心律不整性昏厥之診斷與治療

Diagnosis and Management of Arrhythmic Syncope

心律不整性昏厥是指因心跳過慢或過快所引起的昏厥。因心跳過慢心律不整所引起的昏厥包括病竇症候群與房室傳導阻滯。在昏厥發生時，若心電圖證實發生竇性停止、竇房阻滯、或在發生心室上頻脈停止後，產生延長的竇性停歇而昏厥，此時裝置心臟節律器有助於改善昏厥。但若昏厥發生時，沒有同步心電圖異常之佐證，那麼即使裝了節律器，也有可能再發生昏厥。在房室傳導阻滯疾病方面，心臟節律器主要用於治療和昏厥相關之房室傳導障礙。不少研究證實，裝置心臟節律器可有效預防高度房室傳導阻滯患者日後發生昏厥。在心跳過快心律不整方面，主要包括心室上頻脈和陣發性心室頻脈。這些快速不整脈引起之昏厥，第一線治療是心導管不整脈燒灼術。若心室頻脈合併結構性心臟病，或合併左心室收縮功能不良，則除了心導管電燒外，還必須裝置植入式心臟整流去顫器，以預防猝死。本文主要整理自2018年歐洲心臟學會昏厥診斷治療指引，並對心律不整性昏厥的診斷與治療做詳細介紹。

Arrhythmic syncope refers to brady- or tachyarrhythmia-induced syncope. Bradyarrhythmia related syncope includes sick sinus syndrome and atrioventricular block. Pacemaker implantation is beneficial to syncope improvement if there is electrocardiographic evidence of sinus arrest, sinoatrial block, or prolonged sinus pause after supraventricular tachycardia. However, recurrent syncope may develop even with pacemaker implantation if there is no electrocardiographic abnormality. In terms of atrioventricular block, pacemaker is applied to the treatment of syncope related atrioventricular block. Many studies indicate that pacing is highly effective in preventing syncope recurrences when atrioventricular block is documented. Tachyarrhythmia related syncope includes supraventricular tachycardia and paroxysmal ventricular tachycardia. First line therapy for tachyarrhythmia related syncope is catheter ablation. If tachyarrhythmia is accompanied by structural heart disease or left ventricular dysfunction, implantable cardioverter defibrillator should be considered for preventing sudden cardiac death. Here, we summarize 2018 European society of cardiology guidelines for the diagnosis and management of syncope, and will focus on the diagnosis and management of arrhythmic syncope.