心瓣膜病合并房颤及心衰的处理原则精要课件

老年人心瓣膜病合并房颤及心衰的 处理原则 广州市第一人民医院 刘丰 随着人口的老龄化,老年退行性钙化性瓣膜 病逐渐占有重要的地位,是目前老年人的特 殊疾病。 已经成为老年人心力衰竭、心律失常、晕 厥、猝死的原因之一。 对冠心病具有重要预测价值 国外报道的发病率明显高于国内。Pomerance 等 尸检 162 例死于心衰的患者, 分析其原因后发现钙化性瓣膜病 变占45 % ,仅次于冠心病。 Wong 等 在78 例65102 岁的患者中 发现瓣膜退行性改变占74 %。 90100 岁年龄组几近100 % Springer. Verlag ,1982 :6367. . J AM Geriatir soc ,1983 ,3l :156. 国内外报道十分不一致,主要原因有种 族差异、也存在方法学的问题 The incidence and etiological classification of valvular diseases were examined on 358 cases from 3,000 consecutive autopsies of more than 60 years of age. The incidence of valvular disease was 11.9% (358 out of 3,000 cases) Jpn Circ J. 1982 Apr;46(4):337-45 Mitral stenosis was found in 23 cases (6.4%), of which 21 cases were rheumatic and the remaining 2 were mitral ring calcification (MRC). Mitral regurgitation was observed in 126 cases (35.3%): 69 of papillary muscle dysfunction, 26 of mitral valve prolapse (MVP), 16 of MRC, 9 of ruptured chordae tendineae, 3 of rheumatic and 3 of congenital. Jpn Circ J. 1982 Apr;46(4):337-45 Aortic stenosis was noted in 33 cases (9.2%): 27 of calcified, 5 of rheumatic and one of congenital. Aortic regurgitation was found in 169 cases (47.2%): 112 of degenerative, 47 of syphilitic, 7 of rheumatic and 2 of aortitis syndrome. There were 6 cases (1.7%) of tricuspid regurgitation. Jpn Circ J. 1982 Apr;46(4):337-45 Etiological classification revealed 6 cases (1.7%) of congenital, 36 (10%) of rheumatic, 49 (13.7%) of syphilitic, 27 (7.5%) of MVP, 69 (19.3%) of ischemic and 166 (46.4%) of degenerative valvular disease. Jpn Circ J. 1982 Apr;46(4):337-45 A total of 458 cases (11.5%) with valvular heart diseases in the aged (greater than or equal to 60 years) were found among 4,000 consecutive autopsies. They included 204 cases (45%) of aortic regurgitation (AR), 171 cases (37%) of mitral regurgitation (MR), followed by 45 (10%) of aortic stenosis (AS) and 27 cases (6%) of mitral stenosis (MS). J Cardiol Suppl. 1988;19:29-38. an etiology of the valvular diseases, degenerative type was found in 195 cases (43%), ischemic origin in 91 cases (20%), followed by inflammatory origin such as syphilitic in 51 and infective endocarditis in three, aortitis in two and rheumatic in 49 (11%). Congenital origin was also found in 18 cases (4%). J Cardiol Suppl. 1988;19:29-38. 仍关注对老年人风心病 。山西医科大学第一临床医学院心内科从 1979 - 011998 - 12 共收治风心病1 227 例,其中老年风心病215 例,对其逐年发病情 况及95 例资料齐全者临床特点作一回顾分 析 老年风心病215 例,所占比例为17.5 %。逐 年住院比例由1979 年的9 %逐渐增长为 1998 年的42.5 %。又从215 例老年风心病 患者中取资料齐全者95 例,其中男49 例,女 46 例,年龄6080 岁,平均年龄64 岁,平均 病程16.8 年。 老年退行性心脏瓣膜病又称老年钙化性心 脏瓣膜病(SCHVD) , 是一种与年龄相关的 瓣膜退行性变。随着增龄, 心血管系统逐渐 老化, 处于血流不断冲击的瓣膜及其支架易 发生退行性变、纤维化和钙化, 造成主动脉 瓣和(或) 二尖瓣关闭不全及狭窄, 若病变的 心肌扩张和钙化、纤维化涉及传导系统可 以并发各种心律失常 A Novel Role of the Sympatho- Adrenergic System in Regulating Valve Calcification Recent evidence has indicated that the sympathetic nervous system plays an important role inregulating bone deposition and resorption the beta 2-adrenergic receptors(2-AR).In order to test the effect 2-AR on changing the human valve lCs towards osteogenic phenotype cells were treated with the selectlve2-AR agonist ,salmeterol ,in the presence and absence of osteogenic media for 21 days . Supplement circulation vol 114,no 18 october 31 ,2006 Salmeteroltereatment in the presence of osteogenic media significantly reduced the ALP activity from 10.22.9nmol/min/mg proteiy in the osteogenic treated cellc ,to 4.71.9nmol/min/mg protein(p75 years), the management of atrial fibrillation varies; it requires an individual approach, which largely depends on comorbid conditions, underlying cardiac disease, and patient and physician preferences. Drugs Aging. 2002;19(11):819-46 Another serious challenge in the management of chronic atrial fibrillation in older individuals is the prevention of stroke, its primary outcome, by choosing an appropriate antithrombotic treatment (aspirin or warfarin). Several risk- stratification schemes have been validated and may be helpful to determine the best antithrombotic choice in individual patients Drugs Aging. 2002;19(11):819-46 关于抗血栓治疗 (瓣膜病)antithrombotic therapy in native and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international normalized ratio INR, 2.5; range, 2.0 to 3.0) Grade 1C+. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs at a therapeutic INR, we recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C). CHEST 2004; 126:179S-187S). In people with mitral valve prolapse (MVP) without history of systemic embolism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexplained TIAs, we recommend long- term aspirin therapy, 50 to 162 mg/d (Grade 1A). CHEST 2004; 126:179S-187S (房颤)This chapter about antithrombotic therapy in atrial fibrillation (AF) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following (all vitamin K antagonist VKA recommendations have a target international normalized ratio INR of 2.5; range, 2.0 to 3.0): In patients with persistent or paroxysmal AF (PAF) intermittent AF at high risk of stroke (ie, having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age 75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus), we recommend anticoagulation with an oral VKA, such as warfarin (Grade 1A). In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, we recommend antithrombotic therapy with either an oral VKA or aspirin, 325 mg/d, in this group of patients who are at intermediate risk of stroke (Grade 1A). In patients with persistent AF or PAF 5.5 cm) 。 一旦出现明显的左室功能下降,手术结果将 不会令人满意。左室收缩末径可以反映左 室功能,并且不像射血分数那样受前负荷的 影响 AS的心导管诊治:对于超声心动图诊断不明确 的患者,可以做心导管检查,心导管检查的主 要作用是排除伴发的冠心病,在此比其他瓣 膜病更重要,因为主动脉瓣狭窄主要发生在 老年人。通过心导管可做经皮球囊瓣膜成 形术,但与经皮球囊二尖瓣扩张术(PBMC)治 疗二尖瓣狭窄不同,主动脉瓣狭窄的瓣膜成 形术常常不成功,其出血和栓塞的发生率较 高,6 个月的成功率较低 AS的外科治疗:应当认为AS 是一种外科疾 病,因为没有药物可以代替手术治疗,也没有 药物可以改善生存率。非手术治疗的预后 很差。其手术指征为:超声心动图或心导管 检查证实严重的主动脉瓣狭窄并伴有心脏 症状。有少数患者可做瓣膜修补,但瓣膜置 换术的效果更好。手术风险较高的患者可 考虑做心导管球囊成形术。 MR 的药物治疗:发生MR 后,左房扩大增加了 二尖瓣后叶张力,紧拉叶瓣使瓣膜功能失常 加重,所以严重MR 常是进展性的。严重MR 非手术治疗应限制体力活动,减少钠摄入,并 通过合理应用利尿剂增加钠排泄。血管扩 张剂和洋地黄可增加左室衰竭后的前向心 输出量。静脉应用硝普钠或硝酸甘油可减 少后负荷,减少返流,有助于稳定急性或重度 MR 患者病情。 无症状慢性MR 且射血分数正常时,并无后负 荷增加,尚不清楚应用降低后负荷药物是否 有利。ACEI治疗慢性MR 可能有益,特别是 有症状或左室增大者,可减少MR 并使左室 腔减小,但要注意ACEI 降低后负荷可能掩 盖左室功能不全,而有症状MR 患者则适用于 手术治疗。与MS 一样,MR 患者近期心房颤 动应考虑转为窦性心律。心力衰竭晚期患 者应用抗凝药和下肢绷带,可减少静脉血栓 形成和肺栓塞。 MR 的手术治疗:必须全面考虑疾病缓慢进 展的性质和瓣膜修复以及瓣膜置换所带 来的远期及近期风险。没有症状或只在 强体力活动受限者病情可稳定多年,不宜 外科治疗。左室功能受损者手术治疗风 险骤增,远期存活下降,但其保守治疗几 乎没有有效的办法,即使在病情晚期,仍 可考虑手术治疗。如果临床表现与超声 心动图检查不一致时,左心导管检查和心 血管造影可能有助于确认严重MR 的存 在,还有助于发现相关瓣膜病变、病变严 重程度以及发现需同时血管重建的病人 手术的最佳时机:是慢性代偿期到失代偿期 的转变阶段。左室射血分数 60 % ,左室收 缩末径 4.5 cm时手术效果最好。选择手术 时机还要考虑肺动脉高压和心房颤动的情 况 关于老年瓣膜病合并心功能不全治疗 1.正确判断瓣膜的受损部位、程度、范围 2.把临床症状与病变情况结合考虑 3.牢记心功能是病程的分水岭 4.对心功能不全的治疗，应因病而治。 美托洛尔治疗瓣膜性心脏病心力衰 竭的随机对照研究 山西叶氏,经心脏超声确认为瓣膜性心脏病 的心力衰 竭284 例中, 拒绝施行介入或手 术治疗, 同意参与研究的184例, 其中男性80 例, 女性104 例, 年龄31 73 岁(平均56. 48. 3 岁) , 随机分为两组,A 组美托洛尔组 ,B 组常规治疗 延安大学学报(医学科学版) Vo l14 No12 2006 年6 月 所有入选患者接诊后均为按慢性收缩性心 力衰竭治疗指南常规治疗, 待心功能纠正到 以上, 患者一般情况好转后(心功能分级按美 国纽约心脏病学会N YHA 分级法) , 随机分 为两组,A 组美托洛尔组,B 组常规治疗组,A 组开始口服美托洛尔12. 5mg/d, 每2w 增加1 次剂量, 最大用量75mg/d , 长期服用,A、B 两组其他用药均按心衰治疗指南 常规处理, 观察时间2 年。 观察指标 死亡率 统计两组在观察期内组间死亡率和 总死亡率。 延安大学学报(医学科学版) Vo l14 No12 2006 年6 月 美托洛尔的心衰死亡率(4. 3%) , 明显低于总死亡 (9.2% ) 和常规治疗组死亡率(14. 3%) , 两组比较 有统计学意义(P 0. 05)。对心功能的控制与维持 有良好作用,A 组心功能1 2 级者75 例(80. 6%) ,B 组心功能12 者32 例(35.2% ) , 两组比较有统 计学意义(P 0. 05)。同时显示美托洛尔 对心衰患者运动与静息时心室率均有良好控制, 减 少因心衰加重的住院率 延安大学学报(医学科学版) Vo l14 No12 200