JACC｜心脏骤停复苏后，哪几类患者依然很难逃脱死亡？

尽管复苏科学取得了重大进展，但院外心脏骤停（OHCA）复苏后出院的存活率仍然很低，只有不到10%。那么哪几类患者复苏后依然很难逃脱死亡？

在爱思唯尔全医学信息平台ClinicalKey中，近期心血管领域著名期刊JACC (Journal of the American College of Cardiology)上发表了一篇论文（文末“阅读原文”可浏览全文），研究者对美国旧金山4年中18岁至90岁所有突发院外心脏骤停的患者（239例）进行分析，让我们能够尽早识别出这些需要特殊关注的患者。

需心脏骤停复苏的常见原因

在239例患者中，约一半被抢救至住院治疗（133例，55.6%）。其中86例（64.7%）在住院期间死亡，47例（35.3%）存活至出院。VT/VF（室性心动过速/心室纤颤）是最常见的表现节律，在55例（41.3%）心脏骤停（SCA）复苏的患者中有此发现，在SCA幸存者中更常见（78.7%，20.9%）。

所有SCA复苏患者中，最常见的停搏原因是：

• 急性冠状动脉疾病（急性冠状动脉综合征伴或不伴ST段抬高：39.8%）

•  神经系统疾病（中风、颅内出血或癫痫：18%）

• 慢性冠状动脉疾病（已知冠状动脉疾病，无其他明确原因：16.5%）

在复苏后SCA中，69.1%（133例中的92例）发现了心律失常性停搏原因。存活者心律失常的发生率明显高于非存活者（92%，57%；p<0.001）。

排除户外或急诊室死亡（SCD后病例）或非突发性死亡的OHCA，包括了复苏至住院的SCA。

SCA复苏的原因在回顾综合医院记录后确定：心律失常（红色）、心脏/非心律失常（蓝色）或非心脏（绿色）原因。

这些患者容易存活

年龄小的患者更易存活。SCA存活者的平均年龄比SCA非存活者年轻10.3岁以上（95%CI: 4.5-16岁；p<0.001）。

在多变量分析中，VT/VF节律、心律失常原因是SCA复苏后存活至出院的具统计学意义的预测因子。因为目前的复苏方法和自动体外除颤器被设计为针对该病因，从而增加了心律失常原因造成停搏的幸存者数量，他们往往更容易获得治疗。

这些患者容易“再入鬼门关”

值得注意的是，近1/5的神经系统疾病导致的SCA普遍是致命的（28%的SCA非存活者vs. 0%的SCA存活者；p<0.001）。尽管进行了初步复苏，但仍有100%的住院死亡率。

大部分（20/24，83.3%）的神经系统引发的SCA是出血性中风，所有这些中风患者都在停搏发生时服用抗凝或抗血小板药物。这类药物的试验可能遗漏了以OHCAs或SCD表现的颅内出血，因此这些药物的相关风险可能被低估。

所以可以预见，既往中风史与生存率降低相关。

虽然没有药物治疗与生存率增加相关，但钙通道阻滞剂与生存率降低独立相关。

先前的研究表明，二氢吡啶钙通道阻滞剂硝苯地平与OHCA的风险增加有关。这可能是由于其快速降压或冠状动脉盗血后交感神经张力增加所致。然而，这一发现可能不适用于其他钙通道阻滞剂。

研究还发现，有一半使用选择性5-羟色胺再摄取抑制剂（SSRIs）的SCA患者有颅内出血。尽管这一发现可能是偶然的，但它也与SSRIs与血小板功能障碍和出血性中风风险增加相关的报道一致，尤其是在那些服用抗凝剂或抗血小板药物的患者之中。

总结

在心脏骤停复苏后，年龄小、VT/VF节律、心律失常原因造成心脏骤停的患者相对更易存活。

而神经系统疾病引发停搏、有既往中风史、使用钙通道阻滞剂与SSRIs的患者需要特别关注，避免在住院期间依然出现死亡结局。

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