心动过缓和传导异常患者的评估与管理中国专家共识2020

推荐类别和证据水平

心血管植入型电子器械（cardiovascularimplantableelectronicdevices，CIED）适应证，按照国际推荐级别（COR）和证据等级（LOE）分为3类。

1类适应证：根据病情，有明确证据或专家们一 致认为起搏治疗对患者有益、有用或有效，获益

风险。相当于绝对适应证。

Ⅱ类适应证：根据病情，起搏治疗给患者带来的益处和效果证据不足或专家们的意见有分歧。Ⅱ类适应证中又进一步根据证据/观点的倾向性分为Ⅱla（倾向于支持，获益 $>>$ 风险）和lb（意见有分歧，获益 $\geqslant$ 风险）两个亚类。相当于相对适立让正

血类适应证：根据病情，专家们一致认为起搏治疗无效，获益 $=$ 风险；甚至在一些情况下对患者有害，风险 $>$ 获益。因此不需要／不应该植入心脏起搏器，即非适应证。

证据等级：根据证据的来源分为A、B、C3个等

A级：数据来源于多个随机对照试验（randomizedcontrolledtrial，RCT）或荟萃分析或者有1个以上的高质量的随机的临床注册研究。

B级：数据来源于1个RCT或荟萃分析B-R（randomized）」或来源于1个非随机临床试验或荟萃分析[B-NR（nonrandomized）]

C级：随机或非随机的小规模研究、回顾性研究和登记注册研究［C-LD（limiteddate），或者专家根据临床经验得出的一致共识［C-EO（expertopinion）］

一、定义和流行病学

（一）定义

心动过缓可分为两大类：窦房结功能障碍（sinusnodedysfunction，SND）和房室传导阻滞。SND是指窦房结和心房冲动形成和传导异常的症候群，包括窦性心动过缓（窦性心律频率 ${<}50 $ 人窦性停搏（停搏 ${>}3.0$ s）窦房传导阻滞、慢-快综合征、变时性功能不全。房室传导阻滞可分为一度房室传导阻滞、二度房室传导阻滞、三度房室传导阻滞，其中二度房室传导阻滞包括二度1型房室传导阻滞、二度Ⅱ型房室传导阻滞和高度房室传导阻滞。高度房室传导阻滞是指连续3个以上P波被阻滞的严重二度阻滞。传导异常可分为右束支传导阻滞（rightbundlebranchblock，RBBB）、左束支传导阻滞（leftbundlebranchblock，LBBB）左前分支传导阻滞和左后分支传导阻滞。

（二）流行病学

心率减慢和心肌细胞间传导改变可见于正常老年人和心律失常患者，因此心动过缓和传导异常多见于老年人。窦房结、心房组织、房室结和传导系统等部位异常可导致心动过缓、心室肌细胞除极异常

或者心房和心室除极时间不一致。

SND亦称病态窦房结综合征，常由年龄相关的进行性窦房结及周围心房肌组织的退行性纤维化引起67。这些组织的纤维化可导致窦房结冲动形成障碍或者心房组织冲动传导异常；同时，纤维化与多种心动过缓密切相关，这种退行性纤维化也与房性心律失常的形成有关。房性心律失常常与SND同时出现，称为“慢-快综合征”。SND患者也可以同时伴随房室传导阻滞，因为患者相似的纤维化病变也影响房室传导系统-9」。多项大型队列研究显示SND常见于70\~80岁老年患者，其在65岁以上人群中的发病率约为 $1\%$ ,且无性别差异[10-12]。心肌缺血/梗死、浸润性疾病、手术创伤、内分泌功能障碍和神经肌肉疾病等多种病理生理改变都会影响窦房结和房室结的冲动形成和传导，窦房结和房室结组织病变的临床表现非常相似。

目前，没有大型研究报道房室传导阻滞在人群中的患病率及发病率，房室传导阻滞在70岁以上的老年人中更为常见，特别是结构性心脏病的患者[13-15]。一度房室传导阻滞可见于健康成年人,但其可能与心房颤动（房颤）风险升高有关，在20岁的健康人群中， $0.5\%{\sim}2\%$ 的成年人PR间期 ${\tt>}0.2~\mathrm{s}$ 而在老年人群中,这一比例可升至 $5\%^{[\,15-18\,]}$ 群中二度房室传导阻滞的发病率为 $2\%{\sim}9\%$ ，工 $0.9\%{\sim}2\%$ 的患者因房室传导阻滞出现黑朦或者晕厥等症状而需住院治疗[18-9],二度房室传导阻滞的发病率随年龄增加而升高，年龄每增加5岁，其发病风险增加1.34倍；一项来自芬兰的研究发现，二度房室传导阻滞发病风险与性别有关，男性风险为女性的2倍[14-15]。 主度房室传导阻滞的发病率相对较低，为 $0.02\%{\sim}0.04\%$ ，其在健康人群或者无症状人群中的发病率更低，为 $0.001\%$ ，三度房室传导组滞的发病风险与年龄有关，在70岁以上的老年人中发病率最高。糖尿病或者高血压等疾病可增加三度房室传导阻滞的发病风险。在糖尿病患者中，其发病率为 $1.1\%$ ，而在高血压患者中，其发病率为 $0.6\%$ L20-22」

（三）临床表现

心动过缓临床表现多样。患者可无症状，轻者可出现疲倦、乏力、头晕、心悸和运动耐量下降；重者可出现心脑、肾等重要器官供血不足的症状，表现为晕蕨、黑朦、心力衰竭或者阿斯综合征，甚至因心脏停搏或者继发心室颤动而导致死亡。传导异

常的临床表现与传导系统的病变部位有关。单纯RBBB或者分支传导阻滞的患者通常无明显症状，而LBBB患者由于心室不同步或者合并潜在的心肌病，可以表现为心力衰竭。

二、临床评估手段评价

（一）病史和体格检查

详细的病史采集和体格检查是进行临床评估的基础（1，C-EO）。完整的病史应包括起病及诊疗的经过、既往史、个人史、家族史以及全面的心血管病风险评估，其有助于了解心动过缓或传导异常的病因和诱因。体格检查除了了解心动过缓的表现，还应关注潜在的器质性心脏病和全身性疾病的体征[23]。颈动脉窦按摩有助于诊断颈动脉窦压迫综合征，但在实施前应进行颈动脉听诊或颈动脉超声检查，排除颈动脉严重病变，避免颈动脉窦按摩所致脑卒中发生[24]

（二）非侵人性检查

1.静息心电图：静息心电图是对记录到或怀疑心动过缓或传导异常的患者进行初步评估的重要检查手段。所有患者均应行静息12导联心电图（electrocardiogram，ECG）检查，明确心搏频率、节律和传导情况，有助于筛查器质性心脏病或系统性疾病（I.B-NR)25-26]

2.运动心电图：运动心电图通常不作为常规检查，但对于特定的一些患者，如怀疑变时功能不全者（Ⅱla，B-NR）运动期间发生可疑心动过缓相关症状者（la,C-LD） $2:1$ 房室传导阻滞者为判断阻滞部位时（Ⅱa，C-LD）应行运动心电图检查27-28]

3.动态心电图：大部分心动过缓和传导异常的患者，心律失常间断发作，为明确心律失常与症状的相关性,推荐进行心脏节律监测（I,B-NR）29-31」对于发作频繁者，推荐进行 $24\,\mathrm{h} $ $48\,\mathrm{h}$ 连续动态心电图检查。发作频率较低者，推荐更长程的心脏节律监测，相关心脏节律监测器种类和选择对象见表1。

4.心脏影像学检查：对记录到或怀疑心动过缓或传导异常的患者应进行心脏影像学检查，以评估心脏的结构和功能，识别潜在的器质性心脏病[32-35]。新发 LBBB、二度ⅡI型房室传导阻滞、高度房室传导阻滞或三度房室传导阻滞伴或不伴明确器质性心脏病或冠心病者，推荐经胸超声心动图检查（I，B-NR）；其他类型心动过缓或传导异常者，若怀疑存在器质性心脏病，应进行经胸超声心动图检查（Ⅱa，B-NR）；某些心动过缓或束支传导阻滞患者，

表1心脏节律监测器类型及适用人群

|心脏节律监测器类型|选择对象| |---|---| | 非医生处方的智能手 机系统 |可正确使用该技术的患者| |Holter监测器|症状发作频繁，24~48h内能监测到者| | 事件监测器（患者激 活，经电话传输） | 症状呈自发性,发作频繁，在2~6周内 能监测到者；不适用于失能的患者 | | 体外循环事件记录 器（患者或自动激 活） | 症状呈自发性，发作频繁，可疑与心动过 缓或传导异常相关,在2~6周内能监 | |体外Patch监测器| 适用人群与体外循环事件记录器相同； 因无导线，可防水，故应用的依从性 更好 | |移动心脏遥测仪|| || 症状呈自发性，发作频繁，可疑与心动过 缓或传导异常相关者；不适用发作不缓或传导异常相关者；不适用发作不 频繁、持续时间短暂、症状轻微者 | |植人型心脏监测仪| 症状反复发作但不频繁，可疑与心动过 缓或传导异常相关，伴或不伴器质性 |

注：Holter=动态心电图，Patch=贴片式

若怀疑存在器质性心脏病，常规检查未能明确时，应进行更高级别的心脏影像学检查（如经食管超声心动图、心脏CT、心脏磁共振或核素成像）（ⅡIa，C-LD)。无症状窦性心动过缓或一度房室传导阻滞，且无器质性心脏病临床证据者，因检查的诊断率低，心脏影像学检查不作为常规推荐（Ⅲ，B-NR）

5.实验室检查：临床怀疑某些特殊病因或继发性疾病导致的心动过缓或传导异常时，应进行相应的实验室检查[36-38],例如电解质水平、血气分析、甲状腺功能、莱姆病病原学及血清学检查（Ⅱa，C-LD）

6.基因检测：传导异常由基因突变所致确诊者，推荐其一级亲属接受遗传咨询和基因检测，以筛查出类似疾病者（I,C-E0）[39-41]。遗传性传导疾病患者，可以考虑对亲属进行遗传咨询和基因检测，有助于诊断评估（Ⅱb，C-EO）[39-41

7.睡眠呼吸监测：对于有记录或怀疑在睡眠期间发生心动过缓或传导异常的患者，推荐进行睡眠呼吸监测，以验证是否与临床症状相关（I，B-NR）4」。对于存在睡眠相关的心动过缓或传导异常，同时合并阻塞性睡眠呼吸暂停的患者，推荐接受针对睡眠呼吸暂停的相应治疗（如持续气道正压通气和减轻体重）（I,B-NR）[43]。已经植人或考虑植入永久性起搏器的患者，应进行睡眠呼吸暂停的筛查（Ⅱla，B_NRL42,44]

（三）侵人性检查

1.植入型心脏监测仪：植入型心脏监测仪（insertablecardiacmonitor，ICM）是一种能够长时间持续监测患者心电信号的可程控器械，植人于患者的胸前皮下，可自动及手动记录患者的心律失常事件，并可以无线程控及读取数据。ICM克服了体外心电监测仪监测时间相对较短，间断监测，对于偶发、短时间的心律失常的诊断能力有限的局限性，能够提供更长程的持续心脏节律监测，适用于症状发作不频繁或不可预测性的疑似心动过缓或传导异常患者，便于明确心动过缓与临床症状的关系。因此，对于怀疑心动过缓相关症状的患者，若发作不频繁（症状发作间隔 ${>}30\textup{d}$ ）.常规的非侵人性检查未能明确时，应使用ICM进行长程心脏节律监测（Ⅱa，C-LD）[45-47]。另外,ICM 不仅能够提高诊断率,而且有助于患者及时治疗，从而减低整体医疗成本，对于诊断未明且疑似心动过缓或传导阻滞患者，应尽早

植人ICM（ⅡIa,C-LD）[45-48]

2.心内电生理检查：心内电生理检查（electrophysiologystudy，EPS）是导管介人的侵入性检查，可对窦房结功能及房室传导功能进行评估，通常不作为首选方案。对于高度怀疑症状与心动过缓相关的患者，当非侵入性检查不能明确时，可考虑进行EPS(IIb, C-LD )[3-31](图 1 )。

三、窦房结功能障碍

（一）病因学

SND多发于老年人，内源性窦房结及周围心房肌组织的增龄性、进展性和退行性纤维化是SND的重要病理生理改变，其与心率及窦房结恢复时间的延缓相关,是患者出现临床症状的重要原因6-7,49；心肌缺血/梗死、浸润性疾病、胶原血管疾病、外科创伤、内分泌失调、自主神经效应、神经肌肉疾病等多种外源性病因也可通过影响窦房结功能使患者出现相同的临床表现50-51

 图1可疑心动过缓和传导疾病的评估流程图（图中实线表示没有争议的选择策略，虚线表示可能的选择策略，仅基于某些特殊临床情况）

（二）评估流程

弓起SND的病因大多是慢性且不可逆的。但在某些情况下，窦性心动过缓可归因于某些可逆的病因，如急性心肌梗死（心梗）高强度的运动训练、心脏外科手术（心脏瓣膜置换术、MAZE迷宫术、冠状动脉旁路移植术）房颤、电解质紊乱（高钾血症、低钾血症）低血糖、甲状腺功能减退、药物治疗和感染等。对于有症状的SND患者，推荐评估和治疗可逆病因[ 52-58 ](图 2 )。

 图2窦房结功能障碍的评估流程图中華醫学金杂志社 版权所有违者必究Chinese Medical Association Publishing Housc

（三）急诊管理

药物可以用于不同病因引起的心动过缓的急诊治疗。数项观察性研究结果证实血流动力学不稳定的窦性心动过缓和房室传导阻滞患者能够获益于阿托品治疗[53-56]。此外,多个病例报道提示异丙肾上腺素对于心动过缓的治疗可能是有效的。对于症状性或不合并冠状动脉缺血的血流动力学不稳定SND患者，异内肾上腺素、多巴胺、多巴酚丁胺或肾上腺素可被考虑用于增加心率和改善症状57-58]

临时起搏用于药物难治性、血流动力学不稳定性心动过缓的急性治疗，如持续的有症状性的心脏停搏、由心动过缓介导的致死性室性心律失常或由可逆病因引起的严重症状性心动过缓等，可避免未来永久起搏器的植人59]

1.急性心动过缓的药物治疗适应证

I类适应证：对于症状性SND患者，推荐评估和治疗可逆病因（证据水平：C-EO）。

Ⅱ类适应证

Ⅱa类适应证

（1）对于症状性或血流动力学不稳定性的SND患者，应使用阿托品提高窦性心率（证据水平：C-LD53-56

（2）对于因服用过量钙通道阻滞剂而伴有症状或血流动力学损害的心动过缓患者，静脉注射钙剂可以增加心率并改善症状（证据水平：C-LD）57-58」

（3）对于因服用过量β受体阻滞剂或钙通道阻滞剂而伴有症状或血流动力学受损的心动过缓患者，应使用胰高血糖素增加心率和改善症状（证据水平：C-LD）L57-58」

（4）对于因服用过量B受体阻滞剂或钙通道阻滞剂而伴有症状或血流动力学损害的心动过缓患者，应使用高剂量胰岛素治疗增加心率和改善症状（证据水平：C-LD）57-58]

（5）对于因地高辛毒性而伴有症状或血流动力学损害的心动过缓患者，应使用地高辛Fab抗体片段增加心率和改善症状（证据水平：C-LD）57-58］

Ib类适应证：在伴有症状或血流动力学损害且冠状动脉缺血可能较低的SND患者中，可以考虑使用异内肾上腺素、多巴胺、多巴酚丁胺或肾上腺素增加心率和改善症状（证据水平:C-LD）57-58]

2.急诊临时起搏治疗适应证

Ⅱ类适应证

la类适应证：对于药物难治性、持续血流动力

学不稳定的SND患者，在植入永久性起搏器或心动过缓纠正之前，应选择临时起搏导线经静脉起搏以增加心率和改善症状；在某些特殊情况下，可选用永久起搏导线作为临时起搏（证据水平：C-LD）59

lb类适应证：对于有严重症状或血流动力学不稳定的SND患者，在临时经静脉起搏导线、永久性起搏器植人或心动过缓纠正之前，可以考虑选择临时经皮起搏以增加心率和改善症状（证据水平：C-LD）5"

（四）SND的长期管理

准确识别症状与心动过缓之间的时间相关性是决定是否启动永久起搏治疗的总体原则，临床上常选用动态心电图和心电事件记录仪来评估上述症状与心律失常间的关系。心电生理检查作为一种评估窦房结功能的侵人性操作，因其测得参数（如窦房结恢复时间）的敏感度和特异度较差，临床应用较为局限6。生理状态下,迷走神经活动增加可降低静息心率至40次 以下，当年轻人、运动员、正常人睡眠或深度休息中出现迷走神经张力增高介导的无症状性心动过缓时,一般不考虑起搏治疗[61]；当症状性心动过缓被确定是由某些病因如药物过量使用、申状腺功能异常或代谢综合征等引起时，应考虑尽早解除可逆性病因而非起搏治疗6

永久起搏治疗适应证

I类适应证

（1）明确症状是由SND导致的，推荐永久起搏治疗提高心率并改善症状（证据水平：C-LD）63

（2）由于某些疾病必须使用某些类型和剂量的药物治疗，而这些药物又可引起或加重窦性心动过缓并产生临床症状，推荐永久起搏治疗提高心率并改善症状（证据水平：C-EO）。

Ⅱ类适应证

Ⅱa类适应证

（1）对于快-慢综合征患者，如果症状是由于心动过缓导致的，应接受永久起搏治疗，可以提高心率并改善灌注不足的症状（证据水平：C-EO）

（2）对于因窦房结变时功能不全引起症状的患者，应选择带有频率应答功能的起搏器治疗，可以增加活动耐量、改善症状（证据水平：C-EO）

lb类适应证：当症状很可能是由心动过缓导致，但未完全明确时，可以考虑口服茶碱提高心率，改善症状并帮助确定永久起搏的潜在获益（证据水平：C-LD)[64-65]

Ⅲ类适应证

（1）无症状的SND，不建议永久起搏治疗（证据水平·C-LD)[61-62]

（2）虽有类似心动过缓的症状，但证实该症状并非由窦性心动过缓引起，不建议永久起搏治疗（证据水平：C-LD）L61-62]

（3）非必须应用的药物引起的症状性窦性心动过缓,不建议永久起搏治疗（证据水平：C-LD）61-62」

（五）SND起搏植人技术及方法

研究证实，由频率适应性起搏器起搏右心室所另起的心室不同步可能抵消起搏器带来的潜在获益[667]。究竟植入何种起搏系统对于 SND 效果最好？目前证据表明，症状性SND人群中，基于心房的起搏方式优于单腔心室起搏，如房室传导系统完整且无传导异常证据，应植入单腔心房起搏或双腔起搏器（I,B-R）[68-71]；对于已植入双腔起搏器、但房室传导完整的患者应尽可能优化起搏策略以减少右心室起搏比例（Ⅱa，B-R）72」；对于预期寿命较短或起搏比例不高的SND患者而言，单腔右心室起搏具有更优的经济-效益比，在此类人群中进行植入似乎是合理的（Ⅱla，C-EO，图3）。

四、房室传导阻滞

病因学

5引起房室传导阻滞的病因分为遗传性与获得性，其中获得性因素更为常见，包括退行性变、感染、炎症、缺血、医源性、迷走神经过度激活、内环境紊乱等。而房室传导系统退行性变是临床中最为常见的病因。除根据阻滞程度及心电图表现将房室传导阻滞进行分型外，还要考虑房室传导阻滞发生病变的解剖部位定位，这具有重要的临床意义。发生阻滞的病变部位可以在房室结、希氏束内（局限在希氏束）或希氏束下（希氏束以下）。一般来说，房室结水平的阻滞，其逸搏心律较为安全：而希氏束内或希氏束下阻滞的逸搏心律不稳定，可能迅速进展恶化，造成严重临床后果73-74]

（二）评估流程

对于新发房室传导阻滞患者，需评估是否存在可逆病因。如果存在，针对病因治疗即可能恢复，可避免永久起搏（图4）。

（三）急诊管理

对于一过性或可逆性病因引起的房室传导阻滞，如莱姆心肌炎、地高辛过量、急性心梗、内环境紊乱等，推荐给予临时起搏支持以待房室传导功能恢复（1，B-NR）。对于必须接受长期、稳定剂量的

 图3窦房结功能障碍起搏治疗流程图

抗心律失常药物或β受体阻滞剂治疗的患者，如果急诊出现有症状的二度或三度房室传导阻滞，可不需要观察药物洗脱或可逆性，应进行永久起搏治疗（Ⅱa,B-NR)t/5-7/]

1.急性房室传导阻滞的药物治疗适应证

Ⅱ类适应证

Ⅱa类适应证：对于二度或三度房室传导阻滞患者，若存在心动过缓相关症状或血流动力学不稳定，应使用阿托品以改善房室传导、提高心率、改善症状（证据水平：C-LD）53,78-79]

Ⅱb类适应证

（1）若房室传导阻滞病因排除急性冠状动脉缺血，可考虑使用β受体激动剂，如异内肾上腺素、多巴胺、肾上腺素等提高心室率（证据水平:B-NR）80-82）

（2）对于急性冠状动脉缺血引起的房室传导阻滞，可考虑静脉使用氨茶碱提高心室率（证据水平：C-ID）[83,84]

2.急诊临时起搏治疗适应证

Ⅱ类适应证

Ⅱa类适应证

（1）对于存在心动过缓相关症状或血流动力学不稳定的二度或三度房室传导阻滞患者，应予临时经静脉起搏（证据水平：B-NR）85-87]。

（2）若临时经静脉起搏时间较长，应选择外接永久电极导线（证据水平：B-NR）88-91]

lb类适应证：可考虑临时经皮起搏，直到放置临时经静脉起搏或永久起搏器植人或房室传导功能恢复（证据水平：B-R）92-93]。

（四）房室传导阻滞的长期管理

对于一度、二度1型及 $2:1$ 房室传导阻滞，有无心动过缓症状是决定永久起搏适应证的主要依据。但若阻滞位点在房室结以下或存在系统性疾病可能导致房室传导阻滞进展，即使没有心动过缓症状，亦需考虑永久起搏[94-95]。对于已知可逆原因导致的症状性房室传导阻滞患者，首先予病因及支持治疗。若治疗潜在疾病后仍存在房室传导阻滞，推荐行永久起搏[61,%]。迷走神经张力增高引起的房室传导阻滞,若患者无症状,不应行永久起搏[31,97]。房室

 传导阻滞起搏治疗管理流程见图5。

永久起搏治疗适应证

I类适应证

（1）非可逆性二度Ⅱ型、高度及三度房室传导阻滞，不论有无症状，均推荐永久起搏（证据水平：BNIRL94-95,98-99]

（2）对于神经肌肉疾病（包括肌营养不良、Kearns-Sayre综合征等）所致二度、三度房室传导阻

滞或HV（His-ventricular）间期 ${>}70~\mathrm{ms}$ 患者，不论有无症状,均推荐永久起搏（证据水平：B-NR）L100-103」。

（3）持续性房颤合并症状性心动过缓患者，推荐永久起搏（证据水平：C-LD）L104-105］

（4）对于需药物治疗心律失常或其他疾病所致症状性房室传导阻滞患者，若无可替代治疗方案，推荐永久起搏（证据水平：C-LD）75-77]

Ⅱ类适应证

 注：LVEF 左心室射血分数； $\mathrm{CRT=}$ 心脏再同步治疗； 希氏-浦肯野系统起搏图5房室传导阻滞起搏治疗流程图 MEDICAIAS

Ⅱa类适应证

（1）炎症性心肌病（如心脏结节病或淀粉样变）所致二度Ⅱ型、高度及三度房室传导阻滞，应永久起搏（证据水平：B-NR）106-108]

（2）层粘连蛋白A/C基因突变患者（包括肢带和Emery-Dreifuss肌营养不良患者），若PR间期 ${>}240~\mathrm{ms}$ 合并LBBB,应永久起搏（证据水平：B-NR）［109-110』

（3）一度或二度I型房室传导阻滞合并相关心动过缓症状,应永久起搏（证据水平：C-LD）111-112」

lb类适应证：对于神经肌肉疾病患者，若PR间 ${>}240\,\mathrm{ms}$ ，QRS间期 ${>}120\,\mathrm{ms}$ 或存在分支传导阻滞，可考虑永久性起搏（证据水平：C-LD）100-103,113」。

Ⅲ类适应证：对于一度、二度1型及 房室传导组滞患者，若无相关心动过缓症状或阻滞部位在房室结，不建议永久起搏（证据水平：C-LD）[73,94,111-112]

（五）房室传导阻滞起搏植入技术及方法

对于房室传导阻滞患者，推荐双腔起搏优于单腔起搏（1，A）；若预期心室起搏比例较低，而多植入一根心房导线带来并发症可能大于获益，推荐

行单腔心室起搏 ;若由于植入单腔起搏器的窦性心律患者出现起搏器综合征，则推荐升级为双腔起搏器（I,B-R）[69,114-116];若明确房室传导阻滞部位在房室结，可考虑希氏束起搏（Ⅱlb）[1-120]。 近年左束支起搏从概念的形成到临床实践已取得长足进展，对房室传导阻滞患者可考虑行左束支起搏,以尽可能维持左心室同步性[12-124]。对于左心室射血分数（leftventricular ejectionfraction,LVEF）为 $36\%{\sim}50\%$ 的房室传导阻滞患者，并且预期心室起搏比例 $\geqslant40\%$ ，应选择生理性心室起搏方式，包括心脏再同步治疗（cardiacresynchronizationtherapy，CRT）希浦系统起搏（Ⅱa）（125-132」

五、传导异常（一）病因学

传导异常（伴1：1房室传导）有以下可能的原因。

1.生理性：无器质性心脏病患者在心率变化较大的情况下，可能会合并功能性分支或束支传导阻滞。

2.发育性：在矫正性大动脉转位（ccTGA）患者中自发性房室传导阻滞每年的发病率为 $2\%$

心内膜垫缺损是另一种先天性房室传导异常的原因，也是这种临床病症的致死因素[135]

3.遗传性：房室传导异常是多种神经肌肉性疾病的主要特征之一，包括强直性肌营养不良和Emery-Dreifuss肌营养不良等。在疑似Brugada综合征的家族中，一度房室传导阻滞在SCN5A突变携带者中更为常见[136]。致心律失常性右心室心肌病常合并传导异常，表现为ORS波碎裂、束支传导阻滞或ORS波增宽等。线粒体遗传性疾病，如Kearns-Sayre综合征，可表现为心脏传导异常。

4.代谢性：Anderson-Fabry病是一种X染色体相关的溶酶体储存障碍。该疾病在成人中类似肥厚型心肌病合并传导异常137-139]。

5.炎症、免疫或浸润性：结节病、硬皮病、淀粉样变性和血色素沉着病是系统性浸润性疾病，通常累及心脏,并与心脏性猝死相关的传导异常有关140]

6.感染性：如心内膜炎、Chagas病、莱姆心肌炎、弓形虫病等。

7.医源性：导管或导丝在进人心室时可能碰撞束支，导致暂时性束支传导阻滞。在已有对侧束支传导阻滞的情况下，可以导致瞬间的完全性房室传导阻滞。室间隔酒精消融可导致约 $50\%$ 的术后病例出现RBBB。此外，外科心肌切除术、瓣膜手术，尤其是经导管主动脉瓣置换术，也可导致医源性传导异常。

8.缺血性：心肌缺血可能发生室内传导障碍4-4

9.退行性：RBBB和LBBB的患病率随着年龄的增长而增加，其中80岁以上的老年人RBBB患病率在 $10\%$ 以上,而LBBB的患病率为其一半[143]Lenegre-Lev病一般指左心骨架纤维化、主动脉和二尖瓣环钙化，从而导致分支、束支或完全性房室传导阻滞

分支和束支传导阻滞很少有独立的临床症状。而LBBB可导致心脏收缩不同步进而可能会出现心功能减退的症状。此外，间歇性心动过缓是否伴有相应症状是分支或束支传导阻滞患者风险评估的依据之一。

（二）评估流程

动态心电图监测有助于明确症状与心律失常之间的关系，或是发现之前未知的病理性房室传导阻滞。一些队列研究已经充分证明了LBBB与冠状动脉疾病和心力衰竭的出现和进展相关。非特异性室内传导延迟是预后不良的标志。LBBB患者更需要做进一步的影像学及负荷试验等功能学检查来发现潜在的心脏疾病。电生理检查的特异性和敏感性较低，但有助于某些患者的风险评估（图6）

 左束传导阻滞；RBBB 右束支传导阻滞； $\circeq$ 进一步的影像学检查包括磁共振（MRI）CT或经食管超声心动图； $\stackrel{\mathrm{b}}{=}$ 监测的选择基于症状发生的频率： 动态或长程心电监测； $\c=$ 广泛传导异常时，如一度房室传导阻滞合并LBBB

（三）管理

如果传导异常相关疾病是一种进展性疾病，如Emery-Dreifuss肌营养不良或Kearns-Sayre综合征，无论有无症状均可进行起搏治疗。真性交替性束支传导阻滞（ORS波交替出现LBBB和RBBB形态）

是严重房室结下病变的证据，随时会进展为完全性房室传导阻滞。具有传导异常的患者，评估潜在的心脏疾病、结合症状以及基线心电图是传导异常管理的必备流程（图7）

 = $\circeq$ 对于严重的一度房室传导阻滞或一度房室传导阻滞伴神经肌 肉性疾病，参考房室传导阻滞治疗流程 图7传导异常的治疗流程图

永久起搏治疗适应证

I类适应证

（1）双分支或三分支阻滞伴高度房室传导阻滞或间歇性三度房室传导阻滞的患者，推荐永久起搏（证据水平：B-NR）L3，144」

（2）双分支或三分支阻滞伴二度Ⅱ型房室传导阻滞的患者,推荐永久起搏（证据水平:B-NR）3,144]

（3）伴有晕蕨的束支阻滞患者，如果HV间期 $\geqslant\!70~\mathrm{ms}$ 或在电生理检查中发现房室结下阻滞的证据，推荐永久起搏（证据水平：C-LD）（145-146」。

（4）交替性束支阻滞的患者，推荐永久起搏（证据水平：C-LD）[146]

Ⅱ类适应证

Ⅱa类适应证

（1）虽未证实晕厥由房室传导阻滞引起，但可排除由于其他原因（尤其是室速）引起晕蕨的双分支或三分支阻滞患者，应永久起搏（证据水平：B_NR)L3,144J

（2）虽无临床症状，但电生理检查发现HV间 $\geqslant100~\mathrm{ms}$ 的双分支或三分支阻滞患者，应永久起搏（证据水平：B-NR）3,144]

（3）电生理检查时，心房起搏能诱发希氏束以下非生理性阻滞的双分支或三分支阻滞患者，应永久起搏（证据水平：B-NR）3]

（4）预期生存期 ${>}1$ 年的Kearns-Sayre综合征伴传导障碍的患者，应植人带除颤功能的起搏器（证据水平：C-LD）147-148]

Ⅱb类适应证

（1）预期生存期 ${>}1$ 年的Anderson-Fabry病，且ORS时限 ${>}110~\mathrm{ms}$ 的患者，可考虑植入带除颤功能的永久起搏器（证据水平：C-LD）（138,149」。

（2）神经肌肉性疾病（肌营养不良、Kearns-Sayre综合征等）伴发的任何程度的分支阻滞，无论是否有症状，可考虑永久起搏，因为传导阻滞随时会加重（证据水平：C-LD）3]

（3）心力衰竭、LVEF轻中度降低（ $36\%{\sim}50\%$ 且LBBB（ORS时限 $\geqslant\!150~\mathrm{ms}$ )的患者，可以考虑CRT（证据水平：C-LD）L150-152］

血类适应证： $1:1$ 房室传导的单纯传导异常的无症状患者，如没有其他起搏植入适应证，不建议永久起搏（证据水平：B-NR）L3,61,153-157]

六、特殊人群的管理

（一）非心脏手术或操作时心动过缓的风险和

发理里

非心脏手术或操作时发生心动过缓的风险与患者自身因素和/或特定手术或操作相关。患者自身因素包括年龄偏大（ ${>}60$ 岁）合并症较多美国麻醉协会（ASA）分级3\~4级」心率偏慢（ ${<\!60} $ $/\mathrm{min}$ 或血压偏低（ ${<}110/60~\mathrm{mmHg}$ ）、使用 受体阻滞剂或肾素-血管紧张素受体拮抗剂等158-162]

部分非心脏手术或操作与围术期心动过缓发生有关，尤其是刺激三叉神经或迷走神经的手术，例如颌面部手术、颈动脉内膜剥脱或支架植入术、神经外科脊椎或硬脑膜手术等[163-165]。研究发现心动过缓高风险患者预防性植入经静脉临时起搏，能有效预防颈动脉成型/支架植入术中发生的血流动力学不稳定、显著心动过缓或低血压情况【163,166-168]

老年、合并症较多和术前心率较低的患者术中发生心动过缓的风险较高。在非心脏手术中，心动过缓最常见的是SND,而房室传导阻滞少见160-161,169。某些外科手术前植人临时起搏器能有效防治术中心

动过缓的发生[170]。我国学者研究发现,老年非心脏外科手术患者存在严重窦性心动过缓或三度房室传导阻滞、房颤伴RR长间歇、快-慢综合征、完全性左束支传导阻滞、晕蕨病史，则术前应植人经静脉临时起搏器；而存在二度房室传导阻滞、双分支阻滞、完全左后分支阻滞并合并扩张型心脏病等，在全身麻醉、大手术时也应植入经静脉临时起搏器以保证手术安全171-175]

非心脏手术或操作时心动过缓的处理建议

lla类适应证：由于患者本身或者特定手术或操作的原因，评估为围术期易发生心动过缓的高危患者，应预防性临时经静脉起搏治疗（证据水平：B_NBL101,105J

（二）心脏手术后的心动过缓或传导异常的处理

心脏外科手术后心动过缓或房室传导阻滞的发生与心脏手术类型及患者传导系统解剖特点有关。除外科术中损伤外，部分患者术前即表现为窦性心动过缓、传导阻滞或房颤，难以评估窦房结功能。这些患者心动过缓通常难以恢复，如术后房室传导阻滞中仅有 $12\%{\sim}13\%$ 的患者可以在术后6个月内恢复，因此大部分患者需要植入永久起搏器。

1.冠状动脉旁路移植术患者永久起搏器植入 适应证

1类适应证：术后新发窦房结功能不全或房室传导阻滞伴相关临床症状，且持续不缓解，出院前推荐植人永久起搏器（证据水平：B-NR）L176-184]

Ⅱ类适应证

Ia类适应证：行冠脉旁路移植术，术前应常规心外膜临时起搏（证据水平：B-NR）185-186」

lb类适应证：行冠状动脉旁路移植手术的患者，未来可能需要行CRT或心室起搏，可考虑术中放置永久性心外膜左心室导线（证据水平：C-EO）

2.心脏外科房颤消融永久起搏器植入适应证

I类适应证

（1）房颤外科消融术前推荐常规心外膜临时起搏（证据水平：B-NR）187-190]

（2）房颤外科消融术后出现持续性窦房结功能不全或房室传导阻滞，且伴有相应临床症状，出院前推荐植人永久起搏器（证据水平：B-NR）187-190」。

Ⅱ类适应证

lb类适应证：外科房颤消融术患者，临床评估有可能需要植入CRT或有可能需要心室起搏，可考虑在术中植入心外膜左心室导线（证据水平：C-EO）

3.瓣膜置换术或成型术永久起搏器植入适应证

I类适应证

（1）三尖瓣、主动脉置换术或成型术中推荐常规心外膜临时起搏（证据水平：C-LD）191-198］

（2）二尖瓣、三尖瓣、主动脉置换术或成型术后出现持续性窦房结功能不全或房室传导阻滞，且伴有相应临床症状，出院前推荐植入永久起搏器（证据水平：B-NR）191-201]。

Ⅱ类适应证

Ⅱa类适应证

（1）二尖瓣置换或二尖瓣成型术中应常规心外膜临时起搏（证据水平：C-LD）200-202］。

（2）三尖瓣置换或三尖瓣成型术患者，若有术后发生房室传导阻滞的高风险，应常规在术中植入心外膜导线（证据水平：C-LD）195-198,203」

lb类适应证：二尖瓣、主动脉置换术或成型术患者，临床评估有可能需要植人CRT或有可能需要心室起搏，可考虑在术中植入心外膜左心室导线（证据水平：C-EO）。

4.经导管主动脉瓣置换术（transcatheteraortic valvereplacement，TAVR）永久起搏器植入适应证

I类适应证：TAVR术后新发持续房室传导阻滞，且伴有相应临床症状，出院前推荐植人永久起搏器（证据水平：B-NR）[204-208]

Ⅱ类适应证

Ia类适应证：TAVR术后新发持续束支传导阻滞患者，应持续密切随访是否进展为房室传导阻滞（证据水平：B-NR）[209-210]

Ib类适应证：TAVR术后新发持续完全性LBBB患者，可考虑植人永久起搏器（证据水平：DNIDL208,211-213J

5.肥厚梗阻性心肌病外科切除或酒精消融术 永久起搏器植入适应证

I类适应证：肥厚梗阻性心肌病外科切除或酒精消融术后，持续性二度Ⅱ型及以上的房室传导阻滞患者，出院前推荐植入永久起搏器（证据水平：B_NR)L214-217J

Ⅱ类适应证

Ⅱa类适应证：肥厚梗阻性心肌病外科切除或酒精消融术后，临床评估需要起搏治疗，同时患者为猝死高风险人群，预期生存时间 ${>}1$ 年的患者，应植人心律转复除颤器（implantablecardioverterdefibrillator,ICD）（证据水平：B-NR）［218-219】

Ⅱb类适应证

（1）肥厚梗阻性心肌病外科切除或酒精消融术后，发生传导阻滞高概率人群，可考虑延长心电监测时间（证据水平：C-LD）220-221]

（2）肥厚梗阻性心肌病酒精消融术中可考虑行电生理检查，评估房室结传导功能，预测房室传导阻滞发生风险（证据水平：C-LD）222］

（三）成人先天性心脏病心动过缓的管理

成人先天性心脏病（adultcongenitalheartdisease，ACHD）是一组特殊类型的患者，其传导系统解剖、心脏静脉回流、心脏修复以及传导系统疾病进展均发生变化。本建议主要针对成人（而非儿童患者）ACHD，仅采用成人特定的参考文献或专家共识

成人先天性心脏病心动过缓的处理建议

I类适应证

（1）ACHD患者出现症状性SND或变时功能不全，推荐行基于心房的永久起搏（证据水平：B-NR）（2）ACHD患者出现房室传导阻滞相关的症状性心动过缓，推荐永久起搏治疗（证据水平：B-NR）（3）成人先天性完全房室传导阻滞合并任何症状性心动过缓、宽ORS波逸搏心律、日间平均心率 ${<}50 $ $/\mathrm{min}$ 复杂室性异位心律或心室功能不全者，推荐永久起搏治疗（证据水平：B-NR）²23-224（4）ACHD合并术后二度Ⅱ型房室传导阻滞高度房室传导阻滞或三度房室传导阻滞且不可逆者，推荐永久起搏治疗（证据水平：B-NR）225-226」

Ⅱ类适应证

IⅡa类适应证

（1）无症状成人先天性完全性房室传导阻滞者,应给予永久起搏治疗（证据水平：B-NR）L133,223-224,227-228]

（2）ACHD纠正后，因符合心动过缓需要永久起搏的适应证，应植入带有心房抗心动过速起搏功能的起搏器（证据水平：B-NR）229-230］

（3）ACHD存在窦房结和/或房室传导障碍者，需行心脏手术时，同期术中放置心外膜永久起搏导线是合理的（证据水平：C-EO）

lb类适应证：具有起搏器的ACHD患者，可考虑基于心房永久起搏的模式以预防房性心律失常的发生（证据水平：B-NR）231-232]

Ⅲ类适应证：ACHD合并静脉到心腔-体循环分流者（左心室/左心房），植入心内膜起搏导线有潜在危害（证据水平：B-NR）231,233］

（四）急性心肌梗死相关心动过缓的管理

急性心梗时可能会发生一过性窦房结功能不全,也可能发生所有类型的传导障碍[23-237]。需要临时起搏治疗者并不意味着需要永久起搏，多数永久起搏适应证是发生了不可逆性的房室传导系统损伤[238-239]。不管心梗在前壁还是下壁,出现室内传导延迟反映发生了广泛的心肌损伤，而不是单纯电学问题[24]。鉴于心梗区域存在损伤可逆的心肌组织，充分再灌注治疗会改善电传导，因此，心梗患者长期预后主要取决于临床表现、梗死位置和相关的心肌损伤[54-55,78,241-243]。通常前壁心梗伴有房室传导阻滞者比下壁心梗伴相似传导阻滞者的预后更差[ 23,237,241,244g;持续的房室结以下组织传导受损与更严重的心肌损伤有关，预后更差。房室结以下发生传导阻滞时，心室收缩的维持依赖于不可靠的心室逸搏。

急性心梗时植人永久起搏器的适应证基于临床情况及充分的观察。考虑到心梗伴有传导异常往往可能恢复传导，应避免早期（ $<\!72\mathrm{~h~}$ )植人[ 54,243]。对于有起搏需求和LVEF很低的患者来说，考虑植入有除颤功能的CIED是合理的245-246]

急性心梗期间的自主神经紊乱是常见的，有研究提示无房室结下组织传导异常的房室结传导阻滞患者使用阿托品是安全的[53,79,247]。相反,房室结下存在传导疾病或阻滞的患者应用阿托品可能会使传导阻滞恶化，并有潜在的危害。有限的数据提示，如果阿托品无效,氨茶碱/茶碱似乎是安全的54-55]

尽管永久起搏器植人是一种相对低风险的心脏手术，并发症发生率为 $3\%{\sim}7\%$ ，但永久起搏器的植入会对心脏同步收缩以及瓣膜的关闭等产生长远影响[155-156]

急性心肌梗死相关心动过缓的处理建议

I类适应证

（1）急性心梗患者出现药物难治的症状性或显著影响血流动力学的窦房结功能不全或房室传导阻滞时,推荐临时起搏治疗（证据水平：B-NR）234-237]（2）出现窦房结功能不全或房室传导阻滞的急性心梗患者，在决定是否需植入永久起搏器前应观察一段时间（证据水平：B-NR）234,236-237,241-242」 （3）急性心梗患者合并二度Ⅱ型房室传导阻滞、高度房室传导阻滞、交替性束支阻滞或三度房室传导阻滞时（持续的或房室结以下传导阻滞），推荐在观察期后行永久起搏治疗（证据水平：B-NR）242,248」

Ⅱ类适应证

la类适应证：急性心梗患者出现有症状或显著影响血流动力学的窦房结功能不全或房室结水平的房室传导阻滞，使用阿托品是合理的（证据水平：B_NR)L34-55,78]

Ⅲ类适应证

（1）急性心梗患者出现一过性房室传导阻滞是能恢复的，不应植入永久起搏器（证据水平：B-NIR )[155-156, 234, 237, 242, 244-245 ]

（2）急性心梗患者出现新发的束支阻滞或单纯的分支阻滞，无二度或三度房室传导阻滞，不应植入永久起搏器（证据水平：B-NR）142,249-250］

（五）神经系统疾病的管理

许多神经系统疾病可能伴发心动过缓，如颅内压力增高时可能出现心率减慢（Cushing反应）25i对于神经系统疾病合并心动过缓的患者，急性期管理以治疗原发疾病、纠正诱因及药物治疗为主，必要时可行临时起搏治疗。在长期管理方面，需要根据患者的具体情况行个体化治疗。神经肌源性疾病累及心脏的患者，根据病因及发病年龄不同需要进行长期的心电随访,并酌情应用药物治疗[252]。对于引起房室或室内传导阻滞的进展性神经系统疾病患者，推荐永久起搏治疗。

自主神经反射异常是脊髓损伤的并发症之一，多发生于T6或其以上脊髓损伤的患者。脊髓损伤后，上位中枢调控丧失，交感神经活动度上降，引起副交感神经主要是迷走神经反射相对亢进，表现为心动过缓甚至是心脏骤停。自主神经反射异常相关的心动过缓可在数周后自行好转或在移除伤害性刺激后消失,因此无需特殊处理[253-255]。保守治疗后仍有症状性心动过缓的患者，可根据病情行永久起搏治疗。

$0.15\%{\sim}0.30\%$ 的癫痫患者在发作过程中可出现显著的心动过缓[256-258],多表现为发作期心脏停搏,可能引起癫痫猝死及癫痫发作相关外伤。患者癫痫灶多位于颞叶，其次是额叶及岛叶。此外，癫痫患者尤其是长期顽固性癫痫患者可出现自主神经功能素乱,可能也是心动过缓的发生机制之一[259-262]。目前有关永久起搏治疗癫痫相关心动过缓的研究多为小样本临床分析，并且缺乏长期的随访数据，但有限的研究结果提示起搏能够有效减少癫痫患者的晕蕨相关症状[256-258,263]。值得注意的是,患者在植人永久起搏器前需要足够的抗癫痫治疗，包括抗癫痫药物或者外科手术，减少癫痫发作能够有效降低心动过缓所致晕厥的发生风险[264]。永久起搏器提供的

心率支持并不能减少癫痫发作引起的血压降低。

癫痫相关的症状性心动过缓永久性起搏的治疗建议

lla类适应证：癫痫相关的严重症状性心动过缓的患者，如果抗癫痫药物治疗无效，应行永久起搏治疗缓解症状（证据水平：C-LD）256-258,263］。

七、需要永久起搏支持患者的心脏性猝死风险评古

（一）具有永久起搏适应证患者室性心律失常风险评价

肥厚型心肌病、肌强直性营养不良、家族性LaminA/C心肌病、心脏结节病等患者室性心律失常和心脏性猝死风险明显增加，但疾病进程中，可能先出现房室传导阻滞等缓慢性心律失常，而不符合ICD一级预防或二级预防适应证。因此上述疾病患者若具有永久起搏治疗适应证，在植入起搏器前应评估未来发生室性心律失常的风险及是否需要ICD治疗[106,110,246,265-273]。同样,发生过心梗的冠心病患者随着疾病发展，可能由于心肌纤维化、瘢痕或心脏扩大、心力衰竭等原因发生室性心律失常。此类患者若具有心动过缓起搏治疗适应证时，建议通过超声心动图、心脏磁共振或心脏核素显像等影像学检查充分评估患者心肌纤维化及心功能情况，以预估将来发生室性心律失常的风险155,271,273]

有心脏性猝死风险的永久起搏处理建议

Ⅱ类适应证

Ⅱa类适应证

（1）对于浸润性心肌病患者，如心脏结节病或淀粉样变性，若伴有二度Ⅱ型房室传导阻滞、高度房室传导阻滞或三度房室传导阻滞，行永久起搏治疗是合理的，如有需要且预计生存时间超过1年，应植入带有除颤功能的永久起搏器（证据水平：B-NR）106-108。

（2）对于家族性LaminA/C心肌病，包括limb-girdle型和Emery-Dreifuss型肌营养不良症，若伴有PR间期期 ${>}240~\mathrm{ms}$ 和LBBB，行永久起搏治疗是合理的，如有需要目预计生存时间超过1年，可植人带有除颤功能的永久起搏器（证据水平:B-NR）155,271,273」

b类适应证：对于神经肌肉疾病患者，如肌强直性营养不良1型，若PR间期 ${>}240~\mathrm{ms}$ ，ORS时限 ${>}120~\mathrm{ms}$ ，或束支阻滞，可考虑行永久起搏治疗，如有需要且预计生存时间超过1年，可考虑植入带有除颤功能的永久起搏器（证据水平：C-LD）L100-103,113］。

（二）严重心动过缓导致室性心律失常的治疗评价

临床上严重心动过缓（三度/高度房室传导阻滞、窦性停搏等）发生后，可能伴发室性心动过速、心室颤动等恶性心律失常，从而导致患者晕蕨和/或心脏性猝死。该类患者需充分评估是否存在基础器质性心脏病，若诊断为老年退行性变导致严重心动过缓，建议永久起搏治疗，而非植人ICD[246,273]。

八、共同决策

共同决策是指在症状性心动过缓或传导异常的患者中，植人心脏起搏器的治疗方案应由临床医生和患者共同决策，心脏起搏器治疗的选择不仅要依据现有的指南，即最佳的临床证据，还要考虑患者的治疗目标、治疗意愿和价值观。本共识支持并强调共同决策的原则和方法，应以患者整体为中心，根据现有的最佳证据和患者的治疗目标及治疗意愿进行共同决策。

以患者为中心的共同决策管理建议

I类适应证：对拟行心脏起搏器植人或需要调整起搏导线和更换脉冲发生器的患者，应根据现有的适应证指南，考虑其治疗目标、治疗意愿和价值观，充分告知个体化的手术相关的获益和风险，包括潜在的短期和长期的并发症，以及可能的替代治疗方案（证据水平：C-LD）274-279］

Ⅲ类适应证：对有起搏适应证的患者，如果具有严重的合并症，导致起搏治疗不能提供有意义的临床获益，或者患者的治疗意愿强烈排斥心脏起搏器治疗,不推荐植人起搏器（证据水平：C-LD）274-279]

充分考虑患者的治疗意愿对于共同决策至关重要。心动过缓或传导异常的患者对起搏治疗的意愿和接受度各不相同，并可能在患病过程中不断变化。共识编写委员会认为共同决策应作为起搏器治疗的原则和方法而不断完善。

值得注意的是，仅依据临床证据或指南的治疗建议并不是共同决策。应当依据客观证据和对患者健康目标及治疗意愿的理解，医患双方相互共享信息和充分讨论，就首选方案达成共识，并对实施的手术方法形成了知情同意。有证据表明，共同决策有利于患者获得更好的生活质量（qualityoflife，QOL）。但有些患有严重合并症的患者可能无法获得起搏支持或改善0OL的预期益处。例如，在渐进性疾病晚期（包括阿尔兹海默病、转移性肿瘤、近期预期死亡或预后不良的情况）而预计寿命缩短的患者中，起搏器支持的获益无法实现，也不可能对患者总体结果产生积极的影响。虽然心脏起搏器植入的风险相对

较低，如果可能的获益也相当低，则获益风险比并不理想。这些利弊应与患者或患者家属充分讨论。

九、终止起搏治疗的建议

绝大多数患者在起搏器电池耗竭或因导线/起搏器故障需要更换时，都会毫不迟疑地决定更换。但偶尔会遇到一些因其最初植入起搏器的原因不明、有疑问或已经解决,而不再需要持续起搏I280-281]多项研究显示，约 $30\%$ 的心脏起搏器植入是在1类和Ⅱa类推荐适应证之外，其中部分患者可能面临是否需要终止起搏治疗的问题[280-282。由于心动过缓的自然病程有时无法预测，因此终止起搏治疗常是一个困难的决定，必须平衡患者起搏治疗的获益与风险。终止起搏治疗的选择包括将起搏器程控为“关闭”起搏器电池耗竭不冉更换、移除起搏器、移除起搏器并拔除导线。

在需要更换起搏器或处理起搏器相关并发症的患者中，检查显示是自身心律，故最初诊断的起搏适应证可能已解除[283],此外,少数心脏手术[284]或心脏其他疾病如心肌炎[285-286]等导致的心脏传导阻滞也可能恢复，出现这些情况时，与患者共同决策终止起搏治疗是合理的。一项研究发现，没有明确初始或持续起搏适应证的患者，全面评估且严密监测一段时间后，若患者无心动过缓事件发生，则移除起搏器是可行的[287]。另两项回顾性研究分析了CIED相关感染，探讨是否需要再次植入CIED。研究显示，由于最初起搏器适应证已经解除、感染持续不可控制或患者自身偏好等原因，经过至少2周的全面监测后,终止起搏治疗的患者可更多获益[288-289]。其他研究还发现，当SND演变为持续性房颤，连续监测证实这种节律持续6个月以上，且有稳定固有心室率的患者可以不再需要起搏治疗[290-292]。

终止起搏治疗的建议

Ⅱ类适应证

Ⅱa类适应证

（1）对于需要更换起搏器或需要处理与起搏器相关并发症的患者，如果其最初的起搏适应证已被解除（如心肌炎恢复后患者、心脏手术所致传导阻滞已经恢复患者）或最初植入起搏器适应证不明确的患者，那么在关闭起搏并监测一段时间和评估症状后，经共同决策后，终止起搏治疗是合理的（证据水平：C-LD）[283-287]

（2）对于需要处理CIED相关感染如囊袋和/或导线感染等相关并发症的患者，若起搏治疗仅为

了改善生活质量，经共同决策后，终止起搏治疗是合理的（证据水平：C-LD）288-289]

（3）对于需要更换起搏器或需要处理与起搏器相关并发症的SND患者，目前已经转为持续性房颤，且有稳定固有心室率的患者，经共同决策后，终止起搏治疗是合理的（证据水平：C-LD）290-292］利益冲突所有作者均声明不存在利益冲突

执笔人（按姓氏汉语拼音排序）

蔡琳‧陈柯萍‧陈林‧范洁　来春林 李若谷 梁兆光刘启明 邱春光沈法荣 汤宝鹏 王景峰 王玉堂吴钢吴立群项美香徐耕徐伟 徐原宁 杨杰孚杨新春郑良荣郑强荪周贤惠邹建刚

专家工作组（按姓氏汉语拼音排序）

蔡琳（成都市第三人民医院心血管内科），陈柯萍（中国医学科学院阜外医院心律失常中心），陈林（福建省立医院心内二科），陈明龙（南京医科大学第一附属医院心血管内科），范洁（云南省第一人民医院心血管内科），华伟（中国医学科学院阜外医院心律失常中心），黄从新（武汉大学人民医院心血管内科），黄德嘉（四川大学华西医院心脏内科），来春林（山西省人民医院心血管内科），李若谷（上海市胸科医院心血管内科），李学斌（北京大学人民医院心血管内科）梁兆光（哈尔滨医科大学附属第一医院心血管内科），刘启明（中南大学湘雅二医院心血管内科），邱春光（郑州大学第一附属医院心血管内科），沈法荣（浙江绿城心血管病医院心脏中心），宿燕岗（复旦大学附属中山医院心血管内科），汤宝鹏（新疆医科大学第一附属医院心脏中心起搏电生理科），王景峰（中山大学孙逸仙纪念医院心血管内科），王玉堂（中国人民解放军总医院心血管内科），吴立群（上海交通大学医学院附属瑞金医院心血管内科）项美香（浙江大学医学院附属第二医院心血管内科），徐耕（浙江大学医学院附属第二医院心血管内科），徐伟（南京大学医学院附属鼓楼医院心血管内科），杨杰孚（卫生部北京医院心血管内科），杨新春（首都医科大学附属北京朝阳医院心脏中心/河北燕达医院），张澍（中国医学科学院阜外医院心律失常中心），郑良荣（浙江大学医学院附属第一医院心血管内科），郑强苏（西安交通大学第二附属医院心血管内科），邹建刚（南京医科大学第一附属医院心血管内科）

专家工作组秘书

芦颜美（新疆医科大学第一附属医院心脏中心起搏电生理科）

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（收稿日期：2021-02-17）（本文编辑：林娜徐世杰）

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