rates of death from all causes and of hospitalization for heart failure were lower among the patients with a physiologic pacemaker than among those with a ventricular pacemaker, but not significantly so (annual rates of death, 6.6 percent with ventricular pacing and 6.3 percent with physiologic pacing; annual rates of hospitalization for heart failure, 3.5 percent and 3.1 percent, respectively). There were significantly more perioperative complications with physiologic pacing than with ventricular pacing (9.0 percent vs. 3.8 percent, P<0.001).
CONCLUSIONS: Physiologic pacing provides little benefit over ventricular pacing for the prevention of stroke or death due to cardiovascular causes.

PMID 10805823  N Engl J Med. 2000 May 11;342(19):1385-91. doi: 10.1056・・・
著者: William D Toff, A John Camm, J Douglas Skehan, United Kingdom Pacing and Cardiovascular Events Trial Investigators
雑誌名: N Engl J Med. 2005 Jul 14;353(2):145-55. doi: 10.1056/NEJMoa042283.
Abstract/Text BACKGROUND: In the treatment of atrioventricular block, dual-chamber cardiac pacing is thought to confer a clinical benefit as compared with single-chamber ventricular pacing, but the supporting evidence is mainly from retrospective studies. Uncertainty persists regarding the true benefits of dual-chamber pacing, particularly in the elderly, in whom it is used less often than in younger patients.
METHODS: In a multicenter, randomized, parallel-group trial, 2021 patients 70 years of age or older who were undergoing their first pacemaker implant for high-grade atrioventricular block were randomly assigned to receive a single-chamber ventricular pacemaker (1009 patients) or a dual-chamber pacemaker (1012 patients). In the single-chamber group, patients were randomly assigned to receive either fixed-rate pacing (504 patients) or rate-adaptive pacing (505 patients). The primary outcome was death from all causes. Secondary outcomes included atrial fibrillation, heart failure, and a composite of stroke, transient ischemic attack, or other thromboembolism.
RESULTS: The median follow-up period was 4.6 years for mortality and 3 years for other cardiovascular events. The mean annual mortality rate was 7.2 percent in the single-chamber group and 7.4 percent in the dual-chamber group (hazard ratio, 0.96; 95 percent confidence interval, 0.83 to 1.11). We found no significant differences between the group with single-chamber pacing and that with dual-chamber pacing in the rates of atrial fibrillation, heart failure, or a composite of stroke, transient ischemic attack, or other thromboembolism.
CONCLUSIONS: In elderly patients with high-grade atrioventricular block, the pacing mode does not influence the rate of death from all causes during the first five years or the incidence of cardiovascular events during the first three years after implantation of a pacemaker.

Copyright 2005 Massachusetts Medical Society.
PMID 16014884  N Engl J Med. 2005 Jul 14;353(2):145-55. doi: 10.1056/N・・・
著者: C Menozzi, M Brignole, P Alboni, L Boni, N Paparella, G Gaggioli, G Lolli
雑誌名: Am J Cardiol. 1998 Nov 15;82(10):1205-9.
Abstract/Text We performed a prospective study in 35 untreated patients aged > or = 45 years, who had a mean sinus rate at rest of < or = 50 beats/min and/or intermittent sinoatrial block, and symptoms attributable to sinus node dysfunction. The patients were followed up for up to 4 years (mean 17 +/- 15 months). During follow-up, 20 patients (57%) had cardiovascular events that required treatment: 8 had syncope (23%); 6 had overt heart failure (17%); 4 patients had chronic atrial fibrillation (11%); and 2 patients had poorly tolerated episodes of paroxysmal tachyarrhythmias (6%). Actuarial rates of occurrence of all events were 35%, 49%, and 63%, respectively, after 1, 2, and 4 years. At univariate analysis, age > or = 65 years, end-systolic left ventricular diameter > or = 30 mm, end-diastolic left ventricular diameter > or = 52 mm, and ejection fraction < 55% were predictors of cardiovascular events. At multivariate analysis, age, end-diastolic diameter, and ejection fraction remained independent predictors of events. Actuarial rates of occurrence of syncope were 16%, 31%, and 31%, respectively, after 1, 2, and 4 years. Both univariate and multivariate predictors of syncope were history of syncope and corrected sinus node recovery > or = 800 ms. A favorable outcome was observed in the remaining 43% of patients. Thus, clinical cardiovascular events occur in most untreated sick sinus syndrome patients during long-term follow-up, even though a favorable course can be expected in 43% of patients. The outcome can be partly predicted on initial evaluation. In the patients with a favorable outcome, treatment can safely be delayed.

PMID 9832095  Am J Cardiol. 1998 Nov 15;82(10):1205-9.
著者: J Brandt, H Anderson, T Fåhraeus, H Schüller
雑誌名: J Am Coll Cardiol. 1992 Sep;20(3):633-9.
Abstract/Text OBJECTIVES: This study was designed to analyze the incidence and determinants of complications and long-term survival in sinus node disease treated with atrial pacing.
BACKGROUND: Knowledge of the natural history of sinus node disease treated with different pacing modes is imperfect, and controversy exists regarding the optimal pacemaker therapy.
METHODS: A consecutive series of 213 patients with sinus node disease initially treated with atrial pacing was studied for a median follow-up period of 60 months. The end points studied were permanent atrial fibrillation, high grade atrioventricular (AV) block, P wave undersensing, pacing mode change, reoperation and death. Several prognostic factors were evaluated statistically and the survival rate was compared with that of a matched general population.
RESULTS: The incidence rate of permanent atrial fibrillation during follow-up was 7% (1.4%/year). The risk of this arrhythmia increased substantially with age greater than or equal to 70 years at pacemaker implantation. Only 2 of the 15 patients who developed permanent atrial fibrillation required ventricular pacing. High grade AV block occurred in 8.5% (1.8%/year) and its incidence was much greater in patients with complete bundle branch block or bifascicular block (35%) than in patients without such conduction disturbances (6%). A change to ventricular or dual-chamber stimulation was necessary in 14% of all patients, primarily because of early lead dislodgment or high grade AV block. Surgical intervention with maintenance of atrial pacing was required in 7% of patients. The survival rates of 97% at 1 year, 89% at 5 years and 72% at 10 years did not differ significantly from those of a matched general population.
CONCLUSIONS: In sinus node disease, atrial pacing can be successfully applied during long-term follow-up. Patients with complete bundle branch or bifascicular block in addition to sinus node disease should initially receive a dual-chamber pacemaker, but routine application of dual-chamber stimulation does not appear to be warranted.

PMID 1512343  J Am Coll Cardiol. 1992 Sep;20(3):633-9.
著者: Jens Cosedis Nielsen, Poul Erik B Thomsen, Søren Højberg, Mogens Møller, Thomas Vesterlund, Dorthe Dalsgaard, Leif S Mortensen, Tonny Nielsen, Mogens Asklund, Elsebeth V Friis, Per D Christensen, Erik H Simonsen, Ulrik H Eriksen, Gunnar V H Jensen, Jesper H Svendsen, William D Toff, Jeffrey S Healey, Henning R Andersen, DANPACE Investigators
雑誌名: Eur Heart J. 2011 Mar;32(6):686-96. doi: 10.1093/eurheartj/ehr022. Epub 2011 Feb 7.
Abstract/Text AIMS: In patients with sick sinus syndrome, bradycardia can be treated with a single-lead pacemaker or a dual-chamber pacemaker. Previous trials have revealed that pacing modes preserving atrio-ventricular synchrony are superior to single-lead ventricular pacing, but it remains unclear if there is any difference between single-lead atrial pacing (AAIR) and dual-chamber pacing (DDDR).
METHODS AND RESULTS: We randomly assigned 1415 patients referred for first pacemaker implantation to AAIR (n = 707) or DDDR (n = 708) pacing and followed them for a mean of 5.4 ± 2.6 years. The primary outcome was death from any cause. Secondary outcomes included paroxysmal and chronic atrial fibrillation, stroke, heart failure, and need for pacemaker reoperation. In the AAIR group, 209 patients (29.6%) died during follow-up vs. 193 patients (27.3%) in the DDDR group, hazard ratio (HR) 1.06, 95% confidence interval (CI) 0.88-1.29, P = 0.53. Paroxysmal atrial fibrillation was observed in 201 patients (28.4%) in the AAIR group vs. 163 patients (23.0%) in the DDDR group, HR 1.27, 95% CI 1.03-1.56, P = 0.024. A total of 240 patients underwent one or more pacemaker reoperations during follow-up, 156 (22.1%) in the AAIR group vs. 84 (11.9%) in the DDDR group (HR 1.99, 95% CI 1.53-2.59, P < 0.001). The incidence of chronic atrial fibrillation, stroke, and heart failure did not differ between treatment groups.
CONCLUSION: In patients with sick sinus syndrome, there is no statistically significant difference in death from any cause between AAIR pacing and DDDR pacing. AAIR pacing is associated with a higher incidence of paroxysmal atrial fibrillation and a two-fold increased risk of pacemaker reoperation. These findings support the routine use of DDDR pacing in these patients.
CLINICAL TRIAL REGISTRATION: URL http://www.clinicaltrials.gov. Unique identifier: NCT00236158.

PMID 21300730  Eur Heart J. 2011 Mar;32(6):686-96. doi: 10.1093/eurhea・・・
著者: Dian A Munawar, Rajiv Mahajan, Thomas A Agbaedeng, Anand Thiyagarajah, Darragh J Twomey, Kashif Khokhar, Catherine O'Shea, Glenn D Young, Kurt C Roberts-Thomson, Muhammad Munawar, Dennis H Lau, Prashanthan Sanders
雑誌名: Heart Rhythm. 2019 Aug;16(8):1204-1214. doi: 10.1016/j.hrthm.2019.02.020. Epub 2019 Feb 14.
Abstract/Text BACKGROUND: Atrial fibrillation (AF) is common after pacemaker implantation. However, the impact of pacemaker algorithms in AF prevention is not well understood.
OBJECTIVE: The purpose of this study was to evaluate the role of pacing algorithms in preventing AF progression.
METHODS: A systematic search of articles using the PubMed and Embase databases resulted in a total of 754 references. After exclusions, 21 randomized controlled trials (8336 patients) were analyzed, comprising studies reporting ventricular pacing percentage (VP%) (AAI vs DDD, n = 1; reducing ventricular pacing [RedVP] algorithms, n = 2); and atrial pacing therapies (atrial preference pacing [APP], n = 14; atrial antitachycardia pacing [aATP]+APP, n = 3; RedVP+APP+aATP, n = 1).
RESULTS: Low VP% (<10%) lead to a nonsignificant reduction in the progression of AF (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.57-1.13; P = .21; I2 = 67%) compared to high VP% (>10%). APP algorithm reduced premature atrial complexes (PAC) burden (mean difference [MD] -1117.74; 95% CI -1852.36 to -383.11; P = .003; I2 = 67%) but did not decrease AF burden (MD 8.20; 95% CI -5.39 to 21.80; P = .24; I2 = 17%) or AF episodes (MD 0.00; 95% CI -0.24 to 0.25; P = .98; I2 = 0%). Similarly, aATP+APP programming showed no significant difference in AF progression (odds ratio 0.65; 95% CI 0.36-1.14; P = .13; I2 = 61%). No serious adverse events related to algorithm were reported.
CONCLUSION: This meta-analysis of randomized controlled trials demonstrated that algorithms to reduce VP% can be considered safe. Low burden VP% did not significantly suppress AF progression. The atrial pacing therapy algorithms could suppress PAC burden but did not prevent AF progression.

Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.
PMID 30772532  Heart Rhythm. 2019 Aug;16(8):1204-1214. doi: 10.1016/j.・・・
著者: B F Gage, A D Waterman, W Shannon, M Boechler, M W Rich, M J Radford
雑誌名: JAMA. 2001 Jun 13;285(22):2864-70.
Abstract/Text CONTEXT: Patients who have atrial fibrillation (AF) have an increased risk of stroke, but their absolute rate of stroke depends on age and comorbid conditions.
OBJECTIVE: To assess the predictive value of classification schemes that estimate stroke risk in patients with AF.
DESIGN, SETTING, AND PATIENTS: Two existing classification schemes were combined into a new stroke-risk scheme, the CHADS( 2) index, and all 3 classification schemes were validated. The CHADS( 2) was formed by assigning 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and by assigning 2 points for history of stroke or transient ischemic attack. Data from peer review organizations representing 7 states were used to assemble a National Registry of AF (NRAF) consisting of 1733 Medicare beneficiaries aged 65 to 95 years who had nonrheumatic AF and were not prescribed warfarin at hospital discharge.
MAIN OUTCOME MEASURE: Hospitalization for ischemic stroke, determined by Medicare claims data.
RESULTS: During 2121 patient-years of follow-up, 94 patients were readmitted to the hospital for ischemic stroke (stroke rate, 4.4 per 100 patient-years). As indicated by a c statistic greater than 0.5, the 2 existing classification schemes predicted stroke better than chance: c of 0.68 (95% confidence interval [CI], 0.65-0.71) for the scheme developed by the Atrial Fibrillation Investigators (AFI) and c of 0.74 (95% CI, 0.71-0.76) for the Stroke Prevention in Atrial Fibrillation (SPAF) III scheme. However, with a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS( 2) index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS( 2) score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6.
CONCLUSION: The 2 existing classification schemes and especially a new stroke risk index, CHADS( 2), can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.

PMID 11401607  JAMA. 2001 Jun 13;285(22):2864-70.

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから