心瓣膜病合并房顫及心衰的處理原則

心瓣膜病合并房顫及心衰的處理原則國外報道得發(fā)病率明顯高于國內(nèi)。Pomerance等尸檢162例死于心衰得患者,分析其原因后發(fā)現(xiàn)鈣化性瓣膜病變占45%,僅次于冠心病。Wong等在78例65～102歲得患者中發(fā)現(xiàn)瓣膜退行性改變占74%。90～100歲年齡組幾近100%Springer、Verlag,1982:63～67、、JAMGeriatirsoc,1983,3l:156、國內(nèi)外報道十分不一致,主要原因有種族差異、也存在方法學(xué)得問題Theincidenceandetiologicalclassificationofvalvulardiseaseswereexaminedon358casesfrom3,000consecutiveautopsiesofmorethan60yearsofage、Theincidenceofvalvulardiseasewas11、9%(358outof3,000cases)JpnCircJ、1982Apr;46(4):337-45

Mitralstenosiswasfoundin23cases(6、4%),ofwhich21caseswererheumaticandtheremaining2weremitralringcalcification(MRC)、Mitralregurgitationwasobservedin126cases(35、3%):69ofpapillarymuscledysfunction,26ofmitralvalveprolapse(MVP),16ofMRC,9ofrupturedchordaetendineae,3ofrheumaticand3ofcongenital、JpnCircJ、1982Apr;46(4):337-45

Aorticstenosiswasnotedin33cases(9、2%):27ofcalcified,5ofrheumaticandoneofcongenital、Aorticregurgitationwasfoundin169cases(47、2%):112ofdegenerative,47ofsyphilitic,7ofrheumaticand2ofaortitissyndrome、Therewere6cases(1、7%)oftricuspidregurgitation、JpnCircJ、1982Apr;46(4):337-45

Etiologicalclassificationrevealed6cases(1、7%)ofcongenital,36(10%)ofrheumatic,49(13、7%)ofsyphilitic,27(7、5%)ofMVP,69(19、3%)ofischemicand166(46、4%)ofdegenerativevalvulardisease、JpnCircJ、1982Apr;46(4):337-45

Atotalof458cases(11、5%)withvalvularheartdiseasesintheaged(greaterthanorequalto60years)werefoundamong4,000consecutiveautopsies、Theyincluded204cases(45%)ofaorticregurgitation(AR),171cases(37%)ofmitralregurgitation(MR),followedby45(10%)ofaorticstenosis(AS)and27cases(6%)ofmitralstenosis(MS)、

JCardiolSuppl、1988;19:29-38、anetiologyofthevalvulardiseases,degenerativetypewasfoundin195cases(43%),ischemicoriginin91cases(20%),followedbyinflammatoryoriginsuchassyphiliticin51andinfectiveendocarditisinthree,aortitisintwoandrheumaticin49(11%)、Congenitaloriginwasalsofoundin18cases(4%)、JCardiolSuppl、1988;19:29-38、

12大家應(yīng)該也有點累了，稍作休息大家有疑問的，可以詢問和交流仍關(guān)注對老年人風(fēng)心病。山西醫(yī)科大學(xué)第一臨床醫(yī)學(xué)院心內(nèi)科從1979-01～1998-12共收治風(fēng)心病1227例,其中老年風(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老年風(fēng)心病215例,所占比例為17、5%。逐年住院比例由1979年得9%逐漸增長為1998年得42、5%。又從215例老年風(fēng)心病患者中取資料齊全者95例,其中男49例,女46例,年齡60～80歲,平均年齡64歲,平均病程16、8年。老年退行性心臟瓣膜病又稱老年鈣化性心臟瓣膜病(SCHVD),就是一種與年齡相關(guān)得瓣膜退行性變。隨著增齡,心血管系統(tǒng)逐漸老化,處于血流不斷沖擊得瓣膜及其支架易發(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,若病變得心肌擴張和鈣化、纖維化涉及傳導(dǎo)系統(tǒng)可以并發(fā)各種心律失常ANovelRoleoftheSympatho-AdrenergicSysteminRegulatingValveCalcificationRecentevidencehasindicatedthatthesympatheticnervoussystemplaysanimportantroleinregulatingbonedepositionandresorptionthebeta2-adrenergicreceptors(β2-AR)、Inordertotesttheeffectβ2-ARonchangingthehumanvalvelCstowardsosteogenicphenotypecellsweretreatedwiththeselectlveβ2-ARagonist,salmeterol,inthepresenceandabsenceofosteogenicmediafor21days、Supplementcirculationvol114,no18october31,2006Salmeterol tereatmentinthepresenceofosteogenicmediasignificantlyreducedtheALPactivityfrom10、2±2、9nmol/min/mgproteiyintheosteogenictreatedcellc,to4、7±1、9nmol/min/mgprotein(p<0、04,n=3)、TherewasnoincreaseintheALPactivitywhenhumanvalaelcsweretreatedwithsalmeterolalone、Supplementcirculationvol114,no18october31,2006老年瓣膜病合并房顫老年退行性心臟瓣膜病又稱老年鈣化性心臟瓣膜病(SCHVD),就是一種與年齡相關(guān)得瓣膜退行性變。隨著增齡,心血管系統(tǒng)逐漸老化,處于血流不斷沖擊得瓣膜及其支架易發(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,若病變得心肌擴張和鈣化、纖維化涉及傳導(dǎo)系統(tǒng)可以并發(fā)各種心律失常老年瓣膜病合并房顫國內(nèi)姜氏:107例鈣化性心臟瓣膜病中檢出各類心律失常者82例,發(fā)生率為76、16%。室上性心律失常居首位,占52、14%;其次為傳導(dǎo)阻滯,占24、13%;室性心律失常占13、14%。Theriskofthromboembolismiswellknown;otheroutesofatrialfibrillationarelesswellrecognised,suchasitsrelationshipwithdementia,depressionanddeath、Suchconsequencesareresponsiblefordiminishedqualityoflifeandconsiderableeconomiccost、DrugsAging、2002;19(11):819-46

瓣膜病合并房顫得治療原則首先老年瓣膜病合并冠心病、高血壓者居多,其次為糖尿病,表明動脈粥樣硬化得易患因素如高血壓、高膽固醇、高血糖也就是導(dǎo)致瓣膜鈣化得重要因素。因此老年人應(yīng)盡早防治各種引起動脈硬化得因素,這樣可能延緩?fù)诵行孕陌昴げ〉冒l(fā)生,從而減少各類心律失常得發(fā)生,降低死亡率其次此癥除與心房肌缺血有關(guān)外,一個主要因素就是心房肌得退行性變,這與瓣膜得退行性病變就是一致得。一些心房纖顫,部分快速性心房纖顫經(jīng)治療轉(zhuǎn)復(fù)竇律后伴有T波倒置外,其余在心室率正常情況下心電圖并無缺性改變,亦無臨床癥狀,并反復(fù)房顫發(fā)作,不易轉(zhuǎn)復(fù),這種心房纖顫可用心肌及瓣膜得退行性變來解釋,因而不宜強行糾正,室性心律失常雖可暫時糾正,但極易復(fù)發(fā),這亦與心肌得退行性變有關(guān)。Twoalternativesarepossible:restorationandmaintenanceofsinusrhythm,orcontrolofventricularrate,leavingtheatriainarrhythmia、Pharmacologicaloptionsincludeantiarrhythmicdrugs,suchasclassIIIagents,beta-blockersandclassICagents、Thesedrugshavesomeadverseeffects,andcarefulmonitoringisnecessary、DrugsAging、2002;19(11):819-46

Inelderlypatients(arbitrarilydefinedasaged>75years),themanagementofatrialfibrillationvaries;itrequiresanindividualapproach,whichlargelydependsonorbidconditions,underlyingcardiacdisease,andpatientandphysicianpreferences、

DrugsAging、2002;19(11):819-46

Anotherseriouschallengeinthemanagementofchronicatrialfibrillationinolderindividualsisthepreventionofstroke,itsprimaryoute,bychoosinganappropriateantithrombotictreatment(aspirinorwarfarin)、Severalrisk-stratificationschemeshavebeenvalidatedandmaybehelpfultodeterminethebestantithromboticchoiceinindividualpatients

DrugsAging、2002;19(11):819-46

關(guān)于抗血栓治療(瓣膜病)antithrombotictherapyinnativeandprostheticvalvularheartdiseaseispartoftheSeventhACCPConferenceonAntithromboticandThrombolyticTherapy:EvidenceBasedGuidelines、Grade1remendationsarestrongandindicatethatthebenefitsdo,ordonot,outweighrisks,burden,andcosts、Grade2suggeststhatindividualpatients'valuesmayleadtodifferentchoices(forafullunderstandingofthegradingseeGuyattetal,CHEST2004;126:179S-187S)、Amongthekeyremendationsinthischapterarethefollowing:Forpatientswithrheumaticmitralvalvediseaseandatrialfibrillation(AF),orahistoryofprevioussystemicembolism,weremendlong-termoralanticoagulant(OAC)therapy(targetinternationalnormalizedratio[INR],2、5;range,2、0to3、0)[Grade1C+]、ForpatientswithrheumaticmitralvalvediseasewithAForahistoryofsystemicembolismwhosuffersystemicembolismwhilereceivingOACsatatherapeuticINR,weremendaddingaspirin,75to100mg/d(Grade1C)、Forthosepatientsunabletotakeaspirin,weremendaddingdipyridamole,400mg/d,orclopidogrel(Grade1C)、CHEST2004;126:179S-187S)、Inpeoplewithmitralvalveprolapse(MVP)withouthistoryofsystemicembolism,unexplainedtransientischemicattacks(TIAs),orAF,weremendedagainstanyantithrombotictherapy(Grade1C)、InpatientswithMVPanddocumentedbutunexplainedTIAs,weremendlong-termaspirintherapy,50to162mg/d(Grade1A)、CHEST2004;126:179S-187S(房顫)Thischapteraboutantithrombotictherapyinatrialfibrillation(AF)ispartoftheSeventhACCPConferenceonAntithromboticandThrombolyticTherapy:EvidenceBasedGuidelines、Grade1remendationsarestrongandindicatethatthebenefitsdo,ordonot,outweighrisks,burden,andcosts、Grade2suggeststhatindividualpatients'valuesmayleadtodifferentchoices(forafullunderstandingofthegradingseeGuyattetal,CHEST2004;126:179S-187S)、Amongthekeyremendationsinthischapterarethefollowing(allvitaminKantagonist[VKA]remendationshaveatargetinternationalnormalizedratio[INR]of2、5;range,2、0to3、0):InpatientswithpersistentorparoxysmalAF(PAF)[intermittentAF]athighriskofstroke(ie,havinganyofthefollowingfeatures:priorischemicstroke,transientischemicattack,orsystemicembolism,age>75years,moderatelyorseverelyimpairedleftventricularsystolicfunctionand/orcongestiveheartfailure,historyofhypertension,ordiabetesmellitus),weremendanticoagulationwithanoralVKA,suchaswarfarin(Grade1A)、InpatientswithpersistentAForPAF,age65to75years,intheabsenceofotherriskfactors,weremendantithrombotictherapywitheitheranoralVKAoraspirin,325mg/d,inthisgroupofpatientswhoareatintermediateriskofstroke(Grade1A)、InpatientswithpersistentAForPAF<65yearsoldandwithnootherriskfactors,weremendaspirin,325mg/d(Grade1B)、ForpatientswithAFandmitralstenosis,weremendanticoagulationwithanoralVKA(Grade1C+)、CHEST2004;126:179S-187S)、RequiringLowerWarfainDosagestoAchieveTherapeuticAnticoagulationisaStrongRiskFactorforBleedingEvent

Accumulatingevidencesuggestssomegenotypesofenzymesareassociatedwithlowmaintenancedoserequirementandincreasedriskofmajorbleeding、Supplementcirculationvol114,no18october31,2006METHODSInaprospectivecohortfrom550consecutivepatientswithmechanicalvalvereplacementwerestudied、Patientsweredividedintothreegroups(lowerdosagesgroup,warfarinmaintenancedose0、2mg/day/BM)、resultsover4000patient-yearsoffollow-up,PT-INRvaluesfellwithintargetrangerangefor90、2%ofthetimeontreatment、Supplementcirculationvol114,no18october31,2006Therewasnodifferencebetweenthreegroupsaboutpatientcharacteristicsincludinganticoagulantintensity、lowdosagegrouphavesignificantlyincreasedriskofbleeding(figure)Supplementcirculationvol114,no18october31,20065101500、000、250、500、751、00Notsingnificantp=0、0001p=0、0019highdosegroupIntermediatedosegroupLowdosegroupAnalysistime(years)Bleedingeventfreesurvivalbywarfarindose關(guān)于老年瓣膜病合并房顫抗血栓治療1、注意合并癥得情況2、注意各種危險因素3、年齡界限對治療得影響4、多種藥物得相互作用5、出血在老年中得不同表現(xiàn)和不同后果老年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)得改變,最后可導(dǎo)致心臟擴大,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)得變形而影響心室收縮導(dǎo)致心功能不全得發(fā)生,一旦出現(xiàn)癥狀,病情會加快發(fā)展、加重。廣東葉氏,2000年1月至2005年1月收治得40例老年退行性心臟瓣膜病合并心力衰竭與同期收治得40例年齡、性別相匹配得、無瓣膜鈣化合并心力衰竭得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。臨床和實驗醫(yī)學(xué)雜志2006年1月第5卷第1期瓣膜性心臟病患者,主要問題就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得介入或手術(shù)治療。實驗研究表明,單純得心肌細胞牽拉刺激就可促發(fā)心肌重塑,因而治療瓣膜性心臟病得關(guān)鍵就就是修復(fù)瓣膜損害。目前國內(nèi)外較一致得意見就是:所有有癥狀得瓣膜性心臟病心力衰竭(NYHAⅡ級及以上),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)治療就是有效和有益得,可提高長期存活率。有癥狀得二尖瓣狹窄(MS)和主動脈瓣狹窄(AS)應(yīng)當(dāng)考慮手術(shù),手術(shù)同樣適用于有癥狀得二尖瓣關(guān)閉不全(MR)和主動脈瓣關(guān)閉不全(AR)。有些反流性病變得患者在出現(xiàn)癥狀前也可考慮手術(shù),例如左室射血分數(shù)降低或心臟明顯擴大。外科治療包括瓣膜得修補術(shù)和置換術(shù),單純MS可采用經(jīng)皮球囊二尖瓣成形術(shù)。值得注意得就是,如果在瓣膜病得治療中用藥不當(dāng),反而可能加重病情。例如血管擴張劑以及ACEI等具有血管擴張作用得藥物,應(yīng)慎用于瓣膜狹窄得患者,以免后負荷過度降低致心輸出量減少,引起低血壓、暈厥等。MS患者,左心室并無壓力負荷或容量負荷過重,因此沒有任何特殊得內(nèi)科治療洋地黃類無益于單純MS伴竇性心率得病人,但可以用于快速心室率得心房顫動治療,控制心室率效果不好時,可加用小劑量得β阻滯劑。AS患者亦應(yīng)避免應(yīng)用β阻滯劑等負性肌力藥物。β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。

最常受累得就是主動脈瓣膜,其發(fā)生率遠高于其她瓣膜。這主要就是由于主動脈瓣膜所承受得機械壓力較大,尤其在血壓增高時,易引起膠原纖維斷裂形成間隙而有利于鈣鹽沉積。老年瓣膜長期經(jīng)受血流沖擊,瓣葉中糖蛋白與蛋白聚糖得丟失與營養(yǎng)不良,也就是鈣化形成得可能機制。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得絹織支托,受血流沖擊較大亦易受損。AR得藥物治療:降低后負荷得藥物可以改善AR患者得預(yù)后。在一項與地高辛得比較研究中,硝苯地平可以延緩嚴重?zé)o癥狀A(yù)R患者做主動脈瓣置換術(shù)得時機。ACEI也可通過減輕后負荷,增加前向心輸出量而減少返流,可應(yīng)用于以下情況:(1)有癥狀得重度AR患者,因其她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AR得手術(shù)指征:與嚴重MR一樣,AR術(shù)前左室大小與術(shù)后射血分數(shù)得改善直接相關(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數(shù)。另外,如果射血分數(shù)得降低時間小于12～14個月,術(shù)后也可能恢復(fù)正常。嚴重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、左室射血分數(shù)下降(<55%)、左室嚴重擴大(收縮末徑>5、5cm)。一旦出現(xiàn)明顯得左室功能下降,手術(shù)結(jié)果將不會令人滿意。左室收縮末徑可以反映左室功能,并且不像射血分數(shù)那樣受前負荷得影響AS得心導(dǎo)管診治:對于超聲心動圖診斷不明確得患者,可以做心導(dǎo)管檢查,心導(dǎo)管檢查得主要作用就是排除伴發(fā)得冠心病,在此比其她瓣膜病更重要,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,主動脈瓣狹窄得瓣膜成形術(shù)常常不成功,其出血和栓塞得發(fā)生率較高,6個月得成功率較低AS得外科治療:應(yīng)當(dāng)認為AS就是一種外科疾病,因為沒有藥物可以代替手術(shù)治療,也沒有藥物可以改善生存率。非手術(shù)治療得預(yù)后很差。其手術(shù)指征為:超聲心動圖或心導(dǎo)管檢查證實嚴重得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)得效果更好。手術(shù)風(fēng)險較高得患者可考慮做心導(dǎo)管球囊成形術(shù)。MR得藥物治療: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,所以嚴重MR常就是進展性得。嚴重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。血管擴張劑和洋地黃可增加左室衰竭后得前向心輸出量。靜脈應(yīng)用硝普鈉或硝酸甘油可減少后負荷,減少返流,有助于穩(wěn)定急性或重度MR患者病情。無癥狀慢性MR且射血分數(shù)正常時,并無后負荷增加,尚不清楚應(yīng)用降低后