ACR白皮书建议:警惕羟氯喹心脏毒性,心电图可帮助筛查!

2021-11-04 Shirley MedSci原创

10月26日,美国风湿病学会(ACR)发布白皮书,总结目前对羟氯喹(HCQ)/氯喹(CQ) 心脏毒性的认识,并基于共识提出了风险评估与监测指导。

羟氯喹(HCQ)和氯喹(CQ)是是治疗系统性红斑狼疮和类风湿性关节炎的药物。《2020中国系统性红斑狼疮诊疗指南》也建议SLE患者长期使用HCQ作为基础治疗。

10月26日,美国风湿病学会(ACR)发布白皮书,总结目前对羟氯喹(HCQ)/氯喹(CQ) 心脏毒性的认识,并基于共识提出了风险评估与监测指导。

由于在新冠疫情出有报告HCQ和CQ有潜在的抗冠状病毒活性,2020年初此药物的使用有所增加。虽然随机对照试验很快证实了这些治疗方法对COVID- 19无效。但是在此期间,已经多次报道患者的不良反应(包括心律失常和传导系统异常,以及心肌病)与HCQ/CQ使用有关。

 

HCQ/CQ的心脏毒

HCQ和CQ通过阻断钾外流通道与心室肌细胞相互作用,导致QT c延长。

图片图片
体表心电图显示羟氯喹(HCQ)或氯洛喹(CQ)的QT延长作用(图A),服用HCQ后心脏动作电位的变化。
IKs = slow potassium channel(慢钾通道);ISUS = sum of the currents through other potassium channels(通过其他钾通道的电流总和)
虚线对应于心室心肌通过快速钠通道(INa)的快速去极化
 
图片图片

C:正常心肌细胞的复极是由钾离子通过HERG通道从细胞中流出。

D:HCQ或CQ会导致钾离子流出受阻

 

QT间期(简称QT)包括心室除极和复极激动时间,代表心室去极化和复极化过程的总时程,为自QRS波的起点至T波的终点所占的时间,测定值随年龄和性别而变化。QT间期延长会增加心源性猝死的风险,可能与QT间期延长与心尖扭转(一种罕见的多形性室性心动过速)有关。

高风险人群

 

除了药物外,还有一些其他的因素会延长QT,医生应该注意这些高危因素,帮助患者及时规避风险,而有一些因素是可以被改变的,例如肥胖等。


图片

HCQ和CQ主要在哺乳动物的溶酶体中积累,导致PH值偏碱性。主要集中在眼睛(特别是含有黑色素的视网膜上皮)、肾上腺、肾、骨髓、肺、肝和心脏组织。但是往往是剂量依赖性。
 

可以导致患者QTc延长的药物

图片

如果患者有心律不齐的症状,如晕厥、晕厥前期或不明原因的头晕,应按照FDA标签建议进行包括心电图在内的心脏评估。对于接受过长期HCQ/CQ治疗并出现新的心脏症状的患者,医生应高度怀疑心肌病。如果发现没有其他病因的限制性心肌病,应考虑心肌内膜活检。

图片

 

风湿病患者服用羟氯喹导致严重心律失常的发生率尚不清楚。大多数医生不会将心率失常和HCQ\CQ联系起来,所以应当有一部分患者被漏诊。建议对使用HCQ和QC的患者进行心电图筛查和随访,检测患者的心脏功能。

抗疟治疗在治疗SLE疾病中可以减少糖皮质激素的量、降低心血管疾病的风险、减少器官损伤和控制疾病。作为医生应当权衡药物对心脏的毒性,虽然药物收益远大于风险,但是也应该有关注药物毒性的意识。

原文:Desmarais J, Rosenbaum JT, Costenbader KH,et al.American College of Rheumatology White Paper on Antimalarial CardiacToxicity[J]. Arthritis Rheumatol. 2021 Oct 26. doi: 10.1002/art.41934. Epubahead of print.

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1215971, encodeId=1d4012159e1c0, content=<a href='/topic/show?id=ee7b800133e' target=_blank style='color:#2F92EE;'>#羟氯喹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80013, encryptionId=ee7b800133e, topicName=羟氯喹)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=赛华佗, createdTime=Sun May 01 09:56:47 CST 2022, time=2022-05-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1070065, encodeId=1eef10e00651d, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210814/61deb584a399410ca9b720adee4e6850/71825fee35134aee90c3ed9dfe89b69f.jpg, createdBy=3cff5430616, createdName=云舒, createdTime=Sun Nov 14 09:04:11 CST 2021, time=2021-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1400500, encodeId=443214005002a, content=<a href='/topic/show?id=e7c018e7af' target=_blank style='color:#2F92EE;'>#ACR#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1877, encryptionId=e7c018e7af, topicName=ACR)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=19792261142, createdName=10518094zz, createdTime=Sat Nov 06 00:41:35 CST 2021, time=2021-11-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1466715, encodeId=2c491466e15d8, content=<a href='/topic/show?id=741ce17090e' target=_blank style='color:#2F92EE;'>#白皮书#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71709, encryptionId=741ce17090e, topicName=白皮书)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93a16850722, createdName=bbwznl, createdTime=Sat Nov 06 00:41:35 CST 2021, time=2021-11-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1067195, encodeId=6cc9106e19569, content=xuxi, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=70c25441341, createdName=ms1000001920226686, createdTime=Fri Nov 05 10:19:49 CST 2021, time=2021-11-05, status=1, ipAttribution=)]
    2021-11-14 云舒

    学到了

    0

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    2021-11-06 10518094zz
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    2021-11-06 bbwznl
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    2021-11-05 ms1000001920226686

    xuxi

    0

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