心瓣膜病合并房颤与心衰处理办法原则.ppt

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.JAMGeriatirsoc,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,Theincidenceandetiologicalclassificationofvalvulardiseaseswereexaminedon358casesfrom3,000consecutiveautopsiesofmorethan60yearsofage.Theincidenceofvalvulardiseasewas11.9%(358outof3,000cases)JpnCircJ.1982Apr;46(4):337-45,Mitralstenosiswasfoundin23cases(6.4%),ofwhich21caseswererheumaticandtheremaining2weremitralringcalcification(MRC).Mitralregurgitationwasobservedin126cases(35.3%):69ofpapillarymuscledysfunction,26ofmitralvalveprolapse(MVP),16ofMRC,9ofrupturedchordaetendineae,3ofrheumaticand3ofcongenital.JpnCircJ.1982Apr;46(4):337-45,Aorticstenosiswasnotedin33cases(9.2%):27ofcalcified,5ofrheumaticandoneofcongenital.Aorticregurgitationwasfoundin169cases(47.2%):112ofdegenerative,47ofsyphilitic,7ofrheumaticand2ofaortitissyndrome.Therewere6cases(1.7%)oftricuspidregurgitation.JpnCircJ.1982Apr;46(4):337-45,Etiologicalclassificationrevealed6cases(1.7%)ofcongenital,36(10%)ofrheumatic,49(13.7%)ofsyphilitic,27(7.5%)ofMVP,69(19.3%)ofischemicand166(46.4%)ofdegenerativevalvulardisease.JpnCircJ.1982Apr;46(4):337-45,Atotalof458cases(11.5%)withvalvularheartdiseasesintheaged(greaterthanorequalto60years)werefoundamong4,000consecutiveautopsies.Theyincluded204cases(45%)ofaorticregurgitation(AR),171cases(37%)ofmitralregurgitation(MR),followedby45(10%)ofaorticstenosis(AS)and27cases(6%)ofmitralstenosis(MS).JCardiolSuppl.1988;19:29-38.,anetiologyofthevalvulardiseases,degenerativetypewasfoundin195cases(43%),ischemicoriginin91cases(20%),followedbyinflammatoryoriginsuchassyphiliticin51andinfectiveendocarditisinthree,aortitisintwoandrheumaticin49(11%).Congenitaloriginwasalsofoundin18cases(4%).JCardiolSuppl.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1227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,ANovelRoleoftheSympatho-AdrenergicSysteminRegulatingValveCalcification,Recentevidencehasindicatedthatthesympatheticnervoussystemplaysanimportantroleinregulatingbonedepositionandresorptionthebeta2-adrenergicreceptors(2-AR).Inordertotesttheeffect2-ARonchangingthehumanvalvelCstowardsosteogenicphenotypecellsweretreatedwiththeselectlve2-ARagonist,salmeterol,inthepresenceandabsenceofosteogenicmediafor21days.,Supplementcirculationvol114,no18october31,2006,SalmeteroltereatmentinthepresenceofosteogenicmediasignificantlyreducedtheALPactivityfrom10.22.9nmol/min/mgproteiyintheosteogenictreatedcellc,to4.71.9nmol/min/mgprotein(p75years),themanagementofatrialfibrillationvaries;itrequiresanindividualapproach,whichlargelydependsoncomorbidconditions,underlyingcardiacdisease,andpatientandphysicianpreferences.DrugsAging.2002;19(11):819-46,Anotherseriouschallengeinthemanagementofchronicatrialfibrillationinolderindividualsisthepreventionofstroke,itsprimaryoutcome,bychoosinganappropriateantithrombotictreatment(aspirinorwarfarin).Severalrisk-stratificationschemeshavebeenvalidatedandmaybehelpfultodeterminethebestantithromboticchoiceinindividualpatientsDrugsAging.2002;19(11):819-46,关于抗血栓治疗,(瓣膜病)antithrombotictherapyinnativeandprostheticvalvularheartdiseaseispartoftheSeventhACCPConferenceonAntithromboticandThrombolyticTherapy:EvidenceBasedGuidelines.Grade1recommendationsarestrongandindicatethatthebenefitsdo,ordonot,outweighrisks,burden,andcosts.Grade2suggeststhatindividualpatientsvaluesmayleadtodifferentchoices(forafullunderstandingofthegradingseeGuyattetal,CHEST2004;126:179S-187S).,Amongthekeyrecommendationsinthischapterarethefollowing:Forpatientswithrheumaticmitralvalvediseaseandatrialfibrillation(AF),orahistoryofprevioussystemicembolism,werecommendlong-termoralanticoagulant(OAC)therapy(targetinternationalnormalizedratioINR,2.5;range,2.0to3.0)Grade1C+.ForpatientswithrheumaticmitralvalvediseasewithAForahistoryofsystemicembolismwhosuffersystemicembolismwhilereceivingOACsatatherapeuticINR,werecommendaddingaspirin,75to100mg/d(Grade1C).Forthosepatientsunabletotakeaspirin,werecommendaddingdipyridamole,400mg/d,orclopidogrel(Grade1C).,CHEST2004;126:179S-187S).,Inpeoplewithmitralvalveprolapse(MVP)withouthistoryofsystemicembolism,unexplainedtransientischemicattacks(TIAs),orAF,werecommendedagainstanyantithrombotictherapy(Grade1C).InpatientswithMVPanddocumentedbutunexplainedTIAs,werecommendlong-termaspirintherapy,50to162mg/d(Grade1A).,CHEST2004;126:179S-187S,(房颤)Thischapteraboutantithrombotictherapyinatrialfibrillation(AF)ispartoftheSeventhACCPConferenceonAntithromboticandThrombolyticTherapy:EvidenceBasedGuidelines.Grade1recommendationsarestrongandindicatethatthebenefitsdo,ordonot,outweighrisks,burden,andcosts.Grade2suggeststhatindividualpatientsvaluesmayleadtodifferentchoices(forafullunderstandingofthegradingseeGuyattetal,CHEST2004;126:179S-187S).,Amongthekeyrecommendationsinthischapterarethefollowing(allvitaminKantagonistVKArecommendationshaveatargetinternationalnormalizedratioINRof2.5;range,2.0to3.0):InpatientswithpersistentorparoxysmalAF(PAF)intermittentAFathighriskofstroke(ie,havinganyofthefollowingfeatures:priorischemicstroke,transientischemicattack,orsystemicembolism,age75years,moderatelyorseverelyimpairedleftventricularsystolicfunctionand/orcongestiveheartfailure,historyofhypertension,ordiabetesmellitus),werecommendanticoagulationwithanoralVKA,suchaswarfarin(Grade1A).,InpatientswithpersistentAForPAF,age65to75years,intheabsenceofotherriskfactors,werecommendantithrombotictherapywitheitheranoralVKAoraspirin,325mg/d,inthisgroupofpatientswhoareatintermediateriskofstroke(Grade1A).InpatientswithpersistentAForPAF60%,左室收缩末径4.5cm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3173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)Vol14No122006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NYHA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)Vol14No122006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(P0.05)。对心功能的控制与维持有良好作用,A组心功能12级者75例(80.6%),B组心功能