心房颤动的治疗新的循证医学证据英文课件

Management of Atrial Fibrillation：Update in the EBM proofChangSheng Ma Department of Cardiology, Beijing Anzhen Hospital Capital Medical University, P.R. ChinaPrevalence of AF is increasingAdults with AFib(millions)Year2.082.262.442.66 2.943.333.804.784.345.16 5.425.61% 363753YearProportion Aged 80 YrGo: JAMA, 2001： 2370Miyasaka.Circulation.2006:119Year2.04.06.08.010.012.014.016.02000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050Adults with AFib(millions)5.110.28.412.115.9Prevalence of AF is increasingPrevalence %AgePrevalence of AF:the Rotterdam studyHeerinaga.Eur Heart J,2006,9496808 pts., F/U 6.9 yrs， prevalence 5.5%Incidence AgeIncidence of AF:the Rotterdam studyHeerinaga.Eur Heart J,2006,9496808 pts., F/U 6.9 yrs， Incidence 9.9Identified AF： the tip of the icebergv14802 pts aged 65 or over， randomized to systemic screening and opportunistic screeningSystemic screening group:9866 pts.Opportunistic screening group: 4936 pts.vF/U 12 monsRate of new AF case in systemic screening 1.63%，Rate of new AF case in opportunistic screening 1.04%Fitzmaurice.BMJ.2007,383Risk for stroke increased in lone AFJahangir. Circulation. 2007:3050Meta-analysis:antithrombotic therapy of AFHart.Ann Intern Med,2007,857trial pts RR reduced(%)Warfarin vs Placebo 6 2900 64ASA vs Placebo 8 4876 22Warfarin vs ASA 12 12963 39Real world of warfarin in the elderly13.1%4.7%The first 90 days associated with major hemorrhage21% pts withdrawn warfarin for safety issueThe higher risk of stroke, the higher incidence of major hemorrhageHylek. Circulation.2007,2689 HR for ICH was 4.06 for AsiansAsians were at greater risk for warfarin-ralated ICHShen. JACC.2007:309 v Prospective， randomize， controlv 973 pts 75 years old with AFv Randomized into warfarin arm (INR 2.0-3.0) and Aspirin arm(75mg/d)v Mean F/U 2.7 yrsv Primary outcome： fatal or disabling stroke, intracranial haemorrhage, or arterial embolismWarfarin versus aspirin for stroke prevention in the elderly with AF(The Birmingham Atrial Fibrillation Treatment of the Aged Study,BAFTA study)Mant.Lancet,2007,4930.831.155(0.4%)6(0.5%) haemorrhagic0.651.921(0.1%)2(0.2%)Other ICH0.360.323(0.2%)1(0.1%)Embolism48(3.8%)7(0.5%)32(2.5%)23(1.8%)21(1.6%)44(3.4%)0.0050.338(0.6%) disabling nonfatal0.00270.4824(1.8%)Total0.530.695(0.4%) unknown0.00040.3010(0.8%) ischemic0.140.5913(1.0%) fatal0.0030.4621(1.6%)StrokepEvent warfarin(n=488) ASA(n=488)N(Risk peryear) N(Risk peryear) warfarinVS.ASARRWarfarin versus aspirin for stroke prevention in the elderly with AFMant.Lancet,2007,493Mant.Lancet,2007,493Warfarin versus aspirin for stroke prevention in the elderly with AFAnticoagulation in clinical practice2.03/100person-yrs1.17/100person-yrs11,526 pts with AF,54.8% was on warfarinRelative risk for thromb -embolism reduced 51% in warfarin therapyThe intracranial hemorrhage rate increased in warfarin(0.46/100 person-yrs VS 0.23/100 person-yrs）Warfarin was not associated with nonintracranial hemorrhage (1.05/100 person-yrs VS 1.06/100 person-yrs）Go.JAMA 2003:2685Rivaroxaban Enoxaparin873 ptsEndpoints included DVT,PE,all cause mortality Safety： major hemorrhageEndpointsSafetyEriksson. Circulation. 2006: 2374%Rivaroxaban New promise of anticoagulation？vProspective RIKS-HIAv60764 pts， AF 21459 pts,CHF 22345 pts,AF+CHF16960 ptsvF/U 1 yrvHigher mortality rate in AF without CHF pts taking digoxin (RR1.42)vSimilar mortality rate in CHF or AF+CHF pts with or without digoxin Digoxin and mortality in AF:A prospective cohort studyHallberg.Euro J Clin Pharmacol,2007,959Hallberg.Euro J Clin Pharmacol,2007,959Digoxin and mortality in AF:A prospective cohort studyAdverse effects of oral amiodaroneZimetbaum.NEJM.2007:935Bradycardia 5%Prolonged QT In mostTdp AAD:4%Catheter ablation decrease the incidence of stroke755 ptsThe incidence of stroke/TIA was 1.1%0.9% occurred whithin 2 weeks of RFCA79% of pts without risk factor for stroke and 68% of pts with 1 risk factor in sinus discontinued warfarinPatients with sinus rhythm was thromboembolic event free after the procedureOral.Circulation.2006:759Pappone . JACC.2003:185N=589 N=582Catheter ablation reduce strokePappone . JACC.2003:185Catheter ablation improve prognosisNo risk factor： ASA 81- 325mg One moderate risk factor： ASA 81- 325mg or warfarinAny high risk factor or more than one moderate risk factor: warfarinPrinciples of anticoagulationAmiodarone Ablation ！No OHD yesHTN