新发房颤的急诊处理.ppt

新发房颤的急诊处理,房颤分类,初发房颤 阵发性房颤 持续性房颤 持久性房颤 慢性房颤 除此之外，因脑血栓或其他原因住院而发现房颤，患者无明显症状的房颤定义为沉默性房颤。,AF发病率,Framingham研究表明，在50岁60岁、60岁70岁及70岁80岁人群中房颤发病率分别为0.7%、3.5%和6.6%，而在80岁人群中发病率高达 16.3%。同时，男性发病率远高于女性，7080岁男性发病率为9.1%，为该年龄组女性的2倍；80岁男性发病率高达21.9%，而女性为 12.5%。,P A Wolf, et. al, Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.,房颤，脑部的潜在威胁,Compared with subjects free of these conditions, the age-adjusted incidence of stroke was more than doubled in the presence of coronary heart disease (p less than 0.001) and more than trebled in the presence of hypertension (p less than 0.001). There was a more than fourfold excess of stroke in subjects with cardiac failure (p less than 0.001) and a near fivefold excess when atrial fibrillation was present (p less than 0.001). In persons with coronary heart disease or cardiac failure, atrial fibrillation doubled the stroke risk in men and trebled the risk in women. With increasing age the effects of hypertension, coronary heart disease, and cardiac failure on the risk of stroke became progressively weaker (p less than 0.05). Advancing age, however, did not reduce the significant impact of atrial fibrillation. For persons aged 80-89 years, atrial fibrillation was the sole cardiovascular condition to exert an independent effect on stroke incidence (p less than 0.001). The attributable risk of stroke for all cardiovascular contributors decreased with age except for atrial fibrillation, for which the attributable risk increased significantly (p less than 0.01), rising from 1.5% for those aged 50-59 years to 23.5% for those aged 80-89 years. While these findings highlight the impact of each cardiovascular condition on the risk of stroke, the data suggest that the elderly are particularly vulnerable to stroke when atrial fibrillation is present.(ABSTRACT TRUNCATED AT 250 WORDS),1/3未曾接受治疗的AF病人会出现脑卒中 AF患者出现脑卒中的风险是无AF患者的4倍 伴随心衰或者冠心病患者中，AF使男性发生脑卒中的风险增加1倍，使女性发生脑卒中的风险增加2倍。 AF是唯一随年龄递增的脑卒中特特异心血管危险性因素。,急性脑栓塞,心源性占60-70% 起病急骤，以秒计； 既往有各种类型的心脏病、心房纤颤、心肌病、心肌梗死等病史，需注意特发性房颤造成脑栓塞占2.7；昏迷约占33，抽搐高达 25，偏瘫常较完全； 有时可发现其他内脏或肢体的栓塞； 脑脊液检查压力正常或略高，常规检查可能有红细胞，说明有栓塞性出血的可能性； 头颅CT扫 描检查和脑血栓形成相仿，但有时脑水肿较明显；有时在低密度区中有高密度灶存在，说明有栓塞性出血；有时可见多个低密度区，说明有多发性脑栓塞。,AF合并脑卒中患者预后,Saposnik G, et,al, Atrial Fibrillation in Ischemic Stroke: Predicting Response to Thrombolysis and Clinical Outcomes.Stroke. 2012 Nov 20.,Among 12 686 patients with an acute ischemic stroke, 2185 (17.2%) had AF. Overall, AF patients had higher risk of death at 30 days (22.3% versus 10.2%; P0.0001), 1 year (37.1% versus 19.5%; P0.0001) and death or disability at discharge (69.7% versus 54.7%; P0.0001) compared with non-AF patients. After adjustment, thrombolysis was associated with a favorable outcome for patients without AF (relative risk, 1.18; 95% CI, 1.10-1.27), but no benefit was observed for patients with AF (relative risk, 0.91; 95% CI, 0.71-1.17). There was a modestly increased risk of intracranial hemorrhage (any type) (16.5% versus 11.6%; relative risk, 1.42; 95% CI, 1.05-1.91) after thrombolysis among AF compared with non-AF patients. In the logistic regression analysis, there was an interaction between tPA and iScore for a favorable outcome (P-value interaction 0.001). The interaction also was significant (P0.0012) among patients without AF, but did not reach significance (P=0.17) in patients with AF.,在缺血性脑卒中患者，17.2%有AF病史 在脑卒中患者中，对比于无AF的病人，AF患者发病一月，一年内死亡率更高。 在脑卒中患者中，对比于无AF的病人，伴有AF的患者致残率更高。 在脑卒中患者中，由于改善了溶栓治疗，可以使无合并AF患者相关风险减低，但是这对合并AF的患者并没有明显改善。在溶栓治疗后，合并AF的患者出现颅内出血的风险较其他患者升高。,“低危”患者并不真正低危,在使用20年后，ChADS2 的限制性日益受到重视。 某些脑卒中高危因素并未曾纳入到ChADS2评分中。 很多被认为是低危的人群（ ChADS2 =0）患者，发生脑卒中的危险为1.5%/年。因此， ChADS2 =0的“低危”患者并不真正低危。 Gage BF, et al, Validation of clinical classification schemes for predicting stroke: results from theNational Registry of Atrial Fibrillation. JAMA. 2001 Jun 13;285(22):2864-70.,血管病作为一个独立脑卒中影响因子，在旧的ChADS2 中并没有体现。 AF患者发生中风的概率会在65岁之后会增高，在75岁之后，出现中风的风险甚至会更高，但在CHADS2中，没有体现年龄分级。,Olesen JB et al,Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011 Jan 31;342:d124. doi: 10.1136/bmj.d124.,关于女性作为新的脑卒中危险因素的几点说明,有研究表明女性作为一个独立高危因素 但有其他的证据表明若 “年龄少于65，并且没有其他并发症”，则女性不作为一个独立的危险因素。 同时，在满足“年龄少于65，并且没有其他并发症”这个标准的人群中，无论其性别的如何，脑卒中的发生率都很低，因此，不推荐在这类人群中使用抗血栓治疗（即使她们的CHA2DS2-VAS 评分为“1”）,由于CHA2DS2-VASc评分较CHADS2评分纳入血管疾病，年龄（大于65）以及女性等风险因素，更加精细地评估房颤患者中风的风险。 CHA2DS2-VASc评分更加精细，能够辨别那些“真正低风险（truly low-risk）”的患者，避免过度治疗。 由于纳入更多的风险评估因素，在辨别“真正低风险”同时，对于那些“假低风险”的人群， CHA2DS2-VASc能够识别并且提供使用抗血栓治疗的依据。,房颤的治疗,对于阿司匹林，指南提出其在防止脑卒中的地位下降。 Olesen JB在跟踪对比研究132,372例房颤分别使用VKA,阿司匹林以及没有使用抗栓治疗患者的CHADS, CHADS-VASc, and HAS-BLED评分后，得出数据：,Olesen JB, Lip GY, Lindhardsen et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: A net clinical benefit analysis using a real world nationwide cohort study. Thromb Haemost. 2011 Oct;106(4):739-49.,It was the aim of this study to determine the efficacy and safety of vitamin K antagonists (VKAs) and acetylsalicylic acid (ASA) in patients with non-valvular atrial fibrillation (AF), with separate analyses according to predicted thromboembolic and bleeding risk. By individual level-linkage of nationwide registries, we identified all patients discharged with non-valvular AF in Denmark (n=132,372). For every patient, the risk of stroke and bleeding was calculated by CHADS, CHADS-VASc, and HAS-BLED. During follow-up, treatment with VKA and ASA was determined time-dependently. VKA consistently lowered the risk of thromboembolism compared to ASA and no treatment; the combination of VKA+ASA did not yield any additional benefit. In patients at high thromboembolic risk, hazard ratios (95% confidence interval) for thromboembolism were: 1.81 (1.73-1.90), 1.14 (1.06-1.23), and 1.86 (1.78-1.95) for ASA, VKA+ASA, and no treatment, respectively, compared to VKA. The risk of bleeding was increased with VKA, ASA, and VKA+ASA compared to no treatment, the hazard ratios were: 1.0 (VKA; reference), 0.93 (ASA; 0.89-0.97), 1.64 (VKA+ASA; 1.55-1.74), and 0.84 (no treatment; 0.81-0.88), respectively. There was a neutral or positive net clinical benefit (ischaemic stroke vs. intracranial haemorrhage) with VKA alone in patients with a CHADS score of 0, and CHADS-VASc score of 1. This large cohort study confirms the efficacy of VKA and no effect of ASA treatment on the risk of stroke/thromboembolism. Also, the risk of bleeding was increased with both VKA and ASA treatment, but the net clinical benefit was clearly positive, in favour of VKA in patients with increased risk of stroke/thromboembolism.,阿司匹林预防房颤所致卒中的作用有限，并且有潜在危害，尤其在老年患者，其对降低出血的发生率于OAC没有差别。指南仅将抗血小板药物（ASA、氯吡格雷单用或联合）仅限于拒绝使用用口服抗凝药物的患者,新型口服抗凝药物,利伐沙班、阿哌沙斑班,达比他群酯,新型口服抗凝药物,RE-LY，ROCKET-AF，ARISTOTLE等多项双盲临床研究（IA类证据）已表明利伐沙班、阿哌沙斑、达比他群酯等NOACs预防卒中的作用不劣于华法林，且更安全、耐受性较好，颅内出血风险更低。基于此，指南提高了NOACs预防卒中的推荐级别，与华法林相同。,指南指出，非瓣膜性房颤预防血栓栓塞建议：,对于CHA2DS2-VAS=0(例如年龄少于65随孤立的房颤患者)，没有危险因素的低风险患者，不建议使用抗血栓治疗。 对于CHA2DS2-VAS2的患者，若无禁忌症，推荐剂量调整的VKA或者新型口服抗凝药； 对于CHA2DS2-VAS=1的患者，基于出血并发症的风险评估和患者的议员，科考虑给予VKA或新型口服抗凝药。 年龄少于65随地女性孤立房颤患者，（即使CHA2DS2-VAS=1），属于低风险患者，不考虑抗血栓治疗。 当房颤患者不能监测INR，或使用VKA不能使INR在目标值时，推荐使用一种新型口服抗凝药。,维拉卡兰（Vernakalant）,维卡纳兰是一种III型抗心律失常药物，主要作用于心房钾离子快速外流通道（Ito）。 Ito作用于1相心肌复极化过程。延长心房不应期，阻滞速率依赖性的离子通道，延长心房传导,维拉卡兰（Vernakalant）,Camm AJ的一项RCT试验提出，通过研究254例成人在房颤发作3-48小时内使用比维拉卡兰与胺碘酮进行复律。维拉卡兰的90分钟内转复窦率成功率为51.7%，而胺碘酮只有5.2%,提示维拉卡兰要优于胺碘酮。 另外一项Meta分析指出使用维拉卡兰90min内转窦成功率是胺碘酮的8倍，同时未见明显的不良反应。 在有器质性心脏病患者中，维拉卡兰的作用有保留 在持续时间大于7天的房颤治疗中，维拉卡兰不能使其有效转窦,维拉卡兰的安全性,主要不良反应为：味觉改变、打喷嚏、感觉异常、恶心，与安慰剂相比，发生率相近（4.1%vs3.9%），通常在5-10min内缓解。 对于心衰患者，可能引发低血压。 可致心动过缓，通常不需要药物处理。 虽然可致QT间期延长20-25ms，但未见药物相关Tdp。,维拉卡兰适应征：,对于房颤持续7天并存在中等程度结构性心脏病的患者（不伴有收缩压100mmHg，30天内的ACS，NYHA心功能III-IV级或主动脉重度狭窄等）可以考虑静脉使用维拉卡兰，慎用于NYHA心功能I-II级的房颤患者,急性房颤的处理,房颤患者若能复律并长期维持窦性心律，是最理想的治疗结果。急性心房颤动（房颤）患者的早期治疗的益处有消除症状、改善血流动力学、减少血栓栓塞性事件和消除或减轻心房电重构。故症状严重的房颤患者应尽早决定给予转复窦性心律或控制心室率的治疗。,控制心室率,快速心室率和心律不齐易导致房颤患者出现严重的血流动力学紊乱和临床症状。快速心室率的房颤患者通常需要积极控制心室率。 急性房颤发作时，可给予，心室率控制的靶目标为80100次/分。 对于合并严重左心功能不全的房颤患者，应给予胺碘酮治疗。 常用药物为beta-受体阻滞剂以及非二氢吡啶类CCB。,药物复律,对于室率控制充分仍有症状的房颤患者，可考虑转复窦性心律治疗。新近发生的房颤用药物转复为窦性心律的成功率可达70% 以上，但持续时间较长的房颤复律成功率较低。 抗心律失常药物转复率虽然低于同步直流电复律，但是不需要镇静或麻醉，并且可以预防房颤的复发。,药物转复的建议,对于新发