心房纤颤的围手术期管理课件

心房纤颤的围手术期管理1河南中医学院一附院心脏中心关怀敏心房纤颤分类2初发房颤（first-detected

episode

of

AF）阵发性房颤（paroxysmal

AF）持续性房颤（Persistent

AF）永久性房颤（permanent

AF）孤立性房颤（lone

AF）沉默性房颤（silent

AF)急性(24~48h之内)长期(＞1年)心房纤颤的流行病学34房颤的危害5增加死亡率缺血性脑卒中心功能降低心肌缺血生活质量和运动耐力下降预防这些并发症是比较困难的！6房颤引发的卒中较其它病因者更为严重Dulli

DA,

et

al.

Neuroepidemiology.

2003;22:118-123.%卧床患者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房颤患者：生活质量下降AF=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起搏器治疗房颤的新曙光1415161718192021Risk

factorsScoreCRecent

congestive

heart

failure1HHypertension1AAge

≥75

yrs1DDiabetes

mellitus1S2History

of

stroke

or

transient

ischemic

attack(TIA)2非瓣膜性房颤患者的卒中危险分层评估：CHADS2评分1.

Reprinted

from

Curr

Probl

Cardiol,

30(4),

Hersi

A,

et

al,

175-233,

Copyright©2005,

withpermission

fromElsevier.卒中年发生率与

CHADS2评分具有良好的相关性1CHADS2

scoreCHADS2=cardiac

failure,hypertension,

age,diabetes,

andstroke(doubled)卒中发生率(%)22232425262728293031323334口服抗凝药的临床应用:仅约50％患者接受了OAC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1随访11,082例瓣膜性房颤患者，接受口服抗凝药治疗:Total

55%<55岁.>85

岁≥1卒中危险因素*‘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.年龄华法林治疗％50%-------------------------------35ACTIVE

W:治疗方案36多中心、多国、平行组、随机对照试验口服抗凝药－华法林标准治疗

(INR

2.0

–

3.0)至少每月测定一次INR氯吡格雷联合阿司匹林治疗氯吡格雷75

mg/dASA

75-100

mg/dACTIVE

Writing

Group

for

the

ACTIVE

Investigators.

Lancet.

2006;367:1903-1912累计卒中发生风险：OAC优于波立维＋ASARR=1.72

(1.24-2.37),p=0.00137Clopidogrel

+

Aspirin口服抗凝药ACTIVE

Writing

Group

for

the

ACTIVE

Investigators.

Lancet.

2006;367:1903-1912.主要出血风险*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+0.00.05累积危险率0.100.1501234年高危患者数C+A

37723491322925701203ASA

3782345831552517118639阿司匹林氯吡格雷+阿司匹林H