2011 ACCF房颤治疗指南更新解读.ppt

1、1,2011 ACCF/AHA/HRS Focused Update on Management of Pts With AF (Updating the 2006 Guideline),Chenqi Depart of Cardiology, 2nd Affil Hosp to NCU,2,Focuses on several areas,a) recommendations for strict versus lenient heart rate control b) combined use of antiplatelet and anticoagulant therapy c) use

2、 of dronedarone d) catheter ablation of AF,3,I. Rate Control During AF,4,Rate Control During AF,Rate reduction has several benifits Some pts with AF Ventricular rate is well controlled at rest but accelerate during exercise,5,Parameters for optimal rate control remain controversial Criteria for vent

3、ricular rate control vary with age usually 60-80 bpm at rest 90-115 bpm during moderate exercise If the fact does favouring strict rate control?,6,RACE II RAte Control Efficacy in Permanent Atrial Fibrillation A Randomized Comparison of Lenient Rate Control versus Strict Rate Control Concerning Morb

4、idity and Mortality,7,RACE II study,Rate Control Efficacy in Permanent AF,Strict control resting HR 80 during exercise 110,Lenient control resting HR 110,vs.,8,Hypothesis,Lenient control is not inferior to strict control in pts with permanent AF in terms of cardiovascular morbidity and mortality,9,P

5、rimary endpoints,Cardiovascular mortality Hospitalization for heart failure Stroke, systemic emboli, major bleeding Life- threatening arrhythmias,10,No. At Risk Strict303 282 273 262 246 212 131 Lenient311 298 290 285 255 218 138,Lenient,Strict,Cumulative Incidence (%),14.9%,12.9%,months,Cumulative

6、incidence primary outcome,11,Conclusions of RACE II,Lenient control is not inferior to strict control Lenient rate control is more convenient since fewer outpatient visits fewer examinations lower doses less often combination of drugs,12,Limits,Pts included Relatively young (mean 68 yr) Compared to

7、pts encountered in clinic Be healthier Be less symptomatic,13,Recommendation for Rate Control-NEW!,2011 Focused Update Recommendation Class IIINo Benefit 1. Treatment to achieve strict rate control of heart rate (0.40) and no or acceptable symptoms related to the arrhythmia, though uncontrolled tach

8、ycardia may over time be associated with a reversible decline in ventricular performance.3 (Level of Evidence: B),14,II. Combining AnticoagulantWith Antiplatelet Therapy,15,Combining AnticoagulantWith Antiplatelet Therapy,warfarin is effective for prevention of thromboembolism in AF pts ASA offers o

9、nly modest protection Recent studies assessed clopidogrel + ASA for stroke prevention in AF ACTIVE-W ACTIVE-A,ACTIVE W: Treatments,OAC Standard Care (INR 2.0 3.0) INR at least monthly Clopidogrel plus ASA Clopidogrel 75 mg once daily ASA 75-100 mg once daily,16,Outcome Events,Primary Outcome Stroke,

10、 Non-CNS Systemic Embolism, MI, Vascular Death Safety Outcome Major Bleeding,17,Stroke, Non-CNS Systemic Embolism, MI & Vascular Death,Cumulative Hazard Rates,Years,# at Risk C+A 3335 3149 2387 916 OAC 3371 3220 2453 911,3.93 %/year,5.64 %/year,RR = 1.45 P = 0.0002,18,Primary Outcome Components & De

11、ath,19,Major Bleeding,Cumulative Hazard Rates,Years,# at Risk C+A 3335 3172 2403 914 OAC 3371 3212 2423 901,2.4 %/year,2.2 %/year,RR = 1.06 P = 0.67,19,20,Early Termination of ACTIVE W,DSMB recommended early termination of ACTIVE W due to evidence of superiority of oral anticoagulant,21,Conclusions,

12、Oral anticoagulation is superior to clopidogrel plus ASA for prevention of vascular events Rates of major hemorrhage are similar,22,23,Effects of Addition of Clopidogrel to Aspirin in Patients with Atrial Fibrillation who are Unsuitable for Vitamin K Antagonists,24,All patients received aspirin at a

13、 recommended daily dose of 75-100 mg Patients were randomized, double blind, to clopidogrel, 75 mg per day, or matching placebo,ACTIVE A Study Treatments,25,26,27,Components of the Primary Outcome,28,Bleeding,29,Conclusions,Addition of clopidogrel to aspirin in high risk AF patients, unsuitable for

14、VKA: Reduces major vascular events Primarily due to a reduction in stroke With an increase in major bleeding It provides an important benefit to many patients, at an acceptable risk,30,31,III. Emerging and Investigational antithrombotic agents,32,Dabigatran,Dabigatran a prodrug that is rapidly conve

15、rted to an active direct thrombin inhibitor independent of the cytochrome P-450 RE-LY trial recommendations not included it was not approved for clinical use by the FDA,33,Watchman device for atrial appendage closure,Not be included in this update recommendation FDA has not approved clinical use Fut

16、ure guideline maybe OK,34,IV. Recommendations for Dronedarone for the Prevention of Recurrent AF,35,Dronedarone,Similar to amiodarone without iodine moiety Inhibition of L-type calcium current the inward sodium current multiple potassium currents,36,Dronedarone,2 trials (EURIDIS and ADONIS) of persi

17、stent AF Converted 5.8% to sinus rhythm (3.1% for placebo) slows HR in AF by 11-13bpm,37,Dronedarone,Incidence of spontaneous conversion was dose related 5.8% (800 mg) 8.2% (1200 mg) 14.2% (1600mg) Incidence of successful electrical cardioversion not different between groups,38,Dronedarone,DIONYSOS

18、evaluated the efficacy and safety of Dronedarone (D) vs. amiodarone (A) Recurrence of AF DA,39,Dronedarone,ATHENA A placebo-controlled to assess the efficacy of dronedarone 400mg bid for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atr

19、ial flutter,40,ATHENA -Dronedarone,Reduced cardiovascular Hospitalizationor death stroke Increased mortality of pts with recently decompensated HF and depressed LV function associated with more progression of HF,41,Dronedarone,Major adverse effects QT prolongation bradycardia increase plasma creatinine Meta