今日の臨床サポート

高度・完全房室ブロック

著者: 安喰恒輔 川口工業総合病院

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:2021/09/01
参考ガイドライン:
  1. 日本循環器学会/日本不整脈心電学会:不整脈非薬物治療ガイドライン(2018年改訂版)(2018 JCS/JHRS Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias)
  1. 日本循環器学会/日本不整脈心電学会:不整脈薬物治療ガイドライン(2020 年改訂版)(JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias)
  1. 日本循環器学会/日本不整脈心電学会:2021 年 JCS / JHRS ガイドライン 不整脈非薬物治療 フォーカスアップデート版(JCS / JHRS 2021 Guideline Focused Update on Non-Pharmacotherapy of Cardiac Arrhythmias)
  1. American College of Cardiology (ACC)/American Heart Association (AHA)/[https://www.hrsonline.org Heart Rhythm Society (HRS): 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society
  1. European Society of Cardiology (ESC): 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy.
患者向け説明資料

概要・推奨   

  1. 成人慢性完全房室ブロックの治療は、ペースメーカー植込みを原則とする(推奨度1)。
  1. 無症候性の成人先天性完全房室ブロックでも、ペースメーカー植込みが推奨される(推奨度2)。
  1. 心室拍数が低いほどブロック部位は下流であり、治療を急ぐことが強く推奨される(推奨度1)。
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  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
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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:
安喰恒輔 : 特に申告事項無し[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. 参照ガイドラインを最新のものに改めた。 
  1. 房室ブロックの原因となりうる薬剤を追加した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 高度房室ブロック(advanced atrioventricular block、AVB)とは、生理的心房レートで房室伝導比が3:1以下に低下した病態である。房室伝導が完全に途絶しているものを完全房室ブロック(complete AVB)または第3度房室ブロック(3rd degree AVB)と呼ぶ。両者は基本的に同等の病態である。
 
高度房室ブロック

3つのP波に対して1つのQRS波が対応し、房室伝導比は3:1となっている。

出典

img1:  著者提供
 
 
 
完全房室ブロック

12誘導心電図のV1誘導のみ示す。心拍数は30/分と高度の徐脈を呈している。P波とQRS波の間にまったく関連がない(房室解離)。

出典

img1:  著者提供
 
 
 
  1. 一般人口を対象とした調査では完全房室ブロックの頻度は0.016%[1]、成人を対象とした場合には0.18%[2][3]との報告がある。先天性完全房室ブロックでは、2万2,000出生当たり1人と報告されている[4]。完全房室ブロックの頻度は加齢および基礎心疾患の存在とともに増加する。
  1. 診断に際しては心電図記録が必須であり、治療に際しては基礎疾患と誘因の同定がきわめて重要である。
  1. 可逆的原因によらない後天性高度・完全房室ブロックを放置した場合、予後は不良で、早期診断・治療が必要である。
問診・診察のポイント  
緊急対応の必要性の確認:
  1. アダムス・ストークス発作と心不全の症状・徴候の有無・重症度を評価する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: D B Shaw, D Eraut
雑誌名: Br Med J. 1970 Jan 17;1(5689):144-7.
Abstract/Text In a survey in the Exeter area 139 patients with some degrees of abnormal atrioventricular conduction were notified by 282 family doctors. Per 100,000 of the population the prevalence of second-degree and thrid-degree heart block was estimated to be 17.3, of complete block past or present 15.6, and of complete block at the time of survey 13.1. Heart block was commoner in men than women, the sex ratio being 1.4 to 1; its prevalence increased steeply with age, and the morbidity rate was less than that reported by others. If the morbidity figures quoted in this survey are representative of the general population, it reaffirms the policy that pacemakers should be recommended for selected patients only.

PMID 5413952  Br Med J. 1970 Jan 17;1(5689):144-7.
著者: M R HEJTMANCIK, G R HERRMANN, A H SHIELDS, J C WRIGHT
雑誌名: Am Heart J. 1956 Sep;52(3):369-78.
Abstract/Text
PMID 13354599  Am Heart J. 1956 Sep;52(3):369-78.
著者: J C ROWE, P D WHITE
雑誌名: Ann Intern Med. 1958 Aug;49(2):260-70.
Abstract/Text
PMID 13571817  Ann Intern Med. 1958 Aug;49(2):260-70.
著者: R A Friedman, A L Fenrich, N J Kertesz
雑誌名: Pacing Clin Electrophysiol. 2001 Nov;24(11):1681-8.
Abstract/Text
PMID 11816640  Pacing Clin Electrophysiol. 2001 Nov;24(11):1681-8.
著者: Riina Kandolin, Jukka Lehtonen, Markku Kupari
雑誌名: Circ Arrhythm Electrophysiol. 2011 Jun;4(3):303-9. doi: 10.1161/CIRCEP.110.959254. Epub 2011 Mar 22.
Abstract/Text BACKGROUND: Cardiac sarcoidosis (CS) and giant cell myocarditis (GCM) may present as high-degree atrioventricular block (AVB), but their proportion of the causal spectrum of AVB is not well-known. We investigated the prevalence of biopsy-verified CS and GCM in young and middle-aged adults undergoing pacemaker (PM) implantation for AVB.
METHODS AND RESULTS: We used the PM registry of Helsinki University Central Hospital to identify all patients aged 18 to 55 years who underwent PM implantation for AVB between January 1999 and April 2009 and reviewed their medical records. In total, 133 patients had either second- or third-degree AVB as an indication for PM. Of them, 61 had a known cause for AVB, and they were excluded from further analyses. Among the remaining 72 patients with initially unexplained AVB, biopsy-verified CS or GCM was found in 14 (19%) and 4 (6%) patients, respectively. The majority (16/18, 89%) were women. Among the adult patients aged <55 years, the prevalence of CS and GCM combined was 14% (95% CI, 7.7% to 19.3%) of the whole AVB population and 25% (95% CI, 15% to 35%) of those with an initially unexplained AVB. Over an average of 48 months of follow-up, 7 (39%) of 18 patients with CS or GCM versus 1 of the 54 patients in whom AVB remained idiopathic, experienced either cardiac death, cardiac transplantation, ventricular fibrillation, or treated sustained ventricular tachycardia (P<0.001).
CONCLUSIONS: CS and GCM explain ≥25% of initially unexplained AVB in young and middle-aged adults. These patients are at high risk for adverse cardiac events.

PMID 21427276  Circ Arrhythm Electrophysiol. 2011 Jun;4(3):303-9. doi:・・・
著者: Chiung-Zuan Chiu, Satoshi Nakatani, Guican Zhang, Teruo Tachibana, Fumio Ohmori, Masakazu Yamagishi, Masafumi Kitakaze, Hitonobu Tomoike, Kunio Miyatake
雑誌名: Am J Cardiol. 2005 Jan 1;95(1):143-6. doi: 10.1016/j.amjcard.2004.08.083.
Abstract/Text Forty-three patients with cardiac sarcoidosis were studied echocardiographically before and after (mean follow-up 88 months) steroid therapy to determine the effectiveness of corticosteroids to prevent left ventricular (LV) remodeling and improve LV contractility. In patients with initial LV ejection fractions (LVEFs) >or=55%, long-term steroid therapy showed preventive effects for LV remodeling and LV function. Patients with LVEF <54% showed significant reductions of LV volumes and LVEF improvement. However, in patients with LVEFs <30%, steroid therapy resulted in neither LV volume reductions nor improved LVEFs. In the early or middle stage of the disease, steroid therapy may be protective or therapeutic in preventing LV remodeling and preserving LV function. However, it may not be as effective in the late stage.

PMID 15619415  Am J Cardiol. 2005 Jan 1;95(1):143-6. doi: 10.1016/j.am・・・
著者: R S Cosby, F Lau, R Rhode, E Cafferky, M Mayo
雑誌名: Am J Cardiol. 1966 Feb;17(2):190-3.
Abstract/Text
PMID 5902824  Am J Cardiol. 1966 Feb;17(2):190-3.
著者: B W Johansson
雑誌名: Acta Med Scand Suppl. 1966;451:1-127.
Abstract/Text
PMID 5223645  Acta Med Scand Suppl. 1966;451:1-127.
著者: O Edhag, A Swahn
雑誌名: Acta Med Scand. 1976;200(6):457-63.
Abstract/Text This paper reports the results of a retrospective study carried out with special reference to the survival rate in a series of 101 selected cases including patients with complete heart block (CHB) combined or not combined with Adams-Stokes attacks and patients with arrhythmic syncope without ECG evidence of CHB. All these patients were treated in our Department during 1958-68, none being artificially paced. Twenty-seven patients were alive at the end of the follow-up, i,e 6-15 years after admission to this Department on account of syncopal episodes or CHB. The survival rate--higher in females than males--was lower in the cases of CHB combined with Adams-Stokes attacks than in the cases of asymptomatic CHB. This applied also to the instances in which a complicating disease such as ischaemic heart disease (IHD), hypertension, diabetes, digitalis intoxication or cardiac enlargement coexisted. The survival rate in the 68 cases of CHB was higher at one year (68%) as well as at 5 years (37%) than that reported by other investigators. When assessing the survival rate in cases treated with artificial pacemakers, it is important to study the individual case histories with special reference to a previous or coexisting condition such as IHD, hypertension, diabetes or the presence of cardiac enlargement. The present results support the view that the indications for treatment with artificial pacing should be wide, albeit that the prognosis in this series was more favourable than might have been anticipated from observations by others.

PMID 1015354  Acta Med Scand. 1976;200(6):457-63.
著者: R E TABER, L R ESTOYE, E R GREEN, T GAHAGAN
雑誌名: Circulation. 1964 Feb;29:182-5.
Abstract/Text
PMID 14119383  Circulation. 1964 Feb;29:182-5.
著者: M Michaëlsson, A Jonzon, T Riesenfeld
雑誌名: Circulation. 1995 Aug 1;92(3):442-9.
Abstract/Text BACKGROUND: The prognosis of congenital complete atrioventricular block (CCHB) is usually considered favorable in adults. This belief is based on studies comprising a limited number of patients and with rather short observation times. In the present study, the natural history of the disease was investigated by a prospective follow-up through decades of adult life of patients with a large group having well-defined CCHB without structural heart disease.
METHODS AND RESULTS: The diagnostic criteria of CCHB proposed by Yater were applied. Patients registered as having CCHB in 1964, supplemented by younger patients all without symptoms during their first 15 years of life, were selected. The study was limited to patients with isolated, complete, permanent block. An interview was conducted with all patients and clinical follow-up data obtained. There were finally 102 patients, 61 women and 41 men. In November 1994, the time of observation, after the age of 15 years in survivors, was between 7 and 30 years. The mean age at follow-up or at death was 38 years, median age 37 years, and range 16 to 66 years. Stokes-Adams (SA) attacks occurred in 27 patients, in 8 with a fatal outcome. The first attack was fatal in 6 of these 8 patients. Nineteen survived and a pacemaker (PM) was implanted thereafter. Another 8 patients received a PM because of repeated fainting spells, and 27 others have had a PM implanted for other reasons such as fatigue, effort dyspnea, dizziness, ectopies during exercise tests, mitral regurgitation, and a low ventricular rate (VR). VR decreased with age, with a mean rate at 15 years of 46 beats per minute (bpm), at 16 to 20 years of 43 bpm, at 21 to 30 years of 41 bpm, at 31 to 40 years of 40 bpm, and after 40 years of age of 39 bpm. SA attacks occurred in all 7 patients with prolonged QTc time. Low VR at rest or at work, presence of bundle-branch block pattern, low working capacity, and ectopies at rest and/or during effort were not statistically significant risk factors. SA attacks occurred in 6 patients without any of these signs. Mitral regurgitation developed in 16 patients and 4 died. A PM reduced the risk of death. A change to a lower degree of block occurred in 6 patients.
CONCLUSIONS: Prophylactic PM treatment is recommended even for symptom-free adults with CCHB because of the high incidence of unpredictable SA attacks with considerable mortality from first attacks, a gradually decreasing VR, significant morbidity, and a high incidence of "acquired" mitral insufficiency.

PMID 7634461  Circulation. 1995 Aug 1;92(3):442-9.
著者: E B Esscher
雑誌名: Eur Heart J. 1981 Aug;2(4):281-8.
Abstract/Text
PMID 7297570  Eur Heart J. 1981 Aug;2(4):281-8.
著者: K M Rosen, R C Dhingra, H S Loeb, S H Rahimtoola
雑誌名: Arch Intern Med. 1973 May;131(5):663-72.
Abstract/Text
PMID 4701376  Arch Intern Med. 1973 May;131(5):663-72.
著者: E M McNally, A Benchimol
雑誌名: Am Heart J. 1968 Mar;75(3):380-98.
Abstract/Text
PMID 4867001  Am Heart J. 1968 Mar;75(3):380-98.
著者: K McDonald, J J O'Sullivan, R M Conroy, K Robinson, R Mulcahy
雑誌名: Q J Med. 1990 Mar;74(275):277-82.
Abstract/Text We investigated the relationship between atrioventricular block and in-hospital mortality in 705 successive patients admitted with a first Q-wave myocardial infarction of the anterior or inferior wall. Second- or third-degree atrioventricular block developed in 61 (8.6 per cent) patients and was more frequent in inferior (12.4 per cent) than anterior infarctions (4.9 per cent). A multiple logistic regression identified three factors which were independently correlated with block: inferior infarction, older age and larger infarct size as determined by cardiac enzymes. Mortality was 27.9 per cent in patients with block and 9.3 per cent in those without; it was significantly higher in both anterior (47.0 per cent vs 11.8 per cent) and inferior (20.4 per cent vs 6.7 per cent) infarction groups. When age, infarct size, infarct site and block were analysed simultaneously as predictors of death, block was a significant independent prognostic factor. The relative risk of death, corrected for age and infarct size, in patients showing block was similar for anterior and inferior infarction. Analysis of deaths revealed a higher incidence of unheralded death in inferior infarcts associated with high-degree block.

PMID 2385734  Q J Med. 1990 Mar;74(275):277-82.
著者: P B Berger, N A Ruocco, T J Ryan, M M Frederick, A K Jacobs, D P Faxon
雑誌名: J Am Coll Cardiol. 1992 Sep;20(3):533-40.
Abstract/Text OBJECTIVES: The aim of this study was to determine the incidence and significance of second- or third-degree heart block among patients with inferior myocardial infarction treated with thrombolytic therapy.
BACKGROUND: Data from the prethrombolytic era suggest that heart block occurs in approximately 20% of patients with acute inferior myocardial infarction and is associated with a marked increase in mortality. Little is known about the incidence and prognostic implications of heart block among patients receiving thrombolytic therapy.
METHODS: We studied 1,786 patients with acute inferior myocardial infarction enrolled in the Thrombolysis in Myocardial Infarction (TIMI) II Trial who received recombinant tissue-type plasminogen activator (rt-PA) within 4 h of the onset of symptoms.
RESULTS: Heart block occurred in 214 patients (12%); 113 (6.3%) had heart block on presentation and 101 (5.7%) developed heart block in the 24 h after treatment with rt-PA. Patients with heart block at entry were slightly older and a greater proportion had cardiogenic shock. The 21-day mortality rate among patients with heart block at entry was 7.1% (8 of 113), compared with 2.7% (45 of 1,673) among patients without heart block at study entry (relative risk 2.6, p = 0.007). However, heart block was not independently associated with 21-day mortality after adjustment for other variables, including shock. Mortality and other adverse cardiac events in the following year were similar among patients with and without heart block. Among patients without heart block at study entry, coronary angiography among patients randomly assigned to coronary catheterization 18 to 48 h after admission revealed that the infarct-related artery was occluded in 28.2% (11 of 39) of patients who developed heart block versus 15.5% (112 of 723) of patients without heart block (p = 0.04). The 21-day mortality rate was increased among patients in whom heart block developed after thrombolytic therapy (9.9% [10 of 101] versus 2.2% [35 of 1,572] of patients without heart block, relative risk 4.5, p less than 0.001). Analysis of the increased mortality among patients who developed heart block suggests that mortality was due to severe cardiac dysfunction; no patient was considered to have died as a result of the heart block or its treatment.
CONCLUSIONS: Heart block is common among patients with inferior infarction given thrombolytic therapy and is associated with increased mortality. These clinical and anatomic data provide insight into the mechanism of heart block and increased mortality among such patients.

PMID 1512330  J Am Coll Cardiol. 1992 Sep;20(3):533-40.
著者: P Nicod, E Gilpin, H Dittrich, R Polikar, H Henning, J Ross
雑誌名: J Am Coll Cardiol. 1988 Sep;12(3):589-94.
Abstract/Text Some studies have reported increased short-term mortality and higher incidence of multivessel coronary artery disease in patients with inferior myocardial infarction and complete heart block, but information is lacking on clinical outcome after hospital discharge. Therefore, data were obtained and analyzed in 749 patients who were admitted with inferior myocardial infarction to four different centers and followed up for 1 year. Six hundred fifty-four patients (Group 1) did not have complete heart block and 95 (Group 2) had complete heart block during their hospital stay (incidence rate 12.8%). Compared with Group 1, Group 2 patients were older (66 versus 61 years, p less than 0.01), more often had signs of left ventricular failure (p less than 0.001) and had higher peak creatine kinase values (1,840 versus 1,322 IU/liter, p less than 0.001). The in-hospital mortality rate was higher in Group 2 than in Group 1 (24.2 versus 6.3%, p less than 0.001). However, at discharge there was no difference between Group 1 and Group 2 in clinical characteristics, left ventricular ejection fraction (0.52 +/- 0.12 versus 0.52 +/- 0.11) or incidence of complex ventricular arrhythmias on ambulatory electrocardiographic monitoring. Furthermore, during the year after hospital discharge, patients in Groups 1 and 2 did not have significantly different mortality rates (6.4 versus 10.1%, p = NS). The incidence rate of reinfarction (4%) was the same in Groups 1 and 2. The incidence of coronary artery bypass surgery was slightly but not significantly higher in Group 1 compared with Group 2 (11 versus 4%).(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 3403817  J Am Coll Cardiol. 1988 Sep;12(3):589-94.
著者: T J Ryan, J L Anderson, E M Antman, B A Braniff, N H Brooks, R M Califf, L D Hillis, L F Hiratzka, E Rapaport, B J Riegel, R O Russell, E E Smith, W D Weaver
雑誌名: Circulation. 1996 Nov 1;94(9):2341-50.
Abstract/Text
PMID 8901709  Circulation. 1996 Nov 1;94(9):2341-50.
著者: Writing Committee Members, Fred M Kusumoto, Mark H Schoenfeld, Coletta Barrett, James R Edgerton, Kenneth A Ellenbogen, Michael R Gold, Nora F Goldschlager, Robert M Hamilton, José A Joglar, Robert J Kim, Richard Lee, Joseph E Marine, Christopher J McLeod, Keith R Oken, Kristen K Patton, Cara N Pellegrini, Kimberly A Selzman, Annemarie Thompson, Paul D Varosy
雑誌名: Heart Rhythm. 2019 Sep;16(9):e227-e279. doi: 10.1016/j.hrthm.2018.10.036. Epub 2018 Nov 6.
Abstract/Text
PMID 30412777  Heart Rhythm. 2019 Sep;16(9):e227-e279. doi: 10.1016/j.・・・
著者: Michele Brignole, Angelo Auricchio, Gonzalo Baron-Esquivias, Pierre Bordachar, Giuseppe Boriani, Ole-A Breithardt, John Cleland, Jean-Claude Deharo, Victoria Delgado, Perry M Elliott, Bulent Gorenek, Carsten W Israel, Christophe Leclercq, Cecilia Linde, Lluís Mont, Luigi Padeletti, Richard Sutton, Panos E Vardas, ESC Committee for Practice Guidelines (CPG), Jose Luis Zamorano, Stephan Achenbach, Helmut Baumgartner, Jeroen J Bax, Héctor Bueno, Veronica Dean, Christi Deaton, Cetin Erol, Robert Fagard, Roberto Ferrari, David Hasdai, Arno W Hoes, Paulus Kirchhof, Juhani Knuuti, Philippe Kolh, Patrizio Lancellotti, Ales Linhart, Petros Nihoyannopoulos, Massimo F Piepoli, Piotr Ponikowski, Per Anton Sirnes, Juan Luis Tamargo, Michal Tendera, Adam Torbicki, William Wijns, Stephan Windecker, Document Reviewers, Paulus Kirchhof, Carina Blomstrom-Lundqvist, Luigi P Badano, Farid Aliyev, Dietmar Bänsch, Helmut Baumgartner, Walid Bsata, Peter Buser, Philippe Charron, Jean-Claude Daubert, Dan Dobreanu, Svein Faerestrand, David Hasdai, Arno W Hoes, Jean-Yves Le Heuzey, Hercules Mavrakis, Theresa McDonagh, Jose Luis Merino, Mostapha M Nawar, Jens Cosedis Nielsen, Burkert Pieske, Lidija Poposka, Frank Ruschitzka, Michal Tendera, Isabelle C Van Gelder, Carol M Wilson
雑誌名: Eur Heart J. 2013 Aug;34(29):2281-329. doi: 10.1093/eurheartj/eht150. Epub 2013 Jun 24.
Abstract/Text
PMID 23801822  Eur Heart J. 2013 Aug;34(29):2281-329. doi: 10.1093/eur・・・
著者: M A Alpert, J J Curtis, J F Sanfelippo, G C Flaker, J T Walls, V Mukerji, D Villarreal, S K Katti, N P Madigan, R B Krol
雑誌名: J Am Coll Cardiol. 1986 Apr;7(4):925-32.
Abstract/Text To determine whether survival after permanent ventricular demand (VVI) pacing differs from survival after permanent dual chamber (DVI or DDD) pacing in patients with chronic high degree atrioventricular (AV) block (Mobitz type II or trifascicular block), 132 patients who received a VVI pacemaker (Group 1) and 48 patients who received a DVI or DDD pacemaker (Group 2) were followed up for 1 to 5 years. There was no significant difference in sex distribution, mean age or incidence of coronary heart disease, hypertension, valvular heart disease, diabetes mellitus, stroke or renal failure between Groups 1 and 2. Overall, the predicted cumulative survival rate at 1, 3 and 5 years was 89, 76 and 73%, respectively, for Group 1 and 95, 82 and 70%, respectively, for Group 2. In patients with preexistent congestive heart failure, the predicted cumulative survival rate at 1, 3 and 5 years was 85, 66 and 47%, respectively, for Group 1 (n = 53) and 94, 81 and 69%, respectively, for Group 2 (n = 20). The 5 year predicted cumulative survival rate was significantly lower in Group 1 patients with preexistent congestive heart failure than in Group 2 patients with the same condition (p less than 0.02). There was no significant difference in 5 year cumulative survival rate between Groups 1 and 2 for patients without preexistent congestive heart failure. The results suggest that permanent dual chamber pacing enhances survival to a greater extent than does permanent ventricular demand pacing in patients with high degree AV block and preexistent congestive heart failure.

PMID 3958351  J Am Coll Cardiol. 1986 Apr;7(4):925-32.
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: J Dretzke, W D Toff, G Y H Lip, J Raftery, A Fry-Smith, R Taylor
雑誌名: Cochrane Database Syst Rev. 2004;(2):CD003710. doi: 10.1002/14651858.CD003710.pub2.
Abstract/Text BACKGROUND: Dual chamber pacing or single chamber atrial pacing ('physiologic' pacing) is believed to have an advantage over single chamber ventricular pacing in that it resembles cardiac physiology more closely by maintaining atrioventricular (AV) synchrony and dominance of the sinus node, which in turn may reduce cardiovascular morbidity and mortality thus contributing to patient survival and quality of life. However, a significant proportion of pacemakers currently implanted are single chamber ventricular pacemakers.
OBJECTIVES: The objective of this review was to assess the short- and long-term clinical effectiveness of dual chamber pacemakers compared to single chamber ventricular pacemakers in adults with AV block, sick sinus syndrome or both. An additional objective was to assess separately any potential differences in effectiveness between dual chamber pacing and single chamber atrial pacing. The clinical effectiveness of single chamber atrial pacing versus single chamber ventricular pacing was not examined.
SEARCH STRATEGY: The Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2002), MEDLINE (1966 to 2002), EMBASE (1980 to 2002) and the Science Citation Index (1980 to 2002) were searched on 19th August 2002. Citation lists and web sites were checked and researchers in the field contacted.
SELECTION CRITERIA: Parallel group or crossover randomised controlled trials of at least 48 hours duration comparing dual chamber pacing and single chamber ventricular pacing, and investigating cardiovascular morbidity, mortality, patient related quality of life, exercise capacity and complication rates.
DATA COLLECTION AND ANALYSIS: Data was extracted onto pre-piloted data extraction forms. Quality assessment was undertaken using a checklist, with a sub-sample of quality data independently extracted by a second reviewer. Where appropriate data was available, meta-analysis was performed. Where meta-analysis was not possible, the number of studies showing a positive, neutral or negative direction of effect and statistical significance were simply counted.
MAIN RESULTS: Five parallel and 26 crossover randomised controlled trials were identified. The quality of reporting was found to be poor. Pooled data from parallel studies shows a statistically non-significant preference for physiologic pacing (primarily dual chamber pacing) for the prevention of stroke, heart failure and mortality, and a statistically significant beneficial effect regarding the prevention of atrial fibrillation (odds ratio (OR) 0.79, 95% CI 0.68 to 0.93). Both parallel and crossover studies favour dual chamber pacing with regard to pacemaker syndrome (parallel: Peto OR 0.11, 95% CI 0.08 to 0.14; crossover: standardised mean difference (SMD) -0.74, 95% CI - 0.95 to -0.52). Pooled data from crossover studies shows a statistically significant trend towards dual chamber pacing being more favourable in terms of exercise capacity (SMD -0.24, 95% CI -0.03 to -0.45). No individual studies reported a significantly more favourable outcome with single chamber ventricular pacing.
REVIEWERS' CONCLUSIONS: This review shows a trend towards greater effectiveness with dual chamber pacing compared to single chamber ventricular pacing, which supports the current British Pacing and Electrophysiology Group's Guidelines regarding atrioventricular block. Additional randomised controlled trial evidence from ongoing trials in this area will further inform the debate.

PMID 15106214  Cochrane Database Syst Rev. 2004;(2):CD003710. doi: 10.・・・
著者: E Castelnuovo, K Stein, M Pitt, R Garside, E Payne
雑誌名: Health Technol Assess. 2005 Nov;9(43):iii, xi-xiii, 1-246.
Abstract/Text OBJECTIVES: To estimate the effectiveness and cost-effectiveness of dual-chamber pacemakers versus single-chamber atrial or single-chamber ventricular pacemakers in the treatment of bradycardia due to sick sinus syndrome (SSS) or atrioventricular block (AVB).
DATA SOURCES: Electronic databases and relevant Internet sites. Contact with device manufacturers and experts in the field.
REVIEW METHODS: A systematic review was carried out of randomised controlled trials (RCTs). The quality of selected studies was appraised using standard frameworks. Meta-analyses, using random effects models, were carried out where appropriate. Limited exploration of heterogeneity was possible. Critical appraisal of economic evaluations was carried out using two frameworks. A decision-analytic model was developed using a Markov approach, to estimate the cost-effectiveness of dual-chamber versus ventricular or atrial pacing over 5 and 10 years as cost per quality-adjusted life-year (QALY). Uncertainty was explored using one-way and probabilistic sensitivity analyses.
RESULTS: The searches retrieved a systematic review of effectiveness and cost-effectiveness published in 2002, four parallel group RCTs and 28 cross-over trials. Dual-chamber pacing was associated with lower rates of atrial fibrillation, particularly in SSS, than ventricular pacing, and prevents pacemaker syndrome. Higher rates of atrial fibrillation were seen with dual-chamber pacing than with atrial pacing. Complications occurred more frequently in dual-chamber pacemaker insertion. The cost of a dual-chamber system, over 5 years, including cost of complications and subsequent clinical events in the population, was estimated to be around 7400 pounds. The overall cost difference between single and dual systems is not large over this period: around 700 pounds more for dual-chamber devices. The cost-effectiveness of dual-chamber compared with ventricular pacing was estimated to be around 8500 pounds per QALY in AVB and 9500 pounds in SSS over 5 years, and around 5500 pounds per QALY in both populations over 10 years. Under more conservative assumptions, the cost-effectiveness of dual-chamber pacing is around 30,000 pounds per QALY. The probabilistic sensitivity analysis showed that, under the base-case assumptions, dual-chamber pacing is likely to be considered cost-effective at levels of willingness to pay that are generally considered acceptable by policy makers. In contrast, atrial pacing may be cost-effective compared with dual-chamber pacing.
CONCLUSIONS: Dual-chamber pacing results in small but potentially important benefits in populations with SSS and/or AVB compared with ventricular pacemakers. Pacemaker syndrome is a crucial factor in determining cost-effectiveness; however, difficulties in standardising diagnosis and measurement of severity make it difficult to quantify. Dual-chamber pacing is in common usage in the UK. Recipients are more likely to be younger. Insufficient evidence is currently available to inform policy on specific groups who may benefit most from pacing with dual-chamber devices. Further important research is underway. Outstanding research priorities include the economic evaluation of UKPACE studies of the classification, diagnosis and utility associated with pacemaker syndrome and evidence on the effectiveness of pacemakers in children.

PMID 16266560  Health Technol Assess. 2005 Nov;9(43):iii, xi-xiii, 1-2・・・
著者: Sana Ouali, Elyes Neffeti, Karima Ghoul, Sami Hammas, Slim Kacem, Rim Gribaa, Fahmi Remedi, Essia Boughzela
雑誌名: Pacing Clin Electrophysiol. 2010 May;33(5):583-9. doi: 10.1111/j.1540-8159.2009.02636.x. Epub 2009 Dec 10.
Abstract/Text BACKGROUND: Dual-chamber pacing is believed to have an advantage over single-chamber ventricular pacing. The aim of the study was to determine whether elderly patients with implanted pacemaker for complete atrioventricular block gain significant benefit from dual-chamber (DDD) compared with single-chamber ventricular demand (VVIR).
METHODS: The study was designed as a double-blind randomized two-period crossover study-each pacing mode was maintained for 3 months. Thirty patients (eight men, mean age 76.5 +/- 4.3 years) with implanted PM were submitted to a standard protocol, which included an interview, functional class assessment, quality of life (QoL) questionnaires, 6-minute walk test, and transthoracic echocardiographic examinations. QoL was measured by the SF-36. All these parameters were obtained on DDD mode pacing and VVIR mode pacing. Paired data were compared.
RESULTS: QoL was significantly different between the two groups and showed the best values in DDD. Overall, no patient preferred VVIR mode, 18 preferred DDD mode, and 12 expressed no preference. No differences in mean walking distances were observed between patients with single-chamber and dual-chamber pacing. VVI pacing elicited marked decrease in left ventricle ejection fraction and significant enlargement of the left atrium. DDD pacing resulted in significant increase of the peak systolic velocities in lateral mitral annulus and septal mitral annulus. Early diastolic velocities on both sides of mitral annulus did not change.
CONCLUSION: In active elderly patients with complete heart block, DDD pacing is associated with improved quality of life and systolic ventricular function compared with VVI pacing.

PMID 20015129  Pacing Clin Electrophysiol. 2010 May;33(5):583-9. doi: ・・・
著者: Oscar Cano, Joaquín Osca, María-José Sancho-Tello, Juan M Sánchez, Víctor Ortiz, José E Castro, Antonio Salvador, José Olagüe
雑誌名: Am J Cardiol. 2010 May 15;105(10):1426-32. doi: 10.1016/j.amjcard.2010.01.004. Epub 2010 Mar 30.
Abstract/Text Chronic right ventricular apical pacing (RVAP) has been associated with negative hemodynamic and clinical effects. The aim of the present study was to compare RVAP with right ventricular septal pacing (RVSP) in terms of echocardiographic features and clinical outcomes. A total of 93 patients without structural heart disease and with an indication for a permanent pacemaker were randomly assigned to receive a screw-in lead either in the RV apex (n = 46) or in the RV mid-septum (n = 47). The patients were divided into 3 subgroups according to the percentage of ventricular pacing: control group (n = 21, percentage of ventricular pacing < or =10%), RVAP group (n = 28), or RVSP group (n = 32; both latter groups had a percentage of ventricular pacing >10%). The RVAP group had more intraventricular dyssynchrony and a trend toward a worse left ventricular ejection fraction compared to the RVSP and control groups at 12 months of follow-up (maximal delay to peak systolic velocity between any of the 6 left ventricular basal segments was 57.8 +/- 38.2, 35.5 +/- 20.6, and 36.5 +/- 17.8 ms for RVAP, RVSP, and control group, respectively; p = 0.006; mean left ventricular ejection fraction 62.9 +/- 7.9%, 66.5 +/- 7.2%, and 66.6 +/- 7.2%, respectively, p = 0.14). Up to 48.1% of the RVAP patients showed significant intraventricular dyssynchrony compared to 19.4% of the RVSP patients and 23.8% of the controls (p = 0.04). However, no overt clinical benefits from RVSP were found. In conclusion, RVAP was associated with increased dyssynchrony compared to the RVSP and control patients. RVSP could represent an alternative pacing site in selected patients to reduce the harmful effects of traditional RVAP.

Copyright 2010 Elsevier Inc. All rights reserved.
PMID 20451689  Am J Cardiol. 2010 May 15;105(10):1426-32. doi: 10.1016・・・
著者: Martin Stockburger, Juan José Gómez-Doblas, Gervasio Lamas, Javier Alzueta, Ignacio Fernández-Lozano, Erik Cobo, Uwe Wiegand, Joaquín Fernández de la Concha, Xavier Navarro, Francisco Navarro-López, Eduardo de Teresa
雑誌名: Eur J Heart Fail. 2011 Jun;13(6):633-41. doi: 10.1093/eurjhf/hfr041.
Abstract/Text AIMS: Previous experimental and clinical studies have consistently suggested that right ventricular (RV) apical pacing has important adverse effects. Ventricular pacing (VP), however, is required, and cannot be reduced in many patients with atrioventricular (AV) block. The PREVENT-HF study was an international randomized trial that explored differences in left ventricular (LV) remodelling during RV apical vs. biventricular (BIV) pacing in patients with AV block.
METHODS AND RESULTS: Patients with an expected VP prevalence ≥80% were assigned to RV apical or BIV pacing. The primary endpoint was the change in LV end-diastolic volume (EDV) >12 months. Secondary endpoints were LV end-systolic volume (ESV), LV ejection fraction (EF), mitral regurgitation (MR), and a combination of heart failure (HF) events and cardiovascular hospitalizations. Overall, 108 patients were randomized (RV: 58; BIV: 50). Intention to treat and on-treatment analyses revealed no significant differences in any of the outcomes. Analysis of covariance (ANCOVA) difference for treatment according to randomization (in mL): LVEDV -3.92 (-18.71 to 10.85), P= 0.6; LVESV -1.38 (-12.07 to 9.31), P= 0.80; LVEF 2.47 (-3.00 to 7.94), P= 0.37. Analysis of covariance difference for the on-treatment analysis: LVEDV -4.90 (-20.02 to 10.22, PP= 0.52; LVESV -6.45 (-17.28 to 4.38), P= 0.24, LVEF 2.18 (-3.37 to 7.73), P= 0.44. Furthermore, secondary endpoints did not differ significantly.
CONCLUSION: This study did not demonstrate significant LV volume differences >12 months between RV apical and BIV pacing for AV block. Thus, BIV pacing cannot be recommended as a routine treatment for AV block in these patients. However, the results encourage and inform the design of subsequent larger trials with higher power for detecting small volume changes. ClinicalTrials.gov Identifier: NCT00170326.

PMID 21613427  Eur J Heart Fail. 2011 Jun;13(6):633-41. doi: 10.1093/e・・・

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