1、心房纤颤的围手术期管理心房纤颤的围手术期管理河南中医学院一附院心脏中心河南中医学院一附院心脏中心关怀敏关怀敏心房纤颤分类n初发房颤（初发房颤（first-detected episode of AF）n阵发性房颤（阵发性房颤（paroxysmal AF）n持续性房颤（持续性房颤（Persistent AF）n永久性房颤（永久性房颤（permanent AF）n孤立性孤立性房颤（房颤（lone AF）n沉默性房颤（沉默性房颤（silent AF)n急性急性(2448h之内之内)n长期长期(1年年)心房纤颤的流行病学心房纤颤的流行病学 房颤引发的卒中较其它病因者更为严重房颤引发的卒中较其它病因者更
2、为严重Dulli DA,et al.Neuroepidemiology.2003;22:118-123.Odds ratio for bedridden state following stroke due to AF was 2.23(95%CI,1.87-2.59;p0.0005)%卧床患者卧床患者p0.00054030201005041.2%23.7%With AFWithout AF 房颤患者：生活质量下降房颤患者：生活质量下降AF=atrial fibrillation;CAD=coronary artery disease;SF=Medical Outcomes Study Sho
3、rt Form 36Adapted from:Dorian P,et al.J Am Coll Cardiol.2000;36(4):13031309Note that a lower score represents poorer quality of life.P0.001,compared with patients with AF.SF-36 scoreafCADControlAntiarrhythmic Drugs:Efficacy MaintainingNSR 6 Months 起搏器治疗房颤的新曙光非瓣膜性房颤患者的卒中危险分层评估：非瓣膜性房颤患者的卒中危险分层评估：CHADS
4、2评分评分 CHADS2=cardiac failure,hypertension,age,diabetes,and stroke(doubled)1.Reprinted from Curr Probl Cardiol,30(4),Hersi A,et al,175-233,Copyright 2005,with permission from Elsevier.Risk factorsScoreCRecent congestive heart failure1HHypertension1AAge 75 yrs1DDiabetes mellitus1S2History of stroke or
5、 transient ischemic attack(TIA)2卒中年发生率与卒中年发生率与 CHADS2 评分具有评分具有良好的相关性良好的相关性1CHADS2 score卒中发生率卒中发生率(%)口服抗凝药的临床应用口服抗凝药的临床应用:仅约仅约50患者接受了患者接受了OAC治疗治疗NVAF=非瓣膜性房颤;RF=危险因素1.Go AS,Hylek EM,Borowsky LH,et al.Ann Intern Med.1999;131(12):927-34.OAC的临床使用1 接受口服抗凝治疗的患者数接受口服抗凝治疗的患者数1 随访随访11,082例瓣膜性房颤患者，接受口例瓣膜性房颤患者，
6、接受口服抗凝药治疗服抗凝药治疗:Total55%85 岁岁 35.4%1卒中危险因素卒中危险因素*59.3%理想的理想的 患者患者 62.1%*Previous ischemic stroke,hypertension,congestive heart failure,diabetes mellitus and coronary heart disease.Risk factors,no contraindications,age 6574 years.年龄年龄50%华法林治疗-ACTIVE W:治疗方案n多中心、多国、平行组、随机对照试验多中心、多国、平行组、随机对照试验n口服抗凝药华法林口
7、服抗凝药华法林n 标准治疗标准治疗 (INR 2.0 3.0)(INR 2.0 3.0)n 至少每月测定一次至少每月测定一次INRINRn 氯吡格雷联合阿司匹林治疗氯吡格雷联合阿司匹林治疗n 氯吡格雷氯吡格雷75 mg/d75 mg/dn ASA 75-100 mg/d ASA 75-100 mg/dACTIVE Writing Group for the ACTIVE Investigators.Lancet.2006;367:1903-1912 累计卒中发生风险：累计卒中发生风险：OAC优于波立维优于波立维ASARR=1.72(1.24-2.37),p=0.001Clopidogrel+A
8、spirin口服抗凝药口服抗凝药ACTIVE Writing Group for the ACTIVE Investigators.Lancet.2006;367:1903-1912.0.00.010.020.030.040.00.51.01.5OACClopidogrel+ASA 主要出血风险主要出血风险*Cumulative Hazard Rates Years#at RiskC+A 3335 3172 2403 914OAC 3371 3212 2423 9012.42%/year2.21%/yearRR=1.1(0.83-1.45)P=0.53.ACTIVE Writing Group
9、 for the ACTIVE Investigators.Lancet.2006;367:1903-1912.在卒中方面的获益最大在卒中方面的获益最大408(3.3%/年）296(2.4%/年）氯吡格雷加ASA显著减少所有卒中达28%的相对风险安慰剂+累积危险率0.00.050.100.1501234阿司匹林氯吡格雷+阿司匹林HR=0.72（0.62-0.83）p0.001 3772349132292570120337823458315525171186高危患者数ASAC+A年 The ACTIVE Investigators N Engl J Med 2009;360 VALHeFTn稳心颗粒也有比较好的效果！谢谢 谢！谢！
