重症免疫检查点抑制剂相关心肌炎的临床及心电图特点分析  

Clinical and electrocardiographic characteristics of severe immune checkpoint inhibitor related myocarditis

作　　者：宋文华 张楠[1] 徐钰 孙艺红[3] 陈子良 王玥莹 郑屹 赵珺[1] 张晓伟[1] 徐延敏[1] 李广平[1] 洪立立 刘彤[1] Song Wenhua;Zhang Nan;Xu Yu;Sun Yihong;Chen Ziliang;Wang Yueying;Zheng Yi;Zhao Jun;Zhang Xiaowei;Xu Yanmin;Li Guangping;Hong Lili;Liu Tong(Department of Cardiology,The Second Hospital of Tianjin Medical University,Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease,Tianjin Institute of Cardiology,Tianjin 300211,China;Second Department of Oncology,Tianjin Huanghe Hospital,Tianjin 300110,China;Department of Cardiology,China-Japan Friendship Hospital,Beijing 100029,China)

机构地区：[1]天津医科大学第二医院心脏科,天津市心血管病离子与分子机能重点实验室,天津市心脏病学研究所,天津300211 [2]天津市黄河医院肿瘤2科,天津300110 [3]中日友好医院心内科,北京100029

出　　处：《中华心律失常学杂志》2023年第2期96-103,共8页Chinese Journal of Cardiac Arrhythmias

基　　金：国家自然科学基金(81970270)。

摘　　要：目的分析重症免疫检查点抑制剂(ICI)相关心肌炎患者的临床及心电图特点。方法本研究为一项多中心回顾性研究。收集2018年5月至2022年9月就诊于天津医科大学第二医院、天津市黄河医院、北京中日友好医院的重症ICI相关心肌炎患者的人口学资料(年龄、性别、合并疾病等)、ICI用药类型、临床表现、心电图及治疗方案(是否接受化疗药物及靶向治疗等)等信息,并进行分析。按照患者临床结局分为死亡组和存活组,比较两组患者心律失常及心电图特点。结果共纳入重症ICI相关心肌炎患者13例,其中女6例,年龄为66(61,71)岁,以肺癌患者最多(38.46%,5/13)。自ICI首次用药至心肌炎确诊的中位时间为50 d;其中,基线合并高血压者5例,合并冠心病者4例,合并糖尿病者2例。ICI用药以卡瑞利珠单抗为主(7/13)。患者心电图表现为新发的室上性心律失常(窦性心动过速多见,8/13)、室性心律失常(包括室性早搏及室性心动过速)、心脏传导阻滞(包括左、右束支传导阻滞及房室传导阻滞)、ST-T改变、碎裂QRS波、P波异常和QT间期延长,少数表现为多导联低电压、病理性Q波等。与幸存者相比,死亡患者更多表现为ST段压低[46.15%(6/13)对7.69%(1/13),P=0.029]、碎裂QRS波[53.85%(7/13)对7.69%(1/13),P=0.005]及P波异常[46.15%(6/13)对7.69%(1/13),P=0.029]。结论重症ICI相关心肌炎的临床表现缺乏特异性,心电图可表现为新发的心律失常、ST-T改变、碎裂QRS波、P波异常和QT间期延长,少数可表现为多导联低电压等。Objective To analyze the clinical and electrocardiographic characteristics of patients with severe immune checkpoint inhibitor(ICI)related myocarditis.Methods This was a multicenter retrospective study.Patients with severe ICI-related myocarditis were enrolled from Second Hospital of Tianjin Medical University,Tianjin Huanghe Hospital and Beijing China-Japan Friendship Hospital,from May 2018 to September 2022.Demographic data(age,gender,comorbidity),types of ICI,clinical manifestations,electrocardiogram(ECG)and treatment(whether chemotherapy drugs or targeted therapy were accepted)were analyzed retrospectively.According to clinicaloutcome,patients were divided into death group and surival group.Arrhythmia and characteristics of electrocardiogram were compared.Results A total of 13 patients with severe ICI-related myocarditis were enrolled,including among which 6 females with a median age of 66(61,71)years.Lung cancer patients were represented the most common,with a proportion of 38.46%(5/13).The median time from the first administration of ICI to the diagnosis of myocarditis was 50 days.Five out of 13 patients presented with concomitant hypertension,4 with coronary heart disease and 2 with diabetes at baseline.Camrelizumab was the main drug used in ICI(7/13).Patients presented with new-onset supraventricular arrhythmias(especially sinus tachycardia,8/13),ventricular arrhythmias(including premature ventricular contraction and ventricular tachycardia),heart conduction block(mainly left and right bundle branch block and atrioventricular block),ST-T segment changes,fragmented QRS,abnormal P wave,prolonged QT interval.A few showed multi-lead low voltage and pathological Q wave.Compared with the survivors,the ECG of participants who were dead were more likely to show ST segment depression[46.15%(6/13)vs.7.69%(1/13),P=0.029],fragmented QRS[53.85%(7/13)vs.7.69%(1/13),P=0.005]and abnormal P wave[46.15%(6/13)vs.7.69%(1/13),P=0.029].Conclusion Clinical manifestations of severe ICI-associated myocarditis usually were lack of

关 键 词：心电描记术 免疫检查点抑制剂 心肌炎 心律失常 心脏传导阻滞 

分 类 号：R542.21[医药卫生—心血管疾病]