无创心电检查用于晕厥诊断的价值及局限性
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摘要
晕厥是一种常见症状,其诊疗涉及多个临床学科。它严重影响患者的生存质量,然而约1/3的晕厥病因不明,因此,晕厥的诊断评估非常重要。在神经介导性晕厥中,以血管迷走性晕厥为多见,预后良好;心源性晕厥多由心律失常所诱发,预后差、死亡率高。2017年ACC/AHA/HRS及2018年ESC发布的晕厥诊断与管理指南均对晕厥进行了危险因素分析,并制定了相应的诊疗评估流程。《晕厥诊断与治疗中国专家共识(2018)》充分肯定了上述指南中对晕厥的诊断评估标准及流程,并强调采用短期和长期危险分层方法,规范初步评估,旨在提高晕厥诊断率、节省医疗费用。本文结合各类无创心电检查的特点及其在晕厥诊断评估中的应用和局限性,建议根据晕厥发生的频率、程度与特点,合理选择心电检查项目,预防心源性晕厥导致的猝死。
Syncope is a commonly encountered symptom,and its diagnosis and treatment involve multiple clinical subjects. It seriously affects the life quality of patients,however,its etiology is unknown among about 1/3 of these patients. Therefore,the diagnosis and evaluation of syncope are very important. Vasovagal syncope is common in neurally-mediated syncope with good prognosis; cardiac syncope is often induced by arrhythmia with poor prognosis and high mortality. Both of the 2017 ACC/AHA/HRS and 2018 ESC guidelines for the diagnosis and management of syncope have analyzed the risk factors for syncope,and formulated clinical evaluation procedures correspondingly."Chinese expert consensus statement on clinical diagnosis and treatment of syncope 2018" fully affirmed the criteria and procedures of diagnosis and evaluation for syncope in the above guidelines,emphasized on short-and long-term risk stratification,and standardized initial assessment,in order to raise diagnosis rate and reduce medical cost. Based on characteristics of various noninvasive ECG examinations,and their application and limitations in the diagnosis and evaluation of syncope,this article suggests that ECG examination should be reasonably selected according to the frequency,severity and feature of syncope so as to prevent sudden death caused by cardiac syncope.
Syncope is a commonly encountered symptom,and its diagnosis and treatment involve multiple clinical subjects. It seriously affects the life quality of patients,however,its etiology is unknown among about 1/3 of these patients. Therefore,the diagnosis and evaluation of syncope are very important. Vasovagal syncope is common in neurally-mediated syncope with good prognosis; cardiac syncope is often induced by arrhythmia with poor prognosis and high mortality. Both of the 2017 ACC/AHA/HRS and 2018 ESC guidelines for the diagnosis and management of syncope have analyzed the risk factors for syncope,and formulated clinical evaluation procedures correspondingly."Chinese expert consensus statement on clinical diagnosis and treatment of syncope 2018" fully affirmed the criteria and procedures of diagnosis and evaluation for syncope in the above guidelines,emphasized on short-and long-term risk stratification,and standardized initial assessment,in order to raise diagnosis rate and reduce medical cost. Based on characteristics of various noninvasive ECG examinations,and their application and limitations in the diagnosis and evaluation of syncope,this article suggests that ECG examination should be reasonably selected according to the frequency,severity and feature of syncope so as to prevent sudden death caused by cardiac syncope.
引文
[1]Brignole M,Moya A,de Lange FJ,et al.2018 ESC guidelines for the diagnosis and management of syncope[J].Eur Heart J,2018,39(21):1883-1948.
[2]Ruwald MH,Hansen ML,Lamberts M,et al.The relation between age,sex,comorbidity,and pharmacotherapy and the risk of syncope:a Danish nationwide study[J].Europace,2012,14(10):1506-1514.
[3]Ganzeboom KS,Mairuhu G,Reitsma JB,et al.Lifetime cumulative incidence of syncope in the general population:a study of 549 Dutch subjects aged 35-60 years[J].J Cardiovasc Electrophysiol,2006,17(11):1172-1176.
[4]Brignole M,Moya A,de Lange FJ,et a1.Practical instructions for the 2018 ESC guidelines for the diagnosis and management of syncope[J].Eur Heart J,2018,39(21):e43-e80.
[5]Task Force for the Diagnosis and Management of Syncope,European Society of Cardiology(ESC),European Heart Rhythm Association(EHRA),et al.Guidelines for the diagnosis and management of syncope(version 2009)[J].Eur Heart J,2009,30(21):2631-2671.
[6]Brignole M,Alboni P,Benditt DG,et al.Guidelines on management(diagnosis and treatment)of syncope-update2004:executive summary[J].Eur Heart J,2004,25(22):2054-2072.
[7]Soteriades ES,Evans JC,Larson MG,et al.Incidence and prognosis of syncope[J].N Engl J Med,2002,347(12):878-885.
[8]Shen WK,Sheldon RS,Benditt DG,et a1.2017ACC/AHA/HRS guideline for the evaluation and management of patients with syncope:a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[J].Heart Rhythm,2017,14(8):e155-e217.
[9]中华心血管病杂志编辑委员会,中国生物医学工程学会心律分会,中国老年学和老年医学学会心血管病专业委员会,等.晕厥诊断与治疗中国专家共识(2018)[J].中华心血管病杂志,2019,47(2):96-107.
[10]金红芳,李红霞.直立倾斜试验[J].中华实用儿科临床杂志,2014,29(1):5-7.
[11]Krahn AD,Klein GJ,Yee R.Recurrent syncope:experience with an implantable loop recorder[J].Cardiol Clin,1997,15(2):313-326.
[12]Krahn AD,Klein GJ,Yee R,et al.Cost implications of testing strategy in patients with syncope:randomized assessment of syncope trial[J].J Am Coll Cardiol,2003,42(3):495-501.
[13]Linzer M,Yang EH,Estes NA 3rd,et al.Diagnosing syncope.Part 2:unexplained syncope.Clinical efficacy assessment project of the American College of Physicians[J].Ann Intern Med,1997,127(1):76-86.
[14]Kapoor WN.Evaluation and management of the patient with syncope[J].JAMA,1992,268(18):2553-2560.
[15]余金波,智宏,马根山.2018年欧洲心脏病学会晕厥诊断与管理指南解读[J].中国介入心脏病学杂志,2018,26(9):492-496.
[2]Ruwald MH,Hansen ML,Lamberts M,et al.The relation between age,sex,comorbidity,and pharmacotherapy and the risk of syncope:a Danish nationwide study[J].Europace,2012,14(10):1506-1514.
[3]Ganzeboom KS,Mairuhu G,Reitsma JB,et al.Lifetime cumulative incidence of syncope in the general population:a study of 549 Dutch subjects aged 35-60 years[J].J Cardiovasc Electrophysiol,2006,17(11):1172-1176.
[4]Brignole M,Moya A,de Lange FJ,et a1.Practical instructions for the 2018 ESC guidelines for the diagnosis and management of syncope[J].Eur Heart J,2018,39(21):e43-e80.
[5]Task Force for the Diagnosis and Management of Syncope,European Society of Cardiology(ESC),European Heart Rhythm Association(EHRA),et al.Guidelines for the diagnosis and management of syncope(version 2009)[J].Eur Heart J,2009,30(21):2631-2671.
[6]Brignole M,Alboni P,Benditt DG,et al.Guidelines on management(diagnosis and treatment)of syncope-update2004:executive summary[J].Eur Heart J,2004,25(22):2054-2072.
[7]Soteriades ES,Evans JC,Larson MG,et al.Incidence and prognosis of syncope[J].N Engl J Med,2002,347(12):878-885.
[8]Shen WK,Sheldon RS,Benditt DG,et a1.2017ACC/AHA/HRS guideline for the evaluation and management of patients with syncope:a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[J].Heart Rhythm,2017,14(8):e155-e217.
[9]中华心血管病杂志编辑委员会,中国生物医学工程学会心律分会,中国老年学和老年医学学会心血管病专业委员会,等.晕厥诊断与治疗中国专家共识(2018)[J].中华心血管病杂志,2019,47(2):96-107.
[10]金红芳,李红霞.直立倾斜试验[J].中华实用儿科临床杂志,2014,29(1):5-7.
[11]Krahn AD,Klein GJ,Yee R.Recurrent syncope:experience with an implantable loop recorder[J].Cardiol Clin,1997,15(2):313-326.
[12]Krahn AD,Klein GJ,Yee R,et al.Cost implications of testing strategy in patients with syncope:randomized assessment of syncope trial[J].J Am Coll Cardiol,2003,42(3):495-501.
[13]Linzer M,Yang EH,Estes NA 3rd,et al.Diagnosing syncope.Part 2:unexplained syncope.Clinical efficacy assessment project of the American College of Physicians[J].Ann Intern Med,1997,127(1):76-86.
[14]Kapoor WN.Evaluation and management of the patient with syncope[J].JAMA,1992,268(18):2553-2560.
[15]余金波,智宏,马根山.2018年欧洲心脏病学会晕厥诊断与管理指南解读[J].中国介入心脏病学杂志,2018,26(9):492-496.