心瓣膜病合并房顫及心衰的處理原則

1、老年人心瓣膜病合并房顫及心衰的處理(chl)原則 廣州市第一(dy)人民醫(yī)院 劉豐共七十三頁隨著人口的老齡化,老年(lonin)退行性鈣化性瓣膜病逐漸占有重要的地位,是目前老年(lonin)人的特殊疾病。已經(jīng)成為老年人心力衰竭、心律失常、暈厥、猝死的原因之一。 對冠心病具有重要預(yù)測價值共七十三頁共七十三頁共七十三頁國外報道的發(fā)病率明顯高于國內(nèi)。Pomerance 等 尸檢162 例死于心衰的患者, 分析其原因后發(fā)現(xiàn)(fxin)鈣化性瓣膜病變占45 % ,僅次于冠心病。 Wong 等 在78 例65102 歲的患者中 發(fā)現(xiàn)瓣膜退行性改變占74 %。 90100 歲年齡組幾近100 %Spring

2、er. Verlag ,1982 :6367. J AM Geriatir soc ,1983 ,3l :156.國內(nèi)外報道十分不一致,主要原因有種族差異(chy)、也存在方法學(xué)的問題共七十三頁共七十三頁The incidence and etiological classification of valvular diseases were examined on 358 cases from 3,000 consecutive autopsies of more than 60 years of age. The incidence of valvular disease was 11.9

3、% (358 out of 3,000 cases) Jpn Circ J. 1982 Apr;46(4):337-45 共七十三頁Mitral stenosis was found in 23 cases (6.4%), of which 21 cases were rheumatic and the remaining 2 were mitral ring calcification (MRC). Mitral regurgitation was observed in 126 cases (35.3%): 69 of papillary muscle dysfunction, 26 of

4、 mitral valve prolapse (MVP), 16 of MRC, 9 of ruptured chordae tendineae, 3 of rheumatic and 3 of congenital.Jpn Circ J. 1982 Apr;46(4):337-45 共七十三頁Aortic stenosis was noted in 33 cases (9.2%): 27 of calcified, 5 of rheumatic and one of congenital. Aortic regurgitation was found in 169 cases (47.2%)

5、: 112 of degenerative, 47 of syphilitic, 7 of rheumatic and 2 of aortitis syndrome. There were 6 cases (1.7%) of tricuspid regurgitation.Jpn Circ J. 1982 Apr;46(4):337-45 共七十三頁Etiological classification revealed 6 cases (1.7%) of congenital, 36 (10%) of rheumatic, 49 (13.7%) of syphilitic, 27 (7.5%)

6、 of MVP, 69 (19.3%) of ischemic and 166 (46.4%) of degenerative valvular disease.Jpn Circ J. 1982 Apr;46(4):337-45 共七十三頁A total of 458 cases (11.5%) with valvular heart diseases in the aged (greater than or equal to 60 years) were found among 4,000 consecutive autopsies. They included 204 cases (45%

7、) of aortic regurgitation (AR), 171 cases (37%) of mitral regurgitation (MR), followed by 45 (10%) of aortic stenosis (AS) and 27 cases (6%) of mitral stenosis (MS). J Cardiol Suppl. 1988;19:29-38. 共七十三頁an etiology of the valvular diseases, degenerative type was found in 195 cases (43%), ischemic or

8、igin in 91 cases (20%), followed by inflammatory origin such as syphilitic in 51 and infective endocarditis in three, aortitis in two and rheumatic in 49 (11%). Congenital origin was also found in 18 cases (4%).J Cardiol Suppl. 1988;19:29-38. 共七十三頁共七十三頁共七十三頁仍關(guān)注(gunzh)對老年人風(fēng)心病共七十三頁。山西醫(yī)科大學(xué)第一臨床醫(yī)學(xué)院心內(nèi)科從19

9、79 - 011998 - 12 共收治風(fēng)心病1 227 例,其中(qzhng)老年風(fēng)心病215 例,對其逐年發(fā)病情況及95 例資料齊全者臨床特點作一回顧分析共七十三頁老年風(fēng)心病215 例,所占比例為17.5 %。逐年住院比例由1979 年的9 %逐漸增長為1998 年的42.5 %。又從215 例老年風(fēng)心病患者中取資料齊全者95 例,其中(qzhng)男49 例,女46 例,年齡6080 歲,平均年齡64 歲,平均病程16.8 年。共七十三頁老年退行性心臟瓣膜病又稱老年鈣化性心臟瓣膜病(SCHVD) , 是一種與年齡相關(guān)的瓣膜退行性變。隨著增齡, 心血管系統(tǒng)逐漸(zhjin)老化, 處于血流

10、不斷沖擊的瓣膜及其支架易發(fā)生退行性變、纖維化和鈣化, 造成主動脈瓣和(或) 二尖瓣關(guān)閉不全及狹窄, 若病變的心肌擴張和鈣化、纖維化涉及傳導(dǎo)系統(tǒng)可 以并發(fā)各種心律失常共七十三頁A Novel Role of the Sympatho-Adrenergic System in Regulating Valve CalcificationRecent evidence has indicated that the sympathetic nervous system plays an important role inregulating bone deposition and resorption

11、 the beta 2-adrenergic receptors(2-AR).In order to test the effect 2-AR on changing the human valve lCs towards osteogenic phenotype cells were treated with the selectlve2-AR agonist ,salmeterol ,in the presence and absence of osteogenic media for 21 days .Supplement circulation vol 114,no 18 octobe

12、r 31 ,2006共七十三頁Salmeteroltereatment in the presence of osteogenic media significantly reduced the ALP activity from 10.22.9nmol/min/mg proteiy in the osteogenic treated cellc ,to 4.71.9nmol/min/mg protein(p75 years), the management of atrial fibrillation varies; it requires an individual approach, w

13、hich largely depends on comorbid conditions, underlying cardiac disease, and patient and physician preferences. Drugs Aging. 2002;19(11):819-46 共七十三頁Another serious challenge in the management of chronic atrial fibrillation in older individuals is the prevention of stroke, its primary outcome, by ch

14、oosing an appropriate antithrombotic treatment (aspirin or warfarin). Several risk-stratification schemes have been validated and may be helpful to determine the best antithrombotic choice in individual patients Drugs Aging. 2002;19(11):819-46 共七十三頁關(guān)于(guny)抗血栓治療(瓣膜病)antithrombotic therapy in native

15、and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual pat

16、ients values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). 共七十三頁Among the key recommendations in this chapter are the following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previ

17、ous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international normalized ratio INR, 2.5; range, 2.0 to 3.0) Grade 1C+. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs a

18、t a therapeutic INR, we recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C). CHEST 2004; 126:179S-187S). 共七十三頁In people with mitral valve prolapse (MVP) without history of systemic embol

19、ism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexplained TIAs, we recommend long-term aspirin therapy, 50 to 162 mg/d (Grade 1A). CHEST 2004; 126:179S-187S共七十三頁(房顫)This chapter about a

20、ntithrombotic therapy in atrial fibrillation (AF) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that in

21、dividual patients values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). 共七十三頁Among the key recommendations in this chapter are the following (all vitamin K antagonist VKA recommendations have a target international normalized rati

22、o INR of 2.5; range, 2.0 to 3.0): In patients with persistent or paroxysmal AF (PAF) intermittent AF at high risk of stroke (ie, having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age 75 years, moderately or severely impaired left ventricula

23、r systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus), we recommend anticoagulation with an oral VKA, such as warfarin (Grade 1A). 共七十三頁In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, we recommend antithro

24、mbotic therapy with either an oral VKA or aspirin, 325 mg/d, in this group of patients who are at intermediate risk of stroke (Grade 1A). In patients with persistent AF or PAF 65 years old and with no other risk factors, we recommend aspirin, 325 mg/d (Grade 1B). For patients with AF and mitral sten

25、osis, we recommend anticoagulation with an oral VKA (Grade 1C+). CHEST 2004; 126:179S-187S). 共七十三頁Requiring Lower Warfain Dosages to Achieve Therapeutic Anticoagulation is a Strong Risk Factor for Bleeding Event Accumulating evidence suggests some genotypes of enzymes are associated with low mainten

26、ance dose requirement and increased risk of major bleeding .Supplement circulation vol 114,no 18 october 31 ,2006共七十三頁METHODS In a prospective cohort from 550 consecutive patients with mechanical valve replacement were studied . Patients were divided into three groups (lower dosages group , warfarin

27、 maintenance dose 0.2mg/day/BM).results over 4000 patient-years of follow-up, PT-INR values fell within target range range for 90.2% of the time on treatment .Supplement circulation vol 114,no 18 october 31 ,2006共七十三頁There was no difference between three groups about patient characteristics includin

28、g anticoagulant intensity . low dosage group have significantly increased risk of bleeding (figure)Supplement circulation vol 114,no 18 october 31 ,2006共七十三頁5101500.000.250.500.751.00Not singnificantp=0.0001p=0.0019high dose groupIntermediate dose groupLow dose groupAnalysis time (years)Bleeding eve

29、nt free survival by warfarin dose共七十三頁關(guān)于老年瓣膜病合并(hbng)房顫抗血栓治療1.注意合并癥的情況(qngkung) 2.注意各種危險因素 3.年齡界限對治療的影響 4.多種藥物的相互作用 5.出血在老年中的不同表現(xiàn)和不同后果共七十三頁老年(lonin)瓣膜病合并心功能不全 SDHVD 者年齡均偏大,由于瓣膜狹窄或反流造成血流動力學(xué)的改變,最后可導(dǎo)致心臟(xnzng)擴大 ,可單一左心房擴大或左房、左 室擴大。加之心律失常、左室?guī)缀涡螒B(tài)學(xué)的變形而影響心室收縮導(dǎo)致心功能不全的發(fā)生,一旦出現(xiàn)癥狀,病情會加快發(fā)展、加重。共七十三頁廣東葉氏,2000 年1 月

30、至2005 年1 月收治的40 例老年退行性心臟瓣膜(bnm)病合并心力衰竭與同期收治的40 例年齡、性別相匹配的、無瓣膜(bnm)鈣化合并心力衰竭的冠心病患者進行臨床對比研究,旨在揭示其潛在危險,提請臨床重視。臨床(ln chun)和實驗醫(yī)學(xué)雜志2006 年1 月第5 卷第1 期共七十三頁共七十三頁 瓣膜性心臟病患者,主要問題是瓣膜本身有機械性損害,而任何內(nèi)科治療或藥物均不能使其消除或緩解,更不能用來替代已有肯定療效(lioxio)的介入或手術(shù)治療。實驗研究表明, 單純的心肌細(xì)胞牽拉刺激就可促發(fā)心肌重塑,因而治療瓣膜性心臟病的關(guān)鍵就是修復(fù)瓣膜損害。共七十三頁 目前國內(nèi)外較一致的意見是:所有有

31、癥狀的瓣膜性心臟病心力衰竭(NYHA 級及以上(yshng) ,以及重度主動脈瓣病變伴有暈厥、心絞痛者,均必須進行介入治療或手術(shù)置換瓣膜或修復(fù)瓣膜,因為有充分證據(jù)表明介入或手術(shù)治療是有效和有益的,可提高長期存活率。共七十三頁有癥狀的二尖瓣狹窄(MS) 和主動脈瓣狹窄(AS) 應(yīng)當(dāng)考慮手術(shù),手術(shù)同樣適用于有癥狀的二尖瓣關(guān)閉不全(MR) 和主動脈瓣關(guān)閉不全(AR) 。有些(yuxi)反流性病變的患者在出現(xiàn)癥狀前也可考慮手術(shù),例如左室射血分?jǐn)?shù)降低或心臟明顯擴大。外科治療包括瓣膜的修補術(shù)和置換術(shù),單純MS 可采用經(jīng)皮球囊二尖瓣成形術(shù)。共七十三頁 值得注意的是,如果(rgu)在瓣膜病的治療中用藥不當(dāng),反

32、而可能加重病情。例如血管擴張劑以及ACEI 等具有血管擴張作用的藥物,應(yīng)慎用于瓣膜狹窄的患者,以免后負(fù)荷過度降 低致心輸出量減少,引起低血壓、暈厥等。MS 患者,左心室并無壓力負(fù)荷或容量負(fù)荷過重,因此沒有任何特殊的內(nèi)科治療共七十三頁洋地黃類無益于單純MS 伴竇性心率的病人,但可以用于快速心室率的心房顫動治療,控制心室率效果(xiogu)不好時,可加用小劑量的阻滯劑。AS 患者亦應(yīng)避免應(yīng)用阻滯劑等 負(fù)性肌力藥物。阻滯劑僅適用于心房顫動并快速室率或有竇性心動過速時。共七十三頁 最常受累的是主動脈瓣膜,其發(fā)生率遠(yuǎn)高于其他瓣膜。這主要是由于主動脈瓣膜所承受的機械壓力較大,尤其在血壓增高時,易引起膠原纖

33、維斷裂形成間隙而有利于鈣鹽沉積(chnj)。老年瓣膜長期經(jīng)受血流沖擊,瓣葉中糖蛋白與蛋白聚糖的丟失與營養(yǎng)不良,也是鈣化形成的可能機制 。主動脈瓣膜又以左冠瓣為多見,右冠瓣次之。因左冠瓣與主動脈 瓣環(huán)后緣相連接,此處易形成血流旋渦致瓣膜受損, 使鈣鹽沉積于此 。右冠瓣因缺少致密牢固的絹織支托,受血流沖擊較大亦易受損。共七十三頁AR 的藥物治療:降低后負(fù)荷的藥物可以改善AR 患者的預(yù)后。在一項與地高辛的比較(bjio)研究中,硝苯地平可以延緩嚴(yán)重?zé)o癥狀A(yù)R 患者做主動脈瓣置換術(shù)的時機共七十三頁。ACEI 也可通過(tnggu)減輕后負(fù)荷,增加前向心輸出量而減少返流,可應(yīng)用于以下情況: (1) 有癥

34、狀的重度AR 患者,因其他心臟疾病或非心臟因素而不能手術(shù)者; (2) 重度心力衰竭患者,在換瓣手術(shù)前短期治療以改善血液動力學(xué)異常,此時不能應(yīng)用負(fù)性肌力 藥; (3) 無癥狀A(yù)R 患者,已有左室擴大,而收縮功能正常,可長期應(yīng)用,以延長其代償期; (4) 已經(jīng)手術(shù)置換瓣膜,但仍有持續(xù)左室收縮功能異常共七十三頁AR的手術(shù)指征:與嚴(yán)重MR 一樣(yyng),AR 術(shù)前左室大小與術(shù)后射血分?jǐn)?shù)的改善直接相關(guān),但有兩點重要不同:AR 術(shù)前心室較大者術(shù)后也可以維持正常射血分?jǐn)?shù)。另外,如果射血分?jǐn)?shù)的降低時間小于1214 個月,術(shù)后也可能恢復(fù)正常。共七十三頁 嚴(yán)重AR患者出現(xiàn)下列情況時應(yīng)當(dāng)考慮瓣膜置換:出現(xiàn)癥狀、

35、左室射血分?jǐn)?shù)下降( 5.5 cm) 。 一旦出現(xiàn)明顯的左室功能下降,手術(shù)結(jié)果(ji gu)將不會令人滿意。左室收縮末徑可以反映左室功能,并且不像射血分?jǐn)?shù)那樣受前負(fù)荷的影響共七十三頁AS的心導(dǎo)管診治:對于超聲心動圖診斷不明確的患者(hunzh),可以做心導(dǎo)管檢查,心導(dǎo)管檢查的主要作用是排除伴發(fā)的冠心病,在此比其他瓣膜病更重要,因為主動脈瓣狹窄主要發(fā)生在老年人。通過心導(dǎo)管可做經(jīng)皮球囊瓣膜成形術(shù),但與經(jīng)皮球囊二尖瓣擴張術(shù)(PBMC)治療二尖瓣狹窄不同,主動脈瓣狹窄的瓣膜成形術(shù)常常不成功,其出血和栓塞的發(fā)生率較高,6 個月的成功率較低共七十三頁AS的外科治療:應(yīng)當(dāng)認(rèn)為AS 是一種外科疾病,因為沒有藥物

36、可以代替手術(shù)治療,也沒有藥物可以改善生存率。非手術(shù)治療的預(yù)后很差。其手術(shù)指征為:超聲心動圖或心導(dǎo)管檢查證實嚴(yán)重的主動脈瓣狹窄并伴有心臟癥狀。有少數(shù)患者可做瓣膜修補,但瓣膜置換術(shù)的效果更好。手術(shù)風(fēng)險(fngxin)較高的患者可考慮做心導(dǎo)管球囊成形術(shù)。共七十三頁MR 的藥物治療:發(fā)生MR 后,左房擴大增加了二尖瓣后葉張力,緊拉葉瓣使瓣膜功能失常加重,所以嚴(yán)重MR 常是進展性的。嚴(yán)重MR 非手術(shù)治療應(yīng)限制體力活動,減少鈉攝入,并通過合理應(yīng)用利尿劑增加鈉排泄。血管(xugun)擴張劑和洋地黃可增加左室衰竭后的前向心輸出量。靜脈應(yīng)用硝普鈉或硝酸甘油可減少后負(fù)荷,減少返流,有助于穩(wěn)定急性或重度MR 患者病

37、情。共七十三頁無癥狀慢性MR 且射血分?jǐn)?shù)正常時,并無后負(fù)荷增加,尚不清楚應(yīng)用降低后負(fù)荷藥物是否有利。ACEI治療慢性MR 可能有益,特別是有癥狀或左室增大者,可減少MR 并使左室腔減小,但要注意ACEI 降低后負(fù)荷可能掩 蓋左室功能不全,而有癥狀MR 患者則適用于手術(shù)治療。與MS 一樣,MR 患者近期心房顫動應(yīng)考慮轉(zhuǎn)為竇性心律。心力衰竭晚期(wnq)患者應(yīng)用抗凝藥和下肢繃帶,可減少靜脈血栓形成和肺栓塞。共七十三頁MR 的手術(shù)治療:必須全面考慮疾病緩慢進展的性質(zhì)和瓣膜修復(fù)以及瓣膜置換所帶來的遠(yuǎn)期及近期風(fēng)險。沒有癥狀或只在強體力活動受限者病情可穩(wěn)定多年,不宜外科治療。左室功能受損者手術(shù)治療風(fēng)險驟增

38、,遠(yuǎn)期存活下降,但其保守治療幾乎沒有有效的辦法,即使在病情晚期,仍可考慮手術(shù)治療。如果臨床表現(xiàn)與超聲心動圖檢查不一致時,左心導(dǎo)管檢查和心血管造影可能有助于確認(rèn)嚴(yán)重MR 的存在,還有助于發(fā)現(xiàn)(fxin)相關(guān)瓣膜病變、病變嚴(yán)重程度以及發(fā)現(xiàn)(fxin)需同時血管重建的病人共七十三頁手術(shù)的最佳時機:是慢性(mn xng)代償期到失代償期 的轉(zhuǎn)變階段。左室射血分?jǐn)?shù) 60 % ,左室收縮末徑 4.5 cm時手術(shù)效果最好。選擇手術(shù)時機還要考慮肺動脈高壓和心房顫動的情況共七十三頁關(guān)于(guny)老年瓣膜病合并心功能不全治療1.正確判斷(pndun)瓣膜的受損部位、程度、范圍2.把臨床癥狀與病變情況結(jié)合考慮3.

39、牢記心功能是病程的分水嶺4.對心功能不全的治療，應(yīng)因病而治。共七十三頁美托洛爾治療(zhlio)瓣膜性心臟病心力衰竭的隨機對照研究 山西葉氏,經(jīng)心臟(xnzng)超聲確認(rèn)為瓣膜性心臟(xnzng)病的心力衰 竭284 例中, 拒絕施行介入或手術(shù)治療, 同意參與研究的184例, 其中男性80 例, 女性104 例, 年齡31 73 歲(平均56. 48. 3 歲) , 隨機分為兩組,A 組美托洛爾組,B 組常規(guī)治療 延安大學(xué)學(xué)報(醫(yī)學(xué)科學(xué)版) Vo l14 No12 2006 年6 月共七十三頁共七十三頁所有入選患者接診后均為按慢性收縮(shu su)性心力衰竭治療指南常規(guī)治療, 待心功能糾正到

40、 以上, 患者一般情況好轉(zhuǎn)后(心功能分級按美國紐約心臟病學(xué)會N YHA 分級法) , 隨機分為兩組,A 組美托洛爾組,B 組常規(guī)治療組,A 組開始口服美托洛爾12. 5mg/d, 每2w 增加1 次劑量, 最大用量75mg/d , 長期服用,A、B 兩組其他用藥均按心衰治療指南 常規(guī)處理, 觀察時間2 年。觀察指標(biāo) 死亡率統(tǒng)計兩組在觀察期內(nèi)組間死亡率和總死亡率。延安大學(xué)學(xué)報(醫(yī)學(xué)(yxu)科學(xué)版) Vo l14 No12 2006 年6 月共七十三頁共七十三頁 美托洛爾的心衰死亡率(4. 3%) , 明顯低于總死亡(9.2% ) 和常規(guī)治療組死亡率(14. 3%) , 兩組比較有統(tǒng)計學(xué)意義(P 0. 05)。對心功能的控制與維持有良好作用,A 組心功能1 2 級者75 例(80. 6%) ,B 組心功能12 者32 例(35.2% ) , 兩組比較有統(tǒng)計學(xué)意義(P 0. 05)。同時顯示