Современные предикторы жизнеугрожающих аритмий

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Abstract

In spite of the optimal medication and frequently successful surgical treatment the patients who survived myocardial infarction have higher risk of sudden cardiac death. The basis of fatal arrhythmias in this category of patients has two different electrophysiological variants: acute myocardial ischemia which contributes to its electrical instability and presence of anatomical substrate (most commonly it is a scar after myocardial infarction in past history) which determines the heterogeneity of myocardium. Besides there are following triggers for fatal arrhythmia development: electrolyte, metabolic, neurohumoral disturbances, vegetative dysfunction, drug administration with the impact on conductivity and repolarization (primarily antiarrhythmics). In particularly, combination of trigger factors and exposed myocardium is likely to result in fatal arrhythmias. Searching for factors which are able to detect such "exposed" myocardium and predict the ability of fatal arrhythmia development are the most interesting for clinicians. At present, the implantation of cardioverterdefibrillator in order to prevent sudden cardiac death in such patients is performed according to the single value - left ventricular ejection fraction. International contemporary recommendations (American College of Cardiology Foundation/American Heart Association) show that left ventricular ejection fraction of 35% or less is the main indication for implantation of cardioverter-defibrillator in postinfarction patients. Besides, functional class II or III of New York Heart Association (NYHA) classification and time (not less than 40 days) from the moment of acute event (class I; evidence grade A) are considered to be significant. As a result, according to literature, only one of four implantable devices works out and the vast majority of potential "victims" of sudden death do not receive adequate prophylaxis. A number of additional predictors for detecting possible myocardial substrates of malignant arrhythmias were proposed in order to improve the risk stratification. These are echocardiographic parameters (T-wave alternation, high resolution electrocardiography with calculation of delayed ventricular potentials, duration and dispersion of Q-T interval, tests based on Holter monitoring (variability and turbulence of cardiac rhythm), methods of myocardial visualization (magnetic resonance tomography, computed tomography, tissue Doppler) and different neurohumoral markers. Pathophysiological background and methodological aspects of calculation for each of above mentioned values. Besides, contemporary concepts about risk stratification of malignant arrhythmias and sudden cardiac death in patients with ischemic heart disease and about the value of each prognostic marker for patient selection for the purpose of cardioverter-defibrillator implantation.

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Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery