Профілактика і лікування пароксизмальних тахіаритмій серця в амбулаторно-поліклінічних умовах

Abstract

Лікування і профілактика хворих із пароксизмальними тахіаритміями в амбулаторно-поліклінічних умовах є складною задачею для лікаря-кардіолога. Найбільш доцільним є використання для лікування і довготривалої профілактики пароксизмальних тахіаритмій у хворих із низькою фракцією викиду лівого шлуночка серця антиаритмічних засобів, які не спричиняють значного негативного інотропного ефекту. До них належать антиаритмічні препарати I класу рослинного походження (алапінін і гілуритмал) і III класу (аміодарон і соталол). Для профілактики пароксизмальних тахіаритмій антиаритмічні засоби I A підкласу (новокаїнамід, хінідин, дизопірамід) та I С підкласу (пропафенон, енкаїнід, флекаїнід) можуть використовуватися лише нетривалий період – упродовж 2-4 тижнів. Це обумовлено негативним інотропним ефектом цих антиаритмічних препаратів. Для довготривалої профілактики пароксизмальних тахіаритмій β-адреноблокатори можуть бути використані у хворих із фракцією викиду лівого шлуночка серця (ΔS%) не менше 45%. З метою лікування і профілактики пароксизмальних суправентрикулярних тахіаритмій високу ефективність має комбінована терапія, яка включає алапінін і серцевий глікозид (дигоксин або строфантин). Препаратами першого ряду для лікування і профілактики пароксизмальної шлуночкової тахікардії є аміодарон, лідокаїн, алапінін і новокаїнамід, другого ряду – дизопірамід, гілуритмал, пропафенон та третього ряду – β-адреноблокатори.

Treatment and prophylaxis of patients with paroxysmal tachyarrhythmias in out-hospital conditions is very difficult task for cardiologist. It is most expedient to use antiarrhythmic agents, which are without significant negative inotropic effect (allapinin and gilurytmal – agents of I class, having plant origin, and preparations of III class – amiodarone and sotalol) for treatment and long-lasted prophylaxis paroxysmal tachyarrhythmias in patients with small cardiac output. Antiarrhythmic agents of I A subclass (procainamide, quinidine, disopyramide) and I C subclass (propafenone, encainide, flecainide) can be administered not durative period, which is only 14-28 days. It is conditioned negative inotropic effect of these preparations. Emergency hospitalization is need for treatment of patients with syndrome of early excitation of ventricles (WPW syndrome) and paroxysmal atrial fibrillation. Electrical cardioversion is carried out as soon as possible must be realized for treatment of these patients. Allapinin has the special place among antiarrhythmic agents of I A and I B subclasses. In difference from quinidine, procainamide, disopyramide, mexiletine and others agents of class I allapinin in effective antiarrhythmic doses has a small influence on width of ventricular QRS complexes, PQ interval and QT interval. It does not influence on conductivity in atrioventricular node in antegrade direction. Allapinin does not cause the oppression of sinus node function. This agent abbreviates effective refractory period in atrioventricular node and ventricles. Allapinin reduces permeability of cellular membranes for ions potassium, sodium and calcium. Due to this action it oppresses excitability of cardiac tissue. Allapinin blocks formation of impulses in ectopic centers with raised excitability. That is why it has effect in patients with ectopic arrhythmias. Allapinin has β-adrenostimulated activity. Due to this effect it can be administered in case of combined disorders of rhythm with sinus bradycardia and cardiac failure. Allapinin has also local anesthetic action. It causes moderate dilatation of coronary arteries of heart. Paroxysmal supraventricular arrhythmias can be treated with help several drugs with antiarrhythmic activity. Author of this article had developed a new method for treatment of paroxysmal supraventricular tachycardias, including patients with severe heart failure. In accordance with such method combination of preparation with antiarrhythmic action (allapinin + cardiac glycoside) is applied. First of all one cardiac glycoside – digoxin in dose 0,25 mg or strophantin in the same dose is administered intravenously. Then in 20-30 minutes after use of cardiac glycoside allapinin is administered intravenously in dose 30-40 mg. After interruption of paroxysm of tachyarrhythmia prophylactic treatment must be used. It includes administration orally abovementioned agents. Allapinin is administered orally in daily dose 75 mg. In combination with allapinin digoxin uses orally in dose 0,25 mg 1-2 times a day. In case of positive result of therapy may be reduction of daily dose allapinin till 50 mg (25 mg twice a day) and digoxin till minimal effective, which is 0,25 mg once a day. The criterion of such positive result of therapy was appearance of periods without paroxysms of tachyarrhythmia, which are greater than 1,5-2 periods. These periods are appeared earlier between paroxysms of tachyarrhythmia. Thus, this therapy provides prophylactic effect. Antiarrythmical agents of first line for termination of paroxysmal ventricular tachyarrhythmias are amiodarone and lidocaine. First of all it is necessary to apply amiodarone in dose 300-450 mg (3-6 ml 5% solution) in 20 ml isotonic solution of sodium chloride intravenously slowly during 5-10 minutes. Dose of amiodarone is depended on weight of patient. In paroxysmal ventricular tachycardia it must be 7-10 mg/kg. Overall maximal dose of amiodarone for one day must be not more than 35 mg/kg. In case of absence of effect after use of amiodarone instead this preparation lidocaine can be administered. Lidocaine is applied in the form of 2% solution – 4 ml intravenously without dissolution during 1 minute. Dose of lidocaine is estimated with taking in account weight of patient. It must be 1 mg/kg. In the absence of effect second intravenous administration of lidocaine in dose 0,5 mg/kg is realized. In absence of effect after second administration of lidocaine this agent can be applied third time in dose 0,5 mg/ kg intravenously. Antiarrhythmic agents allapinin and novocainamide have significant effectiveness for suppression paroxysmal ventricular tachycardia. If first order line agents (amiodarone, lidocaine, allapinin and novocainamide) are not effective antiarrhythmic drugs of second-order line (disopyramide, gilurytmal, propafenone) can be applied. Preparations of third-order line (β-blocker agents) can be also efficient. Best effectiveness for surviving of patients with left ventricular dysfunction and malignant ventricular arrhythmias has implantation of cardioverter defibrillator in combine with therapy of antiarrhythmic agents of III class (sotalol or amiodarone).