胺碘酮转复心房纤颤时对QT离散度影响
作者：孙勇 何红 鲁端
单位：杭州 310016 浙江大学医学院附属邵逸夫医院 心内科
关键词：胺碘酮；心房纤颤；QT离散度；QT间期
摘要 目的摘要 目的：评价胺碘酮在治疗心房纤颤中对心肌复 极的影响。方法：测量了48例用胺碘酮转复和维持治疗房颤患者的QT间 期与QT离散度，并与21例阵发房颤和43例健康对照组比较。结果：阵发 房颤动组与健康对照组QT间期和QT离散度无差异(QT:405±44vs397+30ms.QTc:448±47vs424 ±26ms,QTD 29±17vs27±16ms,QTcD:28±19vs26±18ms,P>0.05)，但与 前两对照组比，胺碘酮明显延长QT期间并使QTD增大(QT:465±53vs405±44 or 397±30ms,Q Tc:449±54vs448±47 or 424±26ms,QTD:47±20vs29±19 or 27±16ms,QTcD:49±21vs28 ±19 or 26±18ms,P<0.01)。结论：胺碘酮不仅延长心肌 复极，且使复极离散。
, http://www.100md.com
The effects of amiodarone on QT dispersion
in patients with atrial fibrillation
Sun Yong
(Department of Cardiology,Sir Run Run Shaw Hospital,Hangzhou 310016)
He Hong
(Department of Cardiology,Sir Run Run Shaw Hospital,Hangzhou 310016)
Lu Duan
(Department of Cardiology,Sir Run Run Shaw Hospital,Hangzhou 310016)
, 百拇医药
ABSTRACT OBJECTIVE：This study evaluated the eff ects of amiodarone on the myocardial repolarization in the patients with atrial fibrillation.METHODS:QT dispersions measured from 12-lead standard surface ECG were retrospectively assessed in 48 patients treated with Amiodarone ,and compared with that of paroxysmal atrial fibrillation and health groups.RESULTS:No disparity in QT interval and QT dispersion was found between paroxysmal atrial fibrillation and health group(QT:405±44vs397+30ms.QTc:448±47 vs424±26ms,QTD 29±17vs27±16ms,QTcD:28±19vs26±18ms,P>0.05). However,compared with these two group,we found that both of the QT interval and QT dispersion significantly increased in Amiodarone group(QT:465±53vs405±44 or 397±30ms,QTc:449±54vs448±47 or 424±26ms,QTD:47±20vs29±19 or 27±16ms,QTcD :49±21vs28±19 or 26±18ms,P<0.01).CONCLUSION:Amiodaro ne not only effectively control atrial fibrillation with QT interval prolongatio n but also increased QT dispersion.
, http://www.100md.com
KEY WORDS amiodarone,atrial fi brillation,QT dispersion,QT interval
Quinidine was used as a classic drug for prevention an d cardioversion of atrial fibrillation,Nowadays,however,Quinidine has been subst ituted by Amiodarone[1,2] in managing atrial fibrillation due to its pro arrhythmic effect and enhanced mortality in patients with atrial fibrillation.Am iodarone was found[3] to have less proarrhythmic effect and proven to be relatively safer.Good efficacy was observed from the therapy of atrial fibrilla tion with Amiodarone in our patients.We evaluated the effect of Amiodarone to de termine its impact on myocardial repolarization.
, 百拇医药
Data and Method
Subjective:All the patients were documented atrial fibrillation with EKG or Holt er from 1994 to 1999.
Exclusion criteria:①patients with cute myocardiac infarction or unstable angina ;②patients with hyperthyroidism;③patients under the treatment of other antiarr hythmic medications classⅠ-classⅣ;④patients with impaired liver and renal fu nction;⑤patients with uncorrected electrolyte disorders.The atrial fibrillation Group had 48 patients with persistent atrial fibrillation,aged 19～62(mean age 39.8±11.9 years),and administered Amiodarone.In this group,there were 33 patie nts who had undergone cardiomyopathy or valve replacement,6 patients with isolat ed atrial fibrillation,5 patients with coronary artery disease,2 patients with d ilated cardiomyopathy and 2 patients with hypertension.43 cases were with NYHA c lass Ⅰ～Ⅱ and 5 cases were with NYHA class Ⅳ.Control group included,patients with paroxysmal atrial fibrillation achieved cardioversion spontaneously and hea lthy subjects accoreling to physical examination.Twenty-one patients were with paroxysmal atrial fibrillation(male 14,female 7),age 30～70 years(mean age 51.4 ±13.5 years).This group included 7 patients with coronary artery disease,4 pati ents with valvular heart disease,8 patients with isolated atrial fibrillation an d 2 patients with hypertension.Twenty patients had NYHA class Ⅰ～Ⅱ and one had NYHA class Ⅲ.There were 43 healthy subjects(male 19,female 24),18～61 years ol d(mean age 35.6±15.3 years).
, http://www.100md.com
Method:Patients continued to take both medications for underlying diseases and a nticoagulation(Aspirin and/or Ticlid).All patients who were examined to have no thrombus in the atrium by echocardiography were administered 200mg 3 times a day for 7 days.Patients with atrial fibrillation resistance to Amiodarone underwent electrical cardioversion.They kept on the same treatment(i.e. Amiodarone 200～4 00mg/d) to maintain the sinus rhythm if their cardioversions were successful.
, http://www.100md.com
QT interval and dispersion measurement:standard 12 lead EKG were done at paper s peed 25mm/s.An unique technician was required to measure QT interval in all lead s during maintenance treatment.Three consequent QT intervals of QRS complex to t ermination of T wave.
Confirmed criteria:QT dispersion is defined as the maximum minus the minimum of QT interval in different leads.QT and QTD are adjusted by Bazzet equation.(i.e.: QTc=QTR-R.QTcD=QTcmax-QTcmin).
, http://www.100md.com
Analysis:All data were analyzed in spss system.Ordinal data were reported as mea n ±SD.P<0.05 was considered significantly.
Result
Therapeutic effect:Eleven patients(23%) in Amiodarone gr oup were converted to sinus rhythm spontaneously in 7 days and the rest 37 patie nts were in electrical cardioversion.Sinus rhythm were maintained in 35 patients (73%) in short term observation(10 days).
Side-effects:Ⅰ°AVB,Ⅱ°AVB occurred in one patient respectively(Both of them disappeared after decreasing dosage of Amiodarone).No fatal arrhythmia happened.
, 百拇医药
QT and QT dispersion:①Paroxysmal atrial fibrillation group was similar to the control group on QT,QTc,QTd,QTCD(P<0.05).②There was significant d ifference between Amiodarone group and the other two groups on myocardiac repola rization parameters(P>0.01).
Tab.1 The effect of Amiodarone on QT and QT dis persion in patients with atrial fibrillation patients(ms)
Group
QT
, http://www.100md.com
QTc
QTD
QTcD
H/n=43
397±30
424±26
27±16
26±18
PAF/n=21
405±44
448±47
29±17
28±19
, 百拇医药
A/n=48
465±53*
499±54*
47±20*
49±21*
*P<0.01,A vs PAF or H,H=health,PAF=Paroxysmal Atri al Fibrillation,A=Amiodarone
Discussion
Amiodarone is one of class Ⅲ anti-arrhythmia medications,It has property of hi gh efficacy and safety.It seldom induces malignant proarrhythmia.It can also dec line mortality of acute myocardiac infarction,consequently,it is considered one of the best anti-arrhythmia medication[3～5].We found Amiodarone could effectively control chronic atrial fibrillation,though spontaneous cardioversion rate is low within one week(23%).But it increased the successful rate by direct currently cardioversion.Moreover,it has satisfactory result in prevention from recurrence of atrial fibrillation in short term(10 days) about 73%.Compared with class Ⅰ anti-arrhythmia medication which has more adverse effect of malignant proarrhythmia,it has mild side-effect on myocardism[6].Here only one p atient began to suffer IAVB and another patients had degree Ⅱ type Ⅱ AVB.No To rsade de points or ventricular fibrillation emerged.
, 百拇医药
The electrophysiology mechanism of medication inducing Torsade De points or vent ricular fibrillation perhaps is based on prolonged myocardial repolarization and repolarization dispersion.Some authors[6,7] pointed out that the reason Amiodarone seldom induces arrhythmia resulted from its property on myocardiac r epolarization.In another words compared with type I anti-arrhythmic medications ,it does not increase QT dispersion,thought it has similar effect to prolong QT interval.
, 百拇医药
So far,the effect of Amiodarone on QT dispersion is controversial.Cui .et al[6] reported Amiodarone could reduce myocardiac re polarization dispersion in coronary artery disease.His opinions was confirmed in patients with hypertrophic cardiomyopathy.However,Hii et al[8 ] showed that Amiodarone has no effect on repolarization dispersion in patien ts with coronary artery disease,and similar conclusion deduced from the latest d ata[9].Our results are different from either of above,even from our pred ictive result.We found that Amiodarone prolonged myocardiac repolarization,and m eanwhile increased myocardiac repolarization dispersion when it was administered in patients with chronic atrial fibrillation.The reason is still unknown.It may be due to underline disease,arrhythmia or dosage of Amiodirone.Further study is needed.
, 百拇医药
References
1，Coplen SE，Antman EM,Berlin JA.Efficacy and safe of quinidine therapy for maintenance of sinus rhythm after cardioversion.Circula tion,1990.82(4)∶1106.
2，Flaker GC,Blackshe ar JL,McBRIDE R.Antiarrhymic drug therapy and cardiac mortality in atrial fibril lation.J Am Coll Cardiol,1992,20(3)∶527.
3，Ceremjuzyski Y,Klechzar E,Kreminska-Pakula M.Eff ects of amiodarone on mortality after myocardial infarction.J Am Coll Cardiol,19 92.20(4)∶1056.
, http://www.100md.com
4，Singh SN,Fletcher RD,Fisher SG,et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricula r arrhythmia.N Engl J Med,1995,333(2)∶77.
5，Doval HC,Nul DR,Grancelli HO,et al.In sufficiency cardiac on argentina(GESICA).Randomized trial of low-dose amiodaron e in severe congestive heart failure.Lancet,1994,334(8291)∶493.
6，Cui G,Sen L,Sager P.Effects of amiodarone,sematil ide and sotalol on QT dispersion.Am J cardiol,1994,74(9)∶896.
, 百拇医药
7，Dritsas A,Gilligan P,Nihoyannopoulos P.Amiodarone reduce QT dispersion in patients with hypertrophic cardiomyopathy.Int J Cardiol ,1992,36(4)∶345.
8，Hii JT,Wyse DG,Gillis AM.Percordial QT interval d ispersion as a marker of torsade de pointes,Pisparate effects of class I a antia rrhythmic drug and amiodarone.Circulation,1992,86(5)∶1376.
9，Grimm W,Steder U,Menz V.Effects of amiodarone on QT dispersion in the 12-leads standard electrocardiogram and its significance f or subsequent arrhythmic events.Clin cardiol,1997,20(2)∶107., http://www.100md.com
单位：杭州 310016 浙江大学医学院附属邵逸夫医院 心内科
关键词：胺碘酮；心房纤颤；QT离散度；QT间期
摘要 目的摘要 目的：评价胺碘酮在治疗心房纤颤中对心肌复 极的影响。方法：测量了48例用胺碘酮转复和维持治疗房颤患者的QT间 期与QT离散度，并与21例阵发房颤和43例健康对照组比较。结果：阵发 房颤动组与健康对照组QT间期和QT离散度无差异(QT:405±44vs397+30ms.QTc:448±47vs424 ±26ms,QTD 29±17vs27±16ms,QTcD:28±19vs26±18ms,P>0.05)，但与 前两对照组比，胺碘酮明显延长QT期间并使QTD增大(QT:465±53vs405±44 or 397±30ms,Q Tc:449±54vs448±47 or 424±26ms,QTD:47±20vs29±19 or 27±16ms,QTcD:49±21vs28 ±19 or 26±18ms,P<0.01)。结论：胺碘酮不仅延长心肌 复极，且使复极离散。
, http://www.100md.com
The effects of amiodarone on QT dispersion
in patients with atrial fibrillation
Sun Yong
(Department of Cardiology,Sir Run Run Shaw Hospital,Hangzhou 310016)
He Hong
(Department of Cardiology,Sir Run Run Shaw Hospital,Hangzhou 310016)
Lu Duan
(Department of Cardiology,Sir Run Run Shaw Hospital,Hangzhou 310016)
, 百拇医药
ABSTRACT OBJECTIVE：This study evaluated the eff ects of amiodarone on the myocardial repolarization in the patients with atrial fibrillation.METHODS:QT dispersions measured from 12-lead standard surface ECG were retrospectively assessed in 48 patients treated with Amiodarone ,and compared with that of paroxysmal atrial fibrillation and health groups.RESULTS:No disparity in QT interval and QT dispersion was found between paroxysmal atrial fibrillation and health group(QT:405±44vs397+30ms.QTc:448±47 vs424±26ms,QTD 29±17vs27±16ms,QTcD:28±19vs26±18ms,P>0.05). However,compared with these two group,we found that both of the QT interval and QT dispersion significantly increased in Amiodarone group(QT:465±53vs405±44 or 397±30ms,QTc:449±54vs448±47 or 424±26ms,QTD:47±20vs29±19 or 27±16ms,QTcD :49±21vs28±19 or 26±18ms,P<0.01).CONCLUSION:Amiodaro ne not only effectively control atrial fibrillation with QT interval prolongatio n but also increased QT dispersion.
, http://www.100md.com
KEY WORDS amiodarone,atrial fi brillation,QT dispersion,QT interval
Quinidine was used as a classic drug for prevention an d cardioversion of atrial fibrillation,Nowadays,however,Quinidine has been subst ituted by Amiodarone[1,2] in managing atrial fibrillation due to its pro arrhythmic effect and enhanced mortality in patients with atrial fibrillation.Am iodarone was found[3] to have less proarrhythmic effect and proven to be relatively safer.Good efficacy was observed from the therapy of atrial fibrilla tion with Amiodarone in our patients.We evaluated the effect of Amiodarone to de termine its impact on myocardial repolarization.
, 百拇医药
Data and Method
Subjective:All the patients were documented atrial fibrillation with EKG or Holt er from 1994 to 1999.
Exclusion criteria:①patients with cute myocardiac infarction or unstable angina ;②patients with hyperthyroidism;③patients under the treatment of other antiarr hythmic medications classⅠ-classⅣ;④patients with impaired liver and renal fu nction;⑤patients with uncorrected electrolyte disorders.The atrial fibrillation Group had 48 patients with persistent atrial fibrillation,aged 19～62(mean age 39.8±11.9 years),and administered Amiodarone.In this group,there were 33 patie nts who had undergone cardiomyopathy or valve replacement,6 patients with isolat ed atrial fibrillation,5 patients with coronary artery disease,2 patients with d ilated cardiomyopathy and 2 patients with hypertension.43 cases were with NYHA c lass Ⅰ～Ⅱ and 5 cases were with NYHA class Ⅳ.Control group included,patients with paroxysmal atrial fibrillation achieved cardioversion spontaneously and hea lthy subjects accoreling to physical examination.Twenty-one patients were with paroxysmal atrial fibrillation(male 14,female 7),age 30～70 years(mean age 51.4 ±13.5 years).This group included 7 patients with coronary artery disease,4 pati ents with valvular heart disease,8 patients with isolated atrial fibrillation an d 2 patients with hypertension.Twenty patients had NYHA class Ⅰ～Ⅱ and one had NYHA class Ⅲ.There were 43 healthy subjects(male 19,female 24),18～61 years ol d(mean age 35.6±15.3 years).
, http://www.100md.com
Method:Patients continued to take both medications for underlying diseases and a nticoagulation(Aspirin and/or Ticlid).All patients who were examined to have no thrombus in the atrium by echocardiography were administered 200mg 3 times a day for 7 days.Patients with atrial fibrillation resistance to Amiodarone underwent electrical cardioversion.They kept on the same treatment(i.e. Amiodarone 200～4 00mg/d) to maintain the sinus rhythm if their cardioversions were successful.
, http://www.100md.com
QT interval and dispersion measurement:standard 12 lead EKG were done at paper s peed 25mm/s.An unique technician was required to measure QT interval in all lead s during maintenance treatment.Three consequent QT intervals of QRS complex to t ermination of T wave.
Confirmed criteria:QT dispersion is defined as the maximum minus the minimum of QT interval in different leads.QT and QTD are adjusted by Bazzet equation.(i.e.: QTc=QTR-R.QTcD=QTcmax-QTcmin).
, http://www.100md.com
Analysis:All data were analyzed in spss system.Ordinal data were reported as mea n ±SD.P<0.05 was considered significantly.
Result
Therapeutic effect:Eleven patients(23%) in Amiodarone gr oup were converted to sinus rhythm spontaneously in 7 days and the rest 37 patie nts were in electrical cardioversion.Sinus rhythm were maintained in 35 patients (73%) in short term observation(10 days).
Side-effects:Ⅰ°AVB,Ⅱ°AVB occurred in one patient respectively(Both of them disappeared after decreasing dosage of Amiodarone).No fatal arrhythmia happened.
, 百拇医药
QT and QT dispersion:①Paroxysmal atrial fibrillation group was similar to the control group on QT,QTc,QTd,QTCD(P<0.05).②There was significant d ifference between Amiodarone group and the other two groups on myocardiac repola rization parameters(P>0.01).
Tab.1 The effect of Amiodarone on QT and QT dis persion in patients with atrial fibrillation patients(ms)
Group
QT
, http://www.100md.com
QTc
QTD
QTcD
H/n=43
397±30
424±26
27±16
26±18
PAF/n=21
405±44
448±47
29±17
28±19
, 百拇医药
A/n=48
465±53*
499±54*
47±20*
49±21*
*P<0.01,A vs PAF or H,H=health,PAF=Paroxysmal Atri al Fibrillation,A=Amiodarone
Discussion
Amiodarone is one of class Ⅲ anti-arrhythmia medications,It has property of hi gh efficacy and safety.It seldom induces malignant proarrhythmia.It can also dec line mortality of acute myocardiac infarction,consequently,it is considered one of the best anti-arrhythmia medication[3～5].We found Amiodarone could effectively control chronic atrial fibrillation,though spontaneous cardioversion rate is low within one week(23%).But it increased the successful rate by direct currently cardioversion.Moreover,it has satisfactory result in prevention from recurrence of atrial fibrillation in short term(10 days) about 73%.Compared with class Ⅰ anti-arrhythmia medication which has more adverse effect of malignant proarrhythmia,it has mild side-effect on myocardism[6].Here only one p atient began to suffer IAVB and another patients had degree Ⅱ type Ⅱ AVB.No To rsade de points or ventricular fibrillation emerged.
, 百拇医药
The electrophysiology mechanism of medication inducing Torsade De points or vent ricular fibrillation perhaps is based on prolonged myocardial repolarization and repolarization dispersion.Some authors[6,7] pointed out that the reason Amiodarone seldom induces arrhythmia resulted from its property on myocardiac r epolarization.In another words compared with type I anti-arrhythmic medications ,it does not increase QT dispersion,thought it has similar effect to prolong QT interval.
, 百拇医药
So far,the effect of Amiodarone on QT dispersion is controversial.Cui .et al[6] reported Amiodarone could reduce myocardiac re polarization dispersion in coronary artery disease.His opinions was confirmed in patients with hypertrophic cardiomyopathy.However,Hii et al[8 ] showed that Amiodarone has no effect on repolarization dispersion in patien ts with coronary artery disease,and similar conclusion deduced from the latest d ata[9].Our results are different from either of above,even from our pred ictive result.We found that Amiodarone prolonged myocardiac repolarization,and m eanwhile increased myocardiac repolarization dispersion when it was administered in patients with chronic atrial fibrillation.The reason is still unknown.It may be due to underline disease,arrhythmia or dosage of Amiodirone.Further study is needed.
, 百拇医药
References
1，Coplen SE，Antman EM,Berlin JA.Efficacy and safe of quinidine therapy for maintenance of sinus rhythm after cardioversion.Circula tion,1990.82(4)∶1106.
2，Flaker GC,Blackshe ar JL,McBRIDE R.Antiarrhymic drug therapy and cardiac mortality in atrial fibril lation.J Am Coll Cardiol,1992,20(3)∶527.
3，Ceremjuzyski Y,Klechzar E,Kreminska-Pakula M.Eff ects of amiodarone on mortality after myocardial infarction.J Am Coll Cardiol,19 92.20(4)∶1056.
, http://www.100md.com
4，Singh SN,Fletcher RD,Fisher SG,et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricula r arrhythmia.N Engl J Med,1995,333(2)∶77.
5，Doval HC,Nul DR,Grancelli HO,et al.In sufficiency cardiac on argentina(GESICA).Randomized trial of low-dose amiodaron e in severe congestive heart failure.Lancet,1994,334(8291)∶493.
6，Cui G,Sen L,Sager P.Effects of amiodarone,sematil ide and sotalol on QT dispersion.Am J cardiol,1994,74(9)∶896.
, 百拇医药
7，Dritsas A,Gilligan P,Nihoyannopoulos P.Amiodarone reduce QT dispersion in patients with hypertrophic cardiomyopathy.Int J Cardiol ,1992,36(4)∶345.
8，Hii JT,Wyse DG,Gillis AM.Percordial QT interval d ispersion as a marker of torsade de pointes,Pisparate effects of class I a antia rrhythmic drug and amiodarone.Circulation,1992,86(5)∶1376.
9，Grimm W,Steder U,Menz V.Effects of amiodarone on QT dispersion in the 12-leads standard electrocardiogram and its significance f or subsequent arrhythmic events.Clin cardiol,1997,20(2)∶107., http://www.100md.com