心房纖顫的圍手術(shù)期管理課件

心房纖顫的圍手術(shù)期管理河南中醫(yī)學(xué)院一附院心臟中心關(guān)懷敏心房纖顫的圍手術(shù)期管理河南中醫(yī)學(xué)院一附院心臟中心1心房纖顫分類初發(fā)房顫（first-detectedepisodeofAF）陣發(fā)性房顫（paroxysmalAF）持續(xù)性房顫（PersistentAF）永久性房顫（permanentAF）孤立性房顫（loneAF）沉默性房顫（silentAF)急性(24~48h之內(nèi))長期(＞1年)心房纖顫分類初發(fā)房顫（first-detectedepis2

心房纖顫的流行病學(xué)心房纖顫的流行病學(xué)3心房纖顫的圍手術(shù)期管理課件4心房纖顫的圍手術(shù)期管理課件5心房纖顫的圍手術(shù)期管理課件6房顫引發(fā)的卒中較其它病因者更為嚴(yán)重DulliDA,etal.Neuroepidemiology.2003;22:118-123.OddsratioforbedriddenstatefollowingstrokeduetoAFwas2.23(95%CI,1.87-2.59;p<0.0005)%臥床患者p<0.00054030201005041.2%23.7%WithAFWithoutAF房顫引發(fā)的卒中較其它病因者更為嚴(yán)重Du7心房纖顫的圍手術(shù)期管理課件8心房纖顫的圍手術(shù)期管理課件9心房纖顫的圍手術(shù)期管理課件10

房顫患者：生活質(zhì)量下降A(chǔ)F=atrialfibrillation;CAD=coronaryarterydisease;SF=MedicalOutcomesStudyShortForm36Adaptedfrom:DorianP,etal.JAmCollCardiol.2000;36(4):1303–1309Notethatalowerscorerepresentspoorerqualityoflife.?P<0.001,comparedwithpatientswithAF.??????SF-36scoreafCADControl房顫患者：生活質(zhì)量下降A(chǔ)F=atrial11心房纖顫的圍手術(shù)期管理課件12AntiarrhythmicDrugs:EfficacyMaintaining

NSR≥6MonthsAntiarrhythmicDrugs:Efficacy13起搏器治療房顫的新曙光起搏器治療房顫的新曙光14心房纖顫的圍手術(shù)期管理課件15心房纖顫的圍手術(shù)期管理課件16心房纖顫的圍手術(shù)期管理課件17心房纖顫的圍手術(shù)期管理課件18心房纖顫的圍手術(shù)期管理課件19心房纖顫的圍手術(shù)期管理課件20心房纖顫的圍手術(shù)期管理課件21非瓣膜性房顫患者的卒中危險(xiǎn)分層評(píng)估：CHADS2評(píng)分CHADS2=cardiacfailure,hypertension,age,diabetes,andstroke(doubled)1.ReprintedfromCurrProblCardiol,30(4),HersiA,etal,175-233,Copyright?2005,withpermissionfromElsevier.RiskfactorsScoreCRecentcongestiveheartfailure1HHypertension1AAge≥75yrs1DDiabetesmellitus1S2Historyofstrokeortransientischemicattack(TIA)2卒中年發(fā)生率與CHADS2評(píng)分具有良好的相關(guān)性1CHADS2score卒中發(fā)生率(%)非瓣膜性房顫患者的卒中危險(xiǎn)分層評(píng)估：CHADS2評(píng)分CHA22心房纖顫的圍手術(shù)期管理課件23心房纖顫的圍手術(shù)期管理課件24心房纖顫的圍手術(shù)期管理課件25心房纖顫的圍手術(shù)期管理課件26心房纖顫的圍手術(shù)期管理課件27心房纖顫的圍手術(shù)期管理課件28心房纖顫的圍手術(shù)期管理課件29心房纖顫的圍手術(shù)期管理課件30心房纖顫的圍手術(shù)期管理課件31心房纖顫的圍手術(shù)期管理課件32心房纖顫的圍手術(shù)期管理課件33心房纖顫的圍手術(shù)期管理課件34口服抗凝藥的臨床應(yīng)用:僅約50％患者接受了OAC治療NVAF=非瓣膜性房顫;RF=危險(xiǎn)因素1.GoAS,HylekEM,BorowskyLH,etal.AnnInternMed.1999;131(12):927-34.OAC的臨床使用1

接受口服抗凝治療的患者數(shù)1

隨訪11,082例瓣膜性房顫患者，接受口服抗凝藥治療:Total 55%<55歲. 44.3%>85歲 35.4%

1卒中危險(xiǎn)因素* 59.3%‘理想的’患者? 62.1%*Previousischemicstroke,hypertension,congestiveheartfailure,diabetesmellitusandcoronaryheartdisease.?Riskfactors,nocontraindications,age65–74years.年齡50%華法林治療％-------------------------------口服抗凝藥的臨床應(yīng)用:僅約50％患者接受了OAC治療NVA35ACTIVEW:治療方案多中心、多國、平行組、隨機(jī)對照試驗(yàn)口服抗凝藥－華法林標(biāo)準(zhǔn)治療(INR2.0–3.0)至少每月測定一次INR氯吡格雷聯(lián)合阿司匹林治療氯吡格雷75mg/dASA75-100mg/dACTIVEWritingGroupfortheACTIVEInvestigators.Lancet.2006;367:1903-1912ACTIVEW:治療方案多中心、多國、平行組、隨機(jī)對照試36累計(jì)卒中發(fā)生風(fēng)險(xiǎn)：OAC優(yōu)于波立維＋ASARR=1.72(1.24-2.37),p=0.001Clopidogrel+Aspirin口服抗凝藥ACTIVEWritingGroupfortheACTIVEInvestigators.Lancet.2006;367:1903-1912.累計(jì)卒中發(fā)生風(fēng)險(xiǎn)：OAC優(yōu)于波立維＋ASARR=37主要出血風(fēng)險(xiǎn)*CumulativeHazardRatesYears#atRiskC+A 3335 3172 2403 914OAC 3371 3212 2423 9012.42%/year2.21%/yearRR=1.1(0.83-1.45)P=0.53.ACTIVEWritingGroupfortheACTIVEInvestigators.Lancet.2006;367:1903-1912.主要出血風(fēng)險(xiǎn)*CumulativeHazardR38在卒中方面的獲益最大408(3.3%/年）296(2.4%/年）氯吡格雷加ASA顯著減少所有卒中達(dá)28%的相對風(fēng)險(xiǎn)安慰劑+

累積危險(xiǎn)率0.00.050.100.1501234阿司匹林氯吡格雷+阿司匹林HR=0.72（0.62-0.83）p<0.001

3772349132292570120337823458315525171186高?；颊邤?shù)ASAC+A年

TheACTIVEInvestigatorsNEnglJMed2009;360在卒中方面的獲益最大408(3.3%/年）296(2.39心房纖顫的圍手術(shù)期管理課件40

VALHeFTVALHeFT41心房纖顫的圍手術(shù)期管理課件42心房纖顫的圍手術(shù)期管理課件43穩(wěn)心顆粒也有比較好的效果！穩(wěn)心顆粒也有比較好的效果！44心房纖顫的圍手術(shù)期管理課件45心房纖顫的圍手術(shù)期管理課件46心房纖顫的圍手術(shù)期管理課件47心房纖顫的圍手術(shù)期管理課件48心房纖顫的圍手術(shù)期管理課件49謝謝！謝謝！50心房纖顫的圍手術(shù)期管理河南中醫(yī)學(xué)院一附院心臟中心關(guān)懷敏心房纖顫的圍手術(shù)期管理河南中醫(yī)學(xué)院一附院心臟中心51心房纖顫分類初發(fā)房顫（first-detectedepisodeofAF）陣發(fā)性房顫（paroxysmalAF）持續(xù)性房顫（PersistentAF）永久性房顫（permanentAF）孤立性房顫（loneAF）沉默性房顫（silentAF)急性(24~48h之內(nèi))長期(＞1年)心房纖顫分類初發(fā)房顫（first-detectedepis52

心房纖顫的流行病學(xué)心房纖顫的流行病學(xué)53心房纖顫的圍手術(shù)期管理課件54心房纖顫的圍手術(shù)期管理課件55心房纖顫的圍手術(shù)期管理課件56房顫引發(fā)的卒中較其它病因者更為嚴(yán)重DulliDA,etal.Neuroepidemiology.2003;22:118-123.OddsratioforbedriddenstatefollowingstrokeduetoAFwas2.23(95%CI,1.87-2.59;p<0.0005)%臥床患者p<0.00054030201005041.2%23.7%WithAFWithoutAF房顫引發(fā)的卒中較其它病因者更為嚴(yán)重Du57心房纖顫的圍手術(shù)期管理課件58心房纖顫的圍手術(shù)期管理課件59心房纖顫的圍手術(shù)期管理課件60

房顫患者：生活質(zhì)量下降A(chǔ)F=atrialfibrillation;CAD=coronaryarterydisease;SF=MedicalOutcomesStudyShortForm36Adaptedfrom:DorianP,etal.JAmCollCardiol.2000;36(4):1303–1309Notethatalowerscorerepresentspoorerqualityoflife.?P<0.001,comparedwithpatientswithAF.??????SF-36scoreafCADControl房顫患者：生活質(zhì)量下降A(chǔ)F=atrial61心房纖顫的圍手術(shù)期管理課件62AntiarrhythmicDrugs:EfficacyMaintaining

NSR≥6MonthsAntiarrhythmicDrugs:Efficacy63起搏器治療房顫的新曙光起搏器治療房顫的新曙光64心房纖顫的圍手術(shù)期管理課件65心房纖顫的圍手術(shù)期管理課件66心房纖顫的圍手術(shù)期管理課件67心房纖顫的圍手術(shù)期管理課件68心房纖顫的圍手術(shù)期管理課件69心房纖顫的圍手術(shù)期管理課件70心房纖顫的圍手術(shù)期管理課件71非瓣膜性房顫患者的卒中危險(xiǎn)分層評(píng)估：CHADS2評(píng)分CHADS2=cardiacfailure,hypertension,age,diabetes,andstroke(doubled)1.ReprintedfromCurrProblCardiol,30(4),HersiA,etal,175-233,Copyright?2005,withpermissionfromElsevier.RiskfactorsScoreCRecentcongestiveheartfailure1HHypertension1AAge≥75yrs1DDiabetesmellitus1S2Historyofstrokeortransientischemicattack(TIA)2卒中年發(fā)生率與CHADS2評(píng)分具有良好的相關(guān)性1CHADS2score卒中發(fā)生率(%)非瓣膜性房顫患者的卒中危險(xiǎn)分層評(píng)估：CHADS2評(píng)分CHA72心房纖顫的圍手術(shù)期管理課件73心房纖顫的圍手術(shù)期管理課件74心房纖顫的圍手術(shù)期管理課件75心房纖顫的圍手術(shù)期管理課件76心房纖顫的圍手術(shù)期管理課件77心房纖顫的圍手術(shù)期管理課件78心房纖顫的圍手術(shù)期管理課件79心房纖顫的圍手術(shù)期管理課件80心房纖顫的圍手術(shù)期管理課件81心房纖顫的圍手術(shù)期管理課件82心房纖顫的圍手術(shù)期管理課件83心房纖顫的圍手術(shù)期管理課件84口服抗凝藥的臨床應(yīng)用:僅約50％患者接受了OAC治療NVAF=非瓣膜性房顫;RF=危險(xiǎn)因素1.GoAS,HylekEM,BorowskyLH,etal.AnnInternMed.1999;131(12):927-34.OAC的臨床使用1

接受口服抗凝治療的患者數(shù)1

隨訪11,082例瓣膜性房顫患者，接受口服抗凝藥治療:Total 55%<55歲. 44.3%>85歲 35.4%

1卒中危險(xiǎn)因素* 59.3%‘理想的’患者? 62.1%*Previousischemicstroke,hypertension,congestiveheartfailure,diabetesmellitusandcoronaryheartdisease.?Riskfactors,nocontraindications,age65–74years.年齡50%華法林治療％-------------------------------口服抗凝藥的臨床應(yīng)用:僅約50％患者接受了OAC治療NVA85ACTIVEW:治療方案多中心、多國、平行組、隨機(jī)對照試驗(yàn)口服抗凝藥－華法林標(biāo)準(zhǔn)治療(INR2.0–3.0)至少每月測定一次INR氯吡格雷聯(lián)合阿司匹林治療氯吡格雷75mg/dASA75-100mg/dACTIVEWritingGroupfortheACTIVEInvestigators.Lancet.2006;367:1903-1912ACTIVEW:治療方案多中心、多國、平行組、隨機(jī)對照試86累計(jì)卒中發(fā)生風(fēng)險(xiǎn)：OAC優(yōu)于波立維＋ASARR=1.72(1.24-2.37),p=0.001Clopidogrel+Aspirin口服抗凝藥ACTIVEWritingGroupfortheACTIVEInvestigators.Lancet.2006;367:1903-1912.累計(jì)卒中發(fā)生風(fēng)險(xiǎn)：OAC優(yōu)于波立維＋ASARR=87主要出血風(fēng)險(xiǎn)*CumulativeHazardRatesYears#atRiskC+A 3335 3172 2403