房颤患者脑卒中的预防.ppt

1、Atrial Fibrillation a simple pulse check to prevent a stroke?,Dr Kneale Metcalf,Overview,Atrial fibrillation Stroke and atrial fibrillation Detecting atrial fibrillation Managing atrial fibrillation,What is atrial fibrillation (AF)?,“Atrial fibrillation is an atrial tachyarrhythmia characterised by

2、predominantly uncoordinated atrial activation”,“A fast / irregular heart”,What happens in the heart?,Sinus rhythm,AF,ECG,Most commonly diagnosed by an ECG:,Classification of AF,The Incidence of AF is Increasing in the United Kingdom,In 1995, 0.9% of the United Kingdom population were affected by AF2

3、 By 2006 this figure had risen to 1.3%1 The prevalence of AF will continue to rise as the proportion of elderly patients increases By 2050, it is estimated that AF will be present in 2% of the general population, and in a far higher proportion of elderly patients2,NICE Clinical Guideline 36 costing

4、report. Available at: .uk/nicemedia/pdf/CG036costingreport.pdf. Accessed January 14, 2010 Stewart S, et al. Heart 2004; 90: 28692; 3. Savelieva I, et al. Europace 2008; 10: 64765,Other points about AF,Can be symptomatic or asymptomatic If asymptomatic then how do you pick it up?,Co

5、re message,Atrial fibrillation is common and getting commoner,AF and stroke,Wolf et al. Stroke 1991; 22: 983-988,One sixth of all strokes are attributable to AF,AF is an Independent Risk Factor for Stroke,AF patients have nearly a fivefold increased risk of stroke compared with patients without AF1,

6、1. Wolf PA, et al. Stroke 1991; 22: 9838,5059,6069,7079,8089,4,3,2,1,0,5,Age (years),4.0,2.6,3.3,4.5,Relative risk of stroke compared to patients without AF,p0.001 for all age groups,The Impact of AF on Stroke Outcomes,Survival is poorer and stroke recurrence rates are higher following AF-related st

7、roke,AF=atrial fibrillation; OR=odds ratio; CI=confidence interval 1. Lin HJ, et al. Stroke 1996; 27: 17604; 2. Dulli DA, et al. Neuroepidemiology 2003; 22: 11823,Framingham (10-year follow up from 1981),AF=atrial fibrillation; OR=odds ratio; CI=confidence interval Dulli DA, et al. Neuroepidemiology

8、 2003; 22: 11823,Patients bedridden on admission (%),p0.0005,40,30,20,10,0,50,41.2%,23.7%,With AF(n=194),Without AF(n=867),Functional outcomes of stroke are significantly worse in patients with AF, and more patients remain bedridden,OR for bedridden state following stroke due to AF was 2.23 (95% CI:

9、 1.87, 2.59),The Impact of AF on Stroke Outcomes,Core message,Atrial fibrillation causes stroke,Detecting AF,Detecting AF,Pulse ECG 24hr ECG Fancy kit,AF how can it be diagnosed?,ECG (preferably 12-lead) Still the cornerstone of AF diagnosis,Opportunistic screening,Taken up by 2 PBC Consortia this y

10、ear in Norfolk during flu vaccination IDEAL setting High risk patients Nurse vaccination Done to protocol GP paid! Evidence of effectivness N Essex screened 30000 in 6 weeks 361 patients newly diagnosed with AF,Protocol,Patients aged over 65 years, who have no record of AF, will have their pulse che

11、cked for at least 30 seconds to look for irregularity. If irregularity is identified, then they will be followed up with: resting 12-lead ECG blood tests for lipid profile, renal function, fasting glucose, full blood count, thyroid function body mass index urinalysis clinical assessment of cardiovas

12、cular system overall evaluation of cardiovascular risk Management options will include: warfarin (or antiplatelet agents if warfarin contraindicated) pulse rate control consideration of referral for cardioversion.,24 hr ECG (and longer),As AF can be paroxysmal then one off pulse or ECG may miss! 24

13、hr ECG may have a better pick up,Effectiveness of different rhythm detectors,Jabaudon D, Sztajzel J, Sievert K et al. Usefulness of ambulatory 7-day ECG monitoring for the detection of atrial fibrillation and flutter after acute stroke and transient ischemic attack. Stroke. 2004;35(7):16471651.,CARD

14、IST Trial,Patients with stroke or TIA No Hx AF 24 hr ECG, 7 day automated device, wrist watch device Comparing AF pick up rate,Core message,AF can be detected by a simple pulse check,Managing AF,Blood thinning Antiplatelets Anticoagulation Rhythm control Rate Stabalisation Operations,The CHADS2 Scor

15、ing System,CHADS2 is a points-based system for predicting risk of stroke in AF based on key risk factors1 Congestive heart failure 1 point Hypertension 1 point Age 75 years 1 point Diabetes mellitus 1 point Stroke or TIA 2 points,Aspirin,Stroke reduction of 19% (95% CI 2% to 34%),Warfarin,Risk reduction of 62% (95% CI 48% to 72%) versus placebo,RE-LY Trial (Dabigatran),Dabigatran Direct thrombin inhibitor NON MONITORED ANTICOAGULATION 18000 patients, compared to warfarin 150mg better than warfarin (RRR 34%),Rate / rhythm control,Beta blockers Amiodarone Flecainide Digoxin Etc. Ne