起搏器指南解讀

2021心臟起搏指南解讀ACC/AHA/HRS北京大學(xué)人民醫(yī)院心臟中心張海澄12007年8月，歐洲心臟病學(xué)會(huì)和歐洲心律學(xué)會(huì)聯(lián)合發(fā)布了“心臟起搏與再同步治療指南〞，這是歐洲首次獨(dú)立發(fā)布的心臟起搏領(lǐng)域的指南22021年5月，ACC/AHA/HRS聯(lián)合發(fā)布了“心臟節(jié)律異常器械治療指南〞31991

ACC/AHA指南1998

ACC/AHA指南2002

ACC/AHA/NASPE指南2007ESC/EHRA指南1993

CHRS指南1998

CHRS指南2003CSPE共識(shí)心臟起搏與ICD指南之路2006CSPE指南〔CRT〕2006ACC/AHA/ESC指南(SCD)2005

ESC指南〔CHF〕2005

ACC/AHA指南2002CHRS/CSPE〔ICD〕2003CHRS指南1984

ACC/AHA指南2021ACC/AHA/HRS指南4分類與證據(jù)等級(jí)分類

I類Should

獲益>>>風(fēng)險(xiǎn)IIa類Reasonable獲益>>風(fēng)險(xiǎn)IIb類Considerable獲益≥風(fēng)險(xiǎn)III類No風(fēng)險(xiǎn)≥獲益證據(jù)等級(jí)證據(jù)等級(jí)A數(shù)據(jù)來自多個(gè)隨機(jī)對(duì)照臨床試驗(yàn)或薈萃分析證據(jù)等級(jí)B數(shù)據(jù)來自一個(gè)單一的隨機(jī)對(duì)照臨床試驗(yàn)或大型的非隨機(jī)研究證據(jù)等級(jí)C專家們的共識(shí)和/或小型研究，回顧性研究以及登記記錄5竇房結(jié)功能不良 病癥性心動(dòng)過緩，包括導(dǎo)致病癥的頻發(fā)停搏 病癥性變時(shí)功能不良 必需藥物治療所致的病癥性心動(dòng)過緩IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC6HR<40bpm，與病癥很可能相關(guān)，但無客觀記錄證據(jù)不明原因暈厥，臨床存在或電生理誘發(fā)的嚴(yán)重竇房結(jié)功能不良

清醒心率長(zhǎng)期<40bpm，但病癥輕微IIIaIIbIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIaIIbIII竇房結(jié)功能不良7 無病癥SND患者 有證據(jù)說明心電圖無心動(dòng)過緩時(shí)出現(xiàn)病癥 非必需藥物治療引起的心動(dòng)過緩IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC竇房結(jié)功能不良8竇房結(jié)功能不良的適應(yīng)證類別證據(jù)等級(jí)1.竇房結(jié)疾病表現(xiàn)為癥狀性心動(dòng)過緩伴或不伴心動(dòng)過緩依賴性心動(dòng)過速；癥狀與心動(dòng)過緩的相關(guān)性必須是自發(fā)的或不可替代藥物療法所導(dǎo)致的2.竇房結(jié)疾病所致的暈厥，無論是自發(fā)的還是由電生理檢查誘發(fā)的3.竇房結(jié)疾病表現(xiàn)為自發(fā)的或不可替代藥物療法所導(dǎo)致的癥狀性變時(shí)功能不全I(xiàn)C1.癥狀性竇房結(jié)疾病，為自發(fā)性或不可替代藥物所致，但無癥狀與節(jié)律相關(guān)性的客觀證據(jù)。休息時(shí)心率應(yīng)該小于40次/分2.無其他原因可以解釋的暈厥，且電生理檢查有異常（CSNRT>800ms）IIaC1.有輕微癥狀的竇房結(jié)疾病，在清醒、休息時(shí)的心率小于40次/分，無變時(shí)功能不全的證據(jù)IIbC1.無癥狀的竇房結(jié)疾病，包括應(yīng)用引起心動(dòng)過緩的藥物2.心電圖發(fā)現(xiàn)竇房結(jié)功能障礙，但癥狀不能直接或間接歸咎于心動(dòng)過緩3.有癥狀的竇房結(jié)功能障礙，其癥狀可歸因于非必需的藥物治療IIIC歐洲2007指南9成人獲得性房室阻滯 病癥性〔包括HF〕三度和高度AVB，或AVB引起室性心律失常 必須藥物治療引起的病癥性三度和高度AVBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC10 清醒時(shí)發(fā)生的三度和高度AVB，無病癥竇性心律患者，竇性停搏≥3.0s，或逸搏<40bpm 清醒時(shí)發(fā)生的三度和高度AVB，無病癥房顫患者，長(zhǎng)間歇≥5.0s〔2021新增〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC成人獲得性房室阻滯11 AVN消融后三度或高度AVB 心外科術(shù)后三度或高度AVB〔無法解決的〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC成人獲得性房室阻滯12 神經(jīng)肌肉疾病引起的三度或高度AVB〔不管有無病癥〕，如強(qiáng)直性肌萎縮，Kearns-sayre綜合征等 病癥性二度AVB，不管類型和阻滯部位IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB成人獲得性房室阻滯13 無病癥、持續(xù)性三度AVB，平均清醒心室率40bpm或以上，心臟擴(kuò)大、或LV功能不良、或阻滯部位在AVN下〔IIa升級(jí)〕 運(yùn)動(dòng)時(shí)出現(xiàn)的二度或三度AVB，無心肌缺血〔2021新增〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC成人獲得性房室阻滯14 持續(xù)性三度AVB，逸搏心率>40bpm，無心臟擴(kuò)大和病癥〔2021新增〕 無病癥二度AVB，電生理檢查證實(shí)阻滯部位在His或以下 病癥性一度或二度AVB，起搏器綜合征樣病癥或血流動(dòng)力學(xué)異常IIIaIIbIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB成人獲得性房室阻滯15無病癥，窄QRS波的二度II型AVB〔備注：寬QRS波的二度II型AVB，包括孤立性RBBB，屬I類適應(yīng)證〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB成人獲得性房室阻滯16 神經(jīng)肌肉疾病引起的低級(jí)別AVB〔不管有無病癥〕，如強(qiáng)直性肌萎縮，Kearns-sayre綜合征等。因AVB進(jìn)展不可預(yù)測(cè) 藥物引起的AVB，即使停藥AVB仍有可能復(fù)發(fā)〔2021新增〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB成人獲得性房室阻滯17 無病癥，一度AVB 無病癥，二度I型AVB，阻滯部位在AVN水平 可逆轉(zhuǎn)、不易復(fù)發(fā)的AVB〔如洋地黃中毒、萊姆氏病、或一過性迷走張力增高-SAHS〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB成人獲得性房室阻滯18獲得性房室阻滯的適應(yīng)證類別證據(jù)等級(jí)1.慢性癥狀性三度或二度房室阻滯（莫氏I型或II型）2.伴有三度或二度房室阻滯的神經(jīng)肌肉性疾病（如強(qiáng)直性肌營(yíng)養(yǎng)不良，克雅氏綜合征等）3.導(dǎo)致三度或二度（莫氏I型或II型）房室阻滯的原因?yàn)椋?）房室交界區(qū)導(dǎo)管射頻消融術(shù)后；（2）外科瓣膜術(shù)后且預(yù)計(jì)不能恢復(fù)者IIICBC1.無癥狀的三度或二度（莫氏I型或II型）房室阻滯2.有癥狀的、PR間期過長(zhǎng)的一度房室阻滯IIaIIaCC1.伴有一度房室阻滯的神經(jīng)肌肉性疾?。ㄈ鐝?qiáng)直性肌營(yíng)養(yǎng)不良，克雅氏綜合征等）IIbB1.無癥狀的一度房室阻滯2.希氏束分叉以上的無癥狀性二度I型房室阻滯3.有望治愈的房室阻滯IIIC歐洲2007指南19

高度AVB和一過性三度AVB

二度II型AVB

左右束支交替性阻滯IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB慢性雙分支阻滯20 無AVB引起暈厥的客觀證據(jù)，但已除外其他可能原因〔尤其是VT〕 無病癥患者，電生理檢查發(fā)現(xiàn)HV≥100ms 無病癥患者，電生理檢查發(fā)現(xiàn)起搏引起的非生理性His下阻滯IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB慢性雙分支阻滯21 神經(jīng)肌肉疾病引起的分支阻滯或雙分支阻滯〔不管有無病癥〕，如強(qiáng)直性肌萎縮，Kearns-sayre綜合征等 無病癥、無AVB的分支阻滯. 無病癥、分支阻滯+一度AVBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB慢性雙分支阻滯22雙束支及三分支阻滯類別證據(jù)等級(jí)1.間歇性三度房室阻滯2.二度II型房室阻滯3.交替性束支阻滯4.有癥狀患者：電生理檢查HV間期顯著延長(zhǎng)（≥100ms），或起搏誘發(fā)出希氏束分叉下阻滯（新增）IC1.不能證明是由于房室阻滯所致的暈厥，但其他可能原因尤其是室性心動(dòng)過速已被排除2.伴有任何程度分支阻滯的神經(jīng)肌肉性疾?。ㄈ鐝?qiáng)直性肌營(yíng)養(yǎng)不良，克雅氏綜合征等）（IIb升為IIa）3.無癥狀患者，電生理檢查意外發(fā)現(xiàn)HV間期顯著延長(zhǎng)（≥100ms），或起搏誘發(fā)出希氏束分叉下阻滯IIaIIaIIaBCC無IIb

1.不伴AVB或癥狀的分支阻滯2.無癥狀的伴一度AVB的分支阻滯IIIB歐洲2007指南23 STEMI，His束及以下水平的持續(xù)性二度AVB、交替性束支阻滯、或三度AVB 一過性高度或三度AVB〔His及以下部位〕，相關(guān)的束支阻滯。如阻滯部位不確定，需要行EPS 有病癥的、持續(xù)性高度或三度AVBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB*Theserecommendationsareconsistentwiththe“ACC/AHAGuidelinesfortheManagementofPatientsWithST-ElevationMyocardialInfarction.〞急性心肌梗死急性期24 持續(xù)性二度或三度AVB，無病癥 一過性AVB，不伴室間傳導(dǎo)障礙 一過性AVB，孤立性左前分支阻滯IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB*Theserecommendationsareconsistentwiththe“ACC/AHAGuidelinesfortheManagementofPatientsWithST-ElevationMyocardialInfarction.〞急性心肌梗死急性期25 新發(fā)生的BBB或分支阻滯，無AVB 持續(xù)性無病癥一度AVB，有束支或分支阻滯IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB*Theserecommendationsareconsistentwiththe“ACC/AHAGuidelinesfortheManagementofPatientsWithST-ElevationMyocardialInfarction.〞急性心肌梗死急性期26頸動(dòng)脈竇高敏綜合征與VVS 頸動(dòng)脈竇刺激引起的反復(fù)暈厥，頸動(dòng)脈竇按壓停搏>3.0s 無明確誘發(fā)事件的暈厥，頸動(dòng)脈竇按壓停搏≥3.0s〔2021新增〕

病癥嚴(yán)重的神經(jīng)源性暈厥，自發(fā)或直立傾斜試驗(yàn)中記錄到心動(dòng)過緩〔降級(jí)〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIaIIbIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB27 無病癥，頸動(dòng)脈竇刺激呈現(xiàn)高敏心臟抑制反響 情境性血管迷走性暈厥，可有效防止IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC頸動(dòng)脈竇高敏綜合征與VVS28 持續(xù)性、長(zhǎng)間歇依賴性VT，不管有無QT延長(zhǎng) 先天性LQTs高?；颊?SND患者，預(yù)防病癥性、難治性、反復(fù)發(fā)作性AFIIIaIIbIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB抗心動(dòng)過速起搏29 頻發(fā)或復(fù)雜的PVCs，無VT，無LQTs

可逆性原因所致TdPIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIA抗心動(dòng)過速起搏30 無其他起搏適應(yīng)證的預(yù)防AF〔2021新增〕IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIB起搏預(yù)防房顫31 LVEF≤35%,QRS≥0.12s，竇性心律，NYHAIII或IV級(jí)，優(yōu)化藥物治療〔CRT-P和CRT-D〕 LVEF≤35%,QRS≥0.12s，房顫，NYHAIII或IV級(jí)，優(yōu)化藥物治療〔CRT-P和CRT-D〕 LVEF≤35%,QRS≥0.12s，NYHAIII或IV級(jí)，優(yōu)化藥物治療，頻繁依賴心室起搏〔CRT〕IIIaIIbIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIA嚴(yán)重收縮功能不良CRT32 LVEF≤35%,QRS≥0.12s，NYHAI或II級(jí)，優(yōu)化藥物治療，有其他植入起搏器或ICD的適應(yīng)證 無病癥LVEF降低患者，無其他起搏適應(yīng)證 因非心臟疾病導(dǎo)致功能狀態(tài)和預(yù)期壽命嚴(yán)重受限的患者IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIC嚴(yán)重收縮功能不良CRT33 HCM患者，具SND或AVB起搏器適應(yīng)證 藥物難治性有病癥的HCM患者，LVOT梗阻較重。猝死高危者植入雙腔ICD 無病癥，或藥物可控制病癥 有病癥，但無LVOT梗阻證據(jù)IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIAIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIICHCM起搏治療34EpsteinA,etal.ACC/AHA/HRS2021GuidelinesforDevice-BasedTherapyofCardiacRhythmAbnormalities.JAmCollCardiol2021;51:e1–62.Figure1.房室阻滯慢性房性心律失常房室同步頻率適應(yīng)NoYes頻率適應(yīng)No心房起搏YesVVIVVIRNoYesVDD頻率適應(yīng)DDDDDDRNoYesNoYesVVIVVIRNoYes35YesNo竇房結(jié)功能不良

NoAAIAAIRDDDRDDDVVIVVIRYesNoYesNoYesNoYesEpsteinA,etal.ACC/AHA/HRS2021GuidelinesforDevice-BasedTherapyofCardiacRhythmAbnormalities.JAmCollCardiol2021;51:e1–62.Figure2.AVB證據(jù)，或可能進(jìn)展為AVB頻率適應(yīng)房室同步頻率適應(yīng)頻率適應(yīng)36竇房結(jié)疾病竇緩房室阻滯否是變時(shí)功能不全不存在變時(shí)功能不全存在/不存在房性快速心律失常：存在房性快速心律失常：不存在DDDR+MPVIIa類證據(jù)等級(jí)CDD