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1河南中醫(yī)學(xué)院一附院心臟中心關(guān)懷敏心房纖顫分類2初發(fā)房顫（first-detected

episode

of

AF）陣發(fā)性房顫（paroxysmal

AF）持續(xù)性房顫（Persistent

AF）永久性房顫（permanent

AF）孤立性房顫（lone

AF）沉默性房顫（silent

AF)急性(24~48h之內(nèi))長(zhǎng)期(＞1年)心房纖顫的流行病學(xué)34房顫的危害5增加死亡率缺血性腦卒中心功能降低心肌缺血生活質(zhì)量和運(yùn)動(dòng)耐力下降預(yù)防這些并發(fā)癥是比較困難的！6房顫引發(fā)的卒中較其它病因者更為嚴(yán)重Dulli

DA,

et

al.

Neuroepidemiology.

2003;22:118-123.%臥床患者p<0.0005Odds

ratio

for

bedridden

state

following

stroke

due

to

AF

was

2.23

(95%

CI,

1.87-2.59;

p<0.0005)201005041.2%403023.7%With

AFWithout

AF78910房顫患者：生活質(zhì)量下降A(chǔ)F=atrial

fibrillation;

CAD=coronary

artery

disease;

SF=Medical

Outcomes

Study

Short

Form

36Adapted

from:

Dorian

P,

et

al.

J

Am

Coll

Cardiol.2000;36(4):1303–1309?SF-36

scoreafCADControl1112Antiarrhythmic

Drugs:

Efficacy

MaintainingNSR

≥6Months13起搏器治療房顫的新曙光1415161718192021Risk

factorsScoreCRecent

congestive

heart

failure1HHypertension1AAge

≥75

yrs1DDiabetes

mellitus1S2History

of

stroke

or

transient

ischemic

attack(TIA)2非瓣膜性房顫患者的卒中危險(xiǎn)分層評(píng)估：CHADS2評(píng)分1.

Reprinted

from

Curr

Probl

Cardiol,

30(4),

Hersi

A,

et

al,

175-233,

Copyright?2005,

withpermission

fromElsevier.卒中年發(fā)生率與

CHADS2評(píng)分具有良好的相關(guān)性1CHADS2

scoreCHADS2=cardiac

failure,hypertension,

age,diabetes,

andstroke(doubled)卒中發(fā)生率(%)22232425262728293031323334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.

Go

AS,

Hylek

EM,

Borowsky

LH,

et

al.

Ann

Intern

Med.

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.>85

歲≥1卒中危險(xiǎn)因素*‘理想的’患者?44.3%35.4%59.3%62.1%*

Previous

ischemic

stroke,

hypertension,congestive

heartfailure

,

diabetes

mellitus

and

coronary

heartdisease.?

Riskfactors,nocontraindications,age65–74years.年齡華法林治療％50%-------------------------------35ACTIVE

W:治療方案36多中心、多國(guó)、平行組、隨機(jī)對(duì)照試驗(yàn)口服抗凝藥－華法林標(biāo)準(zhǔn)治療

(INR

2.0

–

3.0)至少每月測(cè)定一次INR氯吡格雷聯(lián)合阿司匹林治療氯吡格雷75

mg/dASA

75-100

mg/dACTIVE

Writing

Group

for

the

ACTIVE

Investigators.

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=1.72

(1.24-2.37),p=0.00137Clopidogrel

+

Aspirin口服抗凝藥ACTIVE

Writing

Group

for

the

ACTIVE

Investigators.

Lancet.

2006;367:1903-1912.主要出血風(fēng)險(xiǎn)*Cumulative

Hazard

RatesYears#

at

RiskC+AOAC3335337131723212240324239149012.42

%/year2.21

%/yearRR

=

1.1

(0.83-1.45)P

=

0.53.ACTIVE

Writing

Group

for

the

ACTIVE

Investigators.

Lancet.

2006;367:1903-1912.38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(duì)風(fēng)險(xiǎn)安慰劑+0.00.05累積危險(xiǎn)率0.100.1501234年高?；颊邤?shù)C+A

37723491322925701203ASA

3782345831552517118639阿司匹林氯吡格雷+阿司匹林H