Skip to main content
SpringerLink
Log in

Ventrikuläre Herzrhythmusstörungen

Was ist gesichert in der Therapie?

Ventricular arrhythmias

What has been confirmed in therapy?

  • Schwerpunkt: Was ist gesichert in der Therapie?
  • Published:
Der Internist Aims and scope Submit manuscript

Zusammenfassung

Ventrikuläre Arrhythmien umfassen ein breites Spektrum von potenziell benignen einzelnen Extrasystolen bis hin zu malignen Kammertachykardien und Kammerflimmern mit plötzlichem Herzstillstand. Die Diagnose ventrikulärer Rhythmusstörungen erfolgt elektrokardiographisch mithilfe eines 12-Kanal- und 24 h-Langzeit-Elektrokardiogramms, eines externen oder implantierbaren Ereignisrekorders oder während des stationären Monitorings. Die Breitkomplextachykardie stellt bei der Differenzierung zwischen ventrikulärer Tachykardie und supraventrikulärer Tachykardie mit aberranter Überleitung eine Herausforderung dar. Im Anschluss an die Dokumentation ventrikulärer Rhythmusstörungen muss zunächst nach der Ursache in Form einer strukturellen oder elektrischen Kardiomyopathie gesucht werden und die Risikostratifizierung im Hinblick auf einen plötzlichen Herztod erfolgen. Für die Therapie stehen medikamentöse Optionen, interventionelle Verfahren wie die Katheterablation und implantierbare Defibrillatoren zur Verfügung. Der vorliegende Beitrag gibt Hinweise zur Diagnostik ventrikulärer Tachykardien und zugrunde liegender Kardiomyopathien. Darüber hinaus bietet er einen Überblick der medikamentösen und interventionellen Therapieverfahren. Zusätzlich werden die Indikationen für implantierbare und tragbare Defibrillatoren dargestellt.

Abstract

Ventricular arrhythmias include a wide range of potentially benign single ventricular premature contractions to ventricular tachycardia and ventricular fibrillation with a risk for sudden cardiac death. The diagnosis of ventricular arrhythmia is made by 12-lead electrocardiogram, 24 h Holter monitoring, an external or implantable loop recorder, or during in-hospital monitoring. Especially the diagnosis of wide complex tachycardias is challenging in terms of differentiating between ventricular tachycardia and supraventricular tachycardia with aberrant atrioventricular conduction. After documentation of ventricular arrhythmias, diagnostic work-up with respect to structural or electrical cardiomyopathy is mandatory followed by risk stratification for sudden cardiac death. Therapeutic options for treatment of ventricular arrhythmias range from pharmacological therapy and interventional procedures such as catheter ablation and implantable devices. The current article provides an overview of the diagnosis of ventricular tachycardia and underlying cardiomyopathies. Furthermore, medical and interventional therapies are described. In addition, the indications for implantable and wearable defibrillators are presented.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. Adabag AS, Peterson G, Apple FS et al (2010) Etiology of sudden death in the community: results of anatomical, metabolic, and genetic evaluation. Am Heart J 159:33–39. https://doi.org/10.1016/j.ahj.2009.10.019

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bakker ALM, Nijkerk G, Groenemeijer BE et al (2009) The Lewis lead: making recognition of P waves easy during wide QRS complex tachycardia. Circulation 119:e592–e593. https://doi.org/10.1161/CIRCULATIONAHA.109.852053

    Article  PubMed  Google Scholar 

  3. Baman TS, Lange DC, Ilg KJ et al (2010) Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm 7:865–869. https://doi.org/10.1016/j.hrthm.2010.03.036

    Article  PubMed  Google Scholar 

  4. Ban J‑E, Park H‑C, Park J‑S et al (2013) Electrocardiographic and electrophysiological characteristics of premature ventricular complexes associated with left ventricular dysfunction in patients without structural heart disease. Europace 15:735–741. https://doi.org/10.1093/europace/eus371

    Article  PubMed  Google Scholar 

  5. Brugada P, Brugada J, Mont L et al (1991) A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 83:1649–1659

    Article  CAS  PubMed  Google Scholar 

  6. Desai AS, McMurray JJV, Packer M et al (2015) Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of death in heart failure patients. Eur Heart J 36:1990–1997. https://doi.org/10.1093/eurheartj/ehv186

    Article  CAS  PubMed  Google Scholar 

  7. Deyell MW, Park K‑M, Han Y et al (2012) Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm 9:1465–1472. https://doi.org/10.1016/j.hrthm.2012.05.019

    Article  PubMed  Google Scholar 

  8. Duncker D, Bauersachs J, Veltmann C (2016) The wearable cardioverter/defibrillator : temporary protection from sudden cardiac death. Internist (Berl) 57:864–870. https://doi.org/10.1007/s00108-016-0110-2

    Article  CAS  Google Scholar 

  9. Duncker D, Haghikia A, König T et al (2014) Risk for ventricular fibrillation in peripartum cardiomyopathy with severely reduced left ventricular function-value of the wearable cardioverter/defibrillator. Eur J Heart Fail 16:1331–1336. https://doi.org/10.1002/ejhf.188

    Article  PubMed  Google Scholar 

  10. Duncker D, König T, Hohmann S et al (2017) Avoiding untimely implantable cardioverter/defibrillator implantation by intensified heart failure therapy optimization supported by the wearable cardioverter/defibrillator-the PROLONG study. J Am Heart Assoc. https://doi.org/10.1161/JAHA.116.004512

    PubMed  PubMed Central  Google Scholar 

  11. Duncker D, König T, Hohmann S et al (2017) Ventricular arrhythmias in patients with newly diagnosed nonischemic cardiomyopathy: insights from the PROLONG study. Clin Cardiol. https://doi.org/10.1002/clc.22706

    PubMed  Google Scholar 

  12. Duncker D, Veltmann C (2016) The wearable cardioverter/defibrillator - toy or tool? J Atr Fibrillation 8:1367. https://doi.org/10.4022/jafib.1367

    PubMed  PubMed Central  Google Scholar 

  13. Duncker D, Westenfeld R, Konrad T et al (2017) Risk for life-threatening arrhythmia in newly diagnosed peripartum cardiomyopathy with low ejection fraction: a German multi-centre analysis. Clin Res Cardiol 12:767–768. https://doi.org/10.1007/s00392-017-1090-5

    Google Scholar 

  14. Fonarow GC, Yancy CW, Hernandez AF et al (2011) Potential impact of optimal implementation of evidence-based heart failure therapies on mortality. Am Heart J 161:1024–1030.e3. https://doi.org/10.1016/j.ahj.2011.01.027

    Article  PubMed  Google Scholar 

  15. Griffith MJ, Garratt CJ, Mounsey P, Camm AJ (1994) Ventricular tachycardia as default diagnosis in broad complex tachycardia. Lancet 343:386–388

    Article  CAS  PubMed  Google Scholar 

  16. Huikuri HV, Castellanos A, Myerburg RJ (2001) Sudden death due to cardiac arrhythmias. N Engl J Med 345:1473–1482. https://doi.org/10.1056/NEJMra000650

    Article  CAS  PubMed  Google Scholar 

  17. Kempf T, Bavendiek U, Bauersachs J (2017) New pharmacologic therapies for chronic heart failure. Internist (Berl). https://doi.org/10.1007/s00108-017-0277-1

    Google Scholar 

  18. Kober L, Thune JJ, Nielsen JC et al (2016) Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med 375:1221–1230. https://doi.org/10.1056/NEJMoa1608029

    Article  PubMed  Google Scholar 

  19. Lau EW, Pathamanathan RK, Ng GA et al (2000) The Bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia. Pacing Clin Electrophysiol 23:1519–1526

    Article  CAS  PubMed  Google Scholar 

  20. Ling Z, Liu Z, Su L et al (2014) Radiofrequency ablation versus antiarrhythmic medication for treatment of ventricular premature beats from the right ventricular outflow tract: prospective randomized study. Circulation 7:237–243. https://doi.org/10.1161/CIRCEP.113.000805

    CAS  PubMed  Google Scholar 

  21. Martens E, Sinner MF, Siebermair J et al (2014) Incidence of sudden cardiac death in Germany: results from an emergency medical service registry in Lower Saxony. Europace 16:1752–1758. https://doi.org/10.1093/europace/euu153

    Article  PubMed  PubMed Central  Google Scholar 

  22. McMurray JJV, Packer M, Desai AS et al (2014) Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med 371:993–1004. https://doi.org/10.1056/NEJMoa1409077

    Article  PubMed  Google Scholar 

  23. Mountantonakis SE, Frankel DS, Gerstenfeld EP et al (2011) Reversal of outflow tract ventricular premature depolarization-induced cardiomyopathy with ablation: effect of residual arrhythmia burden and preexisting cardiomyopathy on outcome. Heart Rhythm 8:1608–1614. https://doi.org/10.1016/j.hrthm.2011.04.026

    Article  PubMed  Google Scholar 

  24. Neuzner J, Gradaus R (2015) ICD therapy in the primary prevention of sudden cardiac death: risk stratification and patient selection. Herzschrittmacherther Elektrophysiol 26:75–81. https://doi.org/10.1007/s00399-015-0371-9

    Article  CAS  PubMed  Google Scholar 

  25. Pava LF, Perafán P, Badiel M et al (2010) R‑wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias. Heart Rhythm 7:922–926. https://doi.org/10.1016/j.hrthm.2010.03.001

    Article  PubMed  Google Scholar 

  26. Pedersen CT, Kay GN, Kalman J et al (2014) EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. Europace 16:1257–1283. https://doi.org/10.1093/europace/euu194

    Article  PubMed  Google Scholar 

  27. Ponikowski P, Voors AA, Anker SD et al (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. https://doi.org/10.1093/eurheartj/ehw128

    PubMed Central  Google Scholar 

  28. Poole JE, Johnson GW, Hellkamp AS et al (2008) Prognostic importance of defibrillator shocks in patients with heart failure. N Engl J Med 359:1009–1017. https://doi.org/10.1056/NEJMoa071098

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Priori SG, Blomström-Lundqvist C, Mazzanti A et al (2015) 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC)Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 36:2793–2867. https://doi.org/10.1093/eurheartj/ehv316

    Article  PubMed  Google Scholar 

  30. Reddy VY, Reynolds MR, Neuzil P et al (2007) Prophylactic catheter ablation for the prevention of defibrillator therapy. N Engl J Med 357:2657–2665. https://doi.org/10.1056/NEJMoa065457

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Sacher F, Tedrow UB, Field ME et al (2008) Ventricular tachycardia ablation: evolution of patients and procedures over 8 years. Circulation 1:153–161. https://doi.org/10.1161/CIRCEP.108.769471

    PubMed  Google Scholar 

  32. Sapp JL, Wells GA, Parkash R et al (2016) Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs. N Engl J Med 375:111–121. https://doi.org/10.1056/NEJMoa1513614

    Article  CAS  PubMed  Google Scholar 

  33. Schmidt S, Hürlimann D, Starck CT et al (2014) Treatment with higher dosages of heart failure medication is associated with improved outcome following cardiac resynchronization therapy. Eur Heart J 35:1051–1060. https://doi.org/10.1093/eurheartj/eht514

    Article  CAS  PubMed  Google Scholar 

  34. Schwab JO, Bänsch D, Israel C, Nowak B (2015) Statement on the use of wearable cardioverter defibrillators. Kardiologe 9:165–170. https://doi.org/10.1007/s12181-015-0651-y

    Article  Google Scholar 

  35. Shen L, Jhund PS, Petrie MC et al (2017) Declining risk of sudden death in heart failure. N Engl J Med 377:41–51. https://doi.org/10.1056/NEJMoa1609758

    Article  PubMed  Google Scholar 

  36. Shun-Shin MJ, Zheng SL, Cole GD et al (2017) Implantable cardioverter defibrillators for primary prevention of death in left ventricular dysfunction with and without ischaemic heart disease: a meta-analysis of 8567 patients in the 11 trials. Eur Heart J 38:1738–1746. https://doi.org/10.1093/eurheartj/ehx028

    Article  PubMed  PubMed Central  Google Scholar 

  37. Vereckei A, Duray G, Szénási G et al (2007) Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J 28:589–600. https://doi.org/10.1093/eurheartj/ehl473

    Article  PubMed  Google Scholar 

  38. Vereckei A, Duray G, Szénási G et al (2008) New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm 5:89–98. https://doi.org/10.1016/j.hrthm.2007.09.020

    Article  PubMed  Google Scholar 

  39. Wellens HJ (2001) Electrophysiology: ventricular tachycardia: diagnosis of broad QRS complex tachycardia. Heart 86:579–585. https://doi.org/10.1136/heart.86.5.579

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    D. Duncker, J. Bauersachs &  C. Veltmann

Authors
  1. D. Duncker
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Bauersachs
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Veltmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. Veltmann.

Ethics declarations

Interessenkonflikt

C. Veltmann erhielt Vortragshonorare, Reisekostenunterstützung und Honorare für Beratungstätigkeiten von Biotronik, Boehringer Ingelheim, Boston Scientific, Medtronic, Pfizer, St. Jude Medical/Abbott und Zoll sowie Forschungsunterstützung von Zoll. D. Duncker erhielt Vortragshonorare von Boehringer Ingelheim und Zoll, Reisekostenunterstütztung von Biotronik, Medtronic, Sorin, St. Jude Medical und Zoll sowie ein Fellowship-Stipendium von Boston Scientific. J. Bauersachs ist als Referent und/oder Berater für Medtronic und SJM-Thoratec tätig. Er erhielt Forschungsunterstützung von Medtronic, Zoll und Biotronik.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Redaktion

H. Haller, Hannover

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Duncker, D., Bauersachs, J. & Veltmann, C. Ventrikuläre Herzrhythmusstörungen. Internist 58, 1272–1280 (2017). https://doi.org/10.1007/s00108-017-0341-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00108-017-0341-x

Schlüsselwörter

Keywords

Search

Navigation