心房颤动治疗新循证医学证据-英文

1、心房颤动治疗新循证医学证据英文Prevalence of AF is increasingAdults with AFib (millions)Year2.082.262.442.662.943.333.804.784.345.165.425.61%363753YearProportion Aged 80 YrGo: JAMA, 2001：2370Miyasaka.Circulation.2006:119Year2.04.06.08.010.012.014.016.020002005201020152020202520302035204020452050Adults with AFib (mi

2、llions)5.110.28.412.115.9Prevalence of AF is increasingPrevalence %AgePrevalence of AF:the Rotterdam studyHeerinaga.Eur Heart J,2006,9496808 pts., F/U 6.9 yrs，prevalence 5.5%Incidence AgeIncidence of AF:the Rotterdam studyHeerinaga.Eur Heart J,2006,9496808 pts., F/U 6.9 yrs，Incidence 9.9Identified A

3、F：the tip of the iceberg14802 pts aged 65 or over，randomized to systemic screening and opportunistic screening Systemic screening group:9866 pts. Opportunistic screening group: 4936 pts.F/U 12 mons Rate of new AF case in systemic screening 1.63%， Rate of new AF case in opportunistic screening 1.04%F

4、itzmaurice.BMJ.2007,383Risk for stroke increased in lone AFJahangir. Circulation. 2007:3050Meta-analysis:antithrombotic therapy of AFHart.Ann Intern Med,2007,857trialptsRR reduced(%)Warfarin vs Placebo6290064ASA vs Placebo8487622Warfarin vs ASA121296339Real world of warfarin in the elderly13.1%4.7%T

5、he first 90 days associated with major hemorrhage21% pts withdrawn warfarin for safety issueThe higher risk of stroke, the higher incidence of major hemorrhageHylek. Circulation.2007,2689 HR for ICH was 4.06 for AsiansAsians were at greater risk for warfarin-ralated ICHShen. JACC.2007:309 Prospectiv

6、e，randomize，control973 pts 75 years old with AFRandomized into warfarin arm (INR 2.0-3.0) and Aspirin arm(75mg/d)Mean F/U 2.7 yrsPrimary outcome：fatal or disabling stroke, intracranial haemorrhage, or arterial embolismWarfarin versus aspirin for stroke prevention in the elderly with AF(The Birmingha

7、m Atrial Fibrillation Treatment of the Aged Study,BAFTA study)Mant.Lancet,2007,4930.831.155(0.4%)6(0.5%) haemorrhagic0.651.921(0.1%)2(0.2%)Other ICH0.360.323(0.2%)1(0.1%)Embolism48(3.8%)7(0.5%)32(2.5%)23(1.8%)21(1.6%)44(3.4%)0.0050.338(0.6%) disabling nonfatal0.00270.4824(1.8%)Total0.530.695(0.4%) u

8、nknown0.00040.3010(0.8%) ischemic0.140.5913(1.0%) fatal0.0030.4621(1.6%)StrokepEventwarfarin(n=488)ASA(n=488)N(Risk peryear)N(Risk peryear)warfarinVS.ASARRWarfarin versus aspirin for stroke prevention in the elderly with AFMant.Lancet,2007,493Mant.Lancet,2007,493Warfarin versus aspirin for stroke pr

9、evention in the elderly with AFAnticoagulation in clinical practice2.03/100person-yrs1.17/100person-yrs11,526 pts with AF,54.8% was on warfarinRelative risk for thromb -embolism reduced 51% in warfarin therapyThe intracranial hemorrhage rate increased in warfarin(0.46/100 person-yrs VS 0.23/100 pers

10、on-yrs）Warfarin was not associated with nonintracranial hemorrhage (1.05/100 person-yrs VS 1.06/100 person-yrs）Go.JAMA 2003:2685RivaroxabanEnoxaparin873 ptsEndpoints included DVT,PE,all cause mortality Safety：major hemorrhageEndpointsSafetyEriksson. Circulation. 2006: 2374%Rivaroxaban New promise of

11、 anticoagulation？Prospective RIKS-HIA60764 pts，AF 21459 pts,CHF 22345 pts,AF+CHF16960 ptsF/U 1 yrHigher mortality rate in AF without CHF pts taking digoxin (RR1.42)Similar mortality rate in CHF or AF+CHF pts with or without digoxin Digoxin and mortality in AF:A prospective cohort studyHallberg.Euro

12、J Clin Pharmacol,2007,959Hallberg.Euro J Clin Pharmacol,2007,959Digoxin and mortality in AF:A prospective cohort studyAdverse effects of oral amiodaroneZimetbaum.NEJM.2007:935Bradycardia5%Prolonged QT In mostTdp1%Hepatic15%Hyperthyroidism3%Hypothyroidism20%Pulmonary3%Dermatology25-75%Neurologic3-30%

13、Corneal deposits100%Optic neuritis AAD:4%Catheter ablation decrease the incidence of stroke755 ptsThe incidence of stroke/TIA was 1.1%0.9% occurred whithin 2 weeks of RFCA79% of pts without risk factor for stroke and 68% of pts with 1 risk factor in sinus discontinued warfarinPatients with sinus rhy

14、thm was thromboembolic event free after the procedureOral.Circulation.2006:759Pappone . JACC.2003:185N=589N=582Catheter ablation reduce strokePappone . JACC.2003:185Catheter ablation improve prognosisNo risk factor： ASA 81- 325mg One moderate risk factor：ASA 81- 325mg or warfarinAny high risk factor

15、 or more than one moderate risk factor: warfarinPrinciples of anticoagulationAmiodaroneAblation ！No OHD yesHTN yes（concomitanc with LVH amiodaroneablation ）CAD yesHF amiodaroneablation Maintain Sinus RhythmCatheter ablation is a reasonablealternative topharmacological therapy to prevent recurrentAF

16、(IIa,C)Fuster. Circulation.2006 :e257 Indications for catheter ablationThe presence of symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medicationin rare clinical situations, it may be appropriate to perform catheter ablation of AF as first line therapyselected symptomatic patients with heart failure and/or reduced ejection fractionLA thrombus is a contraindicationHRS/EHRA/ECAS Expert Consensus StatementAF Ablation as first-line therapy?(Catheter Ablation vs. Antiarrhythmic Drug Therapyfor Atrial Fibr