从房颤指南看房颤实践 ---- 差距与方向
DESCRIPTION
从房颤指南看房颤实践 ---- 差距与方向. 北京大学人民医院 张海澄. 美国心律失常住院概况. Paroxysmal Supraventricular Tachycardia - 6%. Premature beats - 6%. Atrial Flutter - 4%. Atrial Fibrillation - 21%. Sick Sinus Syndrome - 9%. Conduction Abnormailites - 8%. Ventricular Fibrillation - 2%. Miscellaneous - 21%. - PowerPoint PPT PresentationTRANSCRIPT
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从房颤指南看房颤实践---- 差距与方向
北京大学人民医院张海澄
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美国心律失常住院概况
Atrial Fibrillation - 21%Atrial Fibrillation - 21%
VentricularFibrillation - 2%VentricularFibrillation - 2%
Ventricular Tachycardia - 10%Ventricular Tachycardia - 10%Miscellaneous - 21%Miscellaneous - 21%
ConductionAbnormailites - 8%
ConductionAbnormailites - 8%
Sick SinusSyndrome - 9%Sick SinusSyndrome - 9%
Premature beats - 6%Premature beats - 6%
ParoxysmalSupraventricularTachycardia - 6%
ParoxysmalSupraventricularTachycardia - 6%
Atrial Flutter - 4%Atrial Flutter - 4%
Adapted from Bialy et al.
Stroke rate is approximately 1-3% without anticoagulation
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0
5
10
15
20
25
30
35
50-59 60-69 70-79 80-89
非瓣膜性房颤非瓣膜性房颤
3000838-7
%%
房颤引起的卒中房颤引起的卒中
Stroke 22(18), 1991Stroke 22(18), 1991
• 美国每年美国每年 5050 万卒中万卒中• 约约 20%20% 发生于房颤患者发生于房颤患者
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Lloyd-Jones DM, et al. Circulation. 2010;121:e1-e170.
AHA: Heart Disease and Stroke StatisticsAHA: Heart Disease and Stroke Statistics2010 Update2010 Update
• By 2050, atrial fibrillation (AF) may affect By 2050, atrial fibrillation (AF) may affect 12 million Americans12 million Americans
• AF is a powerful risk factor for strokeAF is a powerful risk factor for stroke
AF independently raises risk 5-fold in AF independently raises risk 5-fold in all age groupsall age groups
• AF is responsible for AF is responsible for ≈ ≈ 15%-20% of all 15%-20% of all strokes strokes
• AF is also an independent risk factor for AF is also an independent risk factor for recurrencerecurrence and and severityseverity
• Severe strokes cost twice as much as Severe strokes cost twice as much as mild strokes, despite similar diagnostic mild strokes, despite similar diagnostic testingtesting
• Comorbidities like AF and ischemic heart Comorbidities like AF and ischemic heart disease predict higher costsdisease predict higher costs
Increase in 10-Year EstimatedRisk Due to AF
0
5
10
15
20
25
No AF With AFEs
tim
ate
d 1
0-y
ea
r s
tro
ke
ra
te (
%)
Men Women
Risk for 55-year-old adults who smoke, have diabetes, and have blood pressures of 138-148 mm Hg
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先抗栓 再评估抗栓治疗贯穿始终
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9
房颤的治疗原则
节律控制
治疗
目标
控制症状
减少住院
控制症状
心率控制
防治心动过速性心肌病
减少住院
抗栓防栓
防止血栓栓塞
减少出血风险
A B C
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10
房颤的治疗原则
控制症状
心率控制 节律控制
治疗
目标
控制症状
防治心动过速性心肌病
减少住院
减少住院
抗栓防栓
防止血栓栓塞
减少出血风险
C B A
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房颤抗凝与卒中风险房颤抗凝与卒中风险
Hart et al. Ann Intern Med. 1999;131:492-501.
WarfarinBetter
ControlBetter
AFASAK
SPAF
BAATAF
CAFA
SPINAF
EAFT
100% 50% 0 -50% -100%
Aggregate
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010203040506070
<55 55-64 65-74 75-84 85
非瓣膜性房颤患者华法林应用情况非瓣膜性房颤患者华法林应用情况
3000838-13
%%
Ann Int Med 131(12), 1999Ann Int Med 131(12), 1999
•在近在近 33 个月内无抗凝禁忌证的房颤患者仅个月内无抗凝禁忌证的房颤患者仅55%55% 应用华法林应用华法林
•其他研究:其他研究: 17%-50%17%-50%
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AFFECTS Registry: Warfarin Use in AF Patients Is Not AFFECTS Registry: Warfarin Use in AF Patients Is Not Yet in Line With Evidence-Based RecommendationsYet in Line With Evidence-Based Recommendations
Kowey PR, et al. Am J Cardiol. 2010;105:1130-1134.
100
80
60
40
20
00
n=2791
n=3832
n=2143
n=384
n=215
n=76
n=0≥ 2
n=280
CHADS2 score
Pat
ient
s as
sig
ned
rhyt
hm
cont
rol r
ecei
ving
war
farin
(%
)
100
80
60
40
20
00
n=1241
n=1822
n=1503
n=354
n=245
n=36
n=1≥ 2
n=213
CHADS2 score
Pat
ient
s as
sig
ned
rate
co
ntro
l rec
eivi
ng w
arfa
rin (
%)Rhythm Control Rate Control
Enrollment End of registry
Anticoagulant use was high among participating cardiologists, but still did not match guidelines and evidence-based recommendations for AF patients. The AFFECTS study did not report the reasons that physicians chose against providing anticoagulation.
AFFECTS: Atrial Fibrillation: Focus on Effective Clinical Treatment Strategies
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Anticoagulation Is Still Underutilized in AF Anticoagulation Is Still Underutilized in AF Patients With High Stroke RiskPatients With High Stroke Risk
Zimetbaum PJ, et al. Am J Med. 2010;123:446-453.
Warfarin use within 30 days of the first diagnosis assessed according to stroke risk, estimated by CHADS2 score
Low risk(n=34,338)
40.1%treated
Moderate risk(n=105,563)
43.5% treated
High risk(n=31,492)
42.1% treated60
40
30
20
10
0
50
Pat
ient
s re
ceiv
ing
wa
rfa
rin (
%)
0 1 2 3 4 5 6n=34,338 n=58,004 n=47,559 n=20,589 n=7711 n=2625 n=567
CHADS2 scoreTotal (n=171,393)
Newly diagnosed AF/flutter (n=51,907)
Pre-existing diagnosed AF/flutter (n=119,486)
17.1 万人
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中国不同危险的急诊房颤患者抗凝治疗情况
中国房颤CHADS2≥2 的患者仅有 19% 接受华法林抗凝
治疗
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0 20 40 60 80 100
3000838-14
%%
Bungard: Pharmacotherapy 20:1060, 2001Bungard: Pharmacotherapy 20:1060, 2001
Low INR <1.6Low INR <1.6
TherapeuticTherapeuticINR 2-3INR 2-3
High INR >3.2High INR >3.2
Efficacy Efficacy 4-fold 4-fold
非瓣膜性房颤患者华法林应用情况非瓣膜性房颤患者华法林应用情况
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INRINR 与颅内出血风险与颅内出血风险
1Fuster V, et al. Circulation 2006;114:e257-e354.2Oden A, et al. Thromb Res 2006;117:493-499.
20
15
10
5
1
1.0 4.0 5.0 6.0 7.02.0 3.0
INR
Od
ds
rati
o
脑栓塞颅内出血
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血栓栓塞风险评估血栓栓塞风险评估与出血风险评估与出血风险评估
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0
5
10
15
20
25
30
0 1 2 3 4 5 6
CHADS2 score
Adj
uste
d st
roke
rat
e (%
/yea
r)*
n=120 n=463 n=523 n=337 n=220 n=65 n=5
CHADSCHADS22 未抗栓患者的卒中风险未抗栓患者的卒中风险
• 非瓣膜性非瓣膜性 AFAF
• 年龄年龄 65-9565-95 岁岁• n = 1733n = 1733
1Fuster V, et al. Circulation. 2006;114:e257-e354.2Gage BF, et al. JAMA. 2001;285:2864-2870.
CHADSCHADS22 Risk Risk CriteriaCriteria ScoreScore
Prior stroke or Prior stroke or TIATIA 22
Age > 75 yearsAge > 75 years 11
HypertensionHypertension 11
Diabetes mellitusDiabetes mellitus 11
Heart failureHeart failure 11
CHADS: congestive heart failure (CHF), hypertension, age >75 years, diabetes, stroke
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CHACHA22DSDS22-VASc-VASc 评分 评分 危险因子危险因子 评分评分
CHF/CHF/ 左室心功能不全左室心功能不全 11高血压高血压 11年龄 年龄 >75>75 岁岁 22糖尿病糖尿病 11卒中卒中 /TIA//TIA/ 血栓血栓 -- 栓塞形成栓塞形成 22血管疾病血管疾病 11年龄在年龄在 65–7465–74 之间之间 11女性女性 11总计总计 99
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CHACHA22DSDS22-VAS-VAS 评分评分
• 评分≥评分≥ 22 :口服抗凝治疗,:口服抗凝治疗, INR 2.0~3.0INR 2.0~3.0
• 评分评分 =1=1 :口服抗凝或阿司匹林:口服抗凝或阿司匹林 75~325mg/75~325mg/ 日,但日,但更推荐口服抗凝治疗更推荐口服抗凝治疗
• 评分评分 =0=0 :阿司匹林:阿司匹林 75~325mg/75~325mg/ 日或不采取抗栓治日或不采取抗栓治疗,但更推荐不采取抗栓治疗 疗,但更推荐不采取抗栓治疗
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Outpatient Bleeding Risk Index: A Simple Index for Outpatient Bleeding Risk Index: A Simple Index for Bleeding Risk EvaluationBleeding Risk Evaluation
Airaksinen KE, et al. Am J Cardiol. 2010;106:175-179.
OBRI:• History of stroke• Age > 65 years• History of gastrointestinal bleeding• Presence of ≥ 1 comorbid condition
Recent myocardial infarctionRenal insufficiencySevere anemiaDiabetes
8
6
4
2
0
*Inc
iden
ce (
%)
Triple therapy
OACOAC + 1antiplatelet
OBRI Score0: low risk
1-2: moderate risk
3-4: high risk
*Incidence: number of major bleeding events during antithrombotic treatment per 100 months of treatment
OBRI: outpatient bleeding risk index
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房颤患者出血风险评估表房颤患者出血风险评估表(( HAS-BLEDHAS-BLED 评分法) 评分法)
首字母首字母 临床特点临床特点 得 分得 分HH 高血压高血压 11AA 肾或肝功能异常 肾或肝功能异常 (( 每项每项 11
分分 ))1 1 或 或 22
SS 卒中卒中 11BB 出血出血 11LL 不稳定的不稳定的 INRINR 值值 11EE 高龄高龄 (e.g. (e.g. 年龄 年龄 >65 >65 岁岁 )) 11DD 吸毒或饮酒史 吸毒或饮酒史 (( 每项每项 11 分分 )) 1 1 或 或 22
总计 总计 99
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对达比加群酯的特殊推荐对达比加群酯的特殊推荐
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New AnticoagulantsNew Anticoagulants
TFPI (tifacogin)
FondaparinuxIdraparinux
RivaroxabanApixabanLY517717YM150DU-176bBetrixabanTAK 442
Dabigatran
ORAL PARENTERAL
DX-9065a
Xa
IIa
TF/VIIa
X IX
IXaVIIIa
Va
II
FibrinFibrinogen
AT
APC (drotrecogin alfa)sTM (ART-123)
Adapted from Weitz & Bates, J Thromb Haemost 2007
TTP889
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RE-LY: 试验设计试验设计
Ezekowitz MD et al. Am Heart J 2009;157:805–10; Connolly SJ et al. N Engl J Med 2009;361:1139–51
主要目的:脑卒中和体循环栓塞的发生率非劣效于华法林主要目的:脑卒中和体循环栓塞的发生率非劣效于华法林 随访期最少为随访期最少为 11 年,最多为年,最多为 33 年,平均为年,平均为 22 年年
伴有中度至高度卒中或全身性栓塞风险的非瓣膜性房颤 ( 至少伴有一项额外的风险因素 )*
R
达比加群酯110 mg BID
n=6000
华法林1 mg, 3 mg, 5 mg
(INR 2.0–3.0)n=6000
达比加群酯150 mg BID
n=6000
*Severe heart-valve disorder, stroke ≤14 days or severe stroke ≤6 months before screening, increased haemorrhage risk, creatinine clearance <30 mL/min, active liver disease, pregnancy; BID = twice daily; INR = international normalized ratio
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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RE-LY 主要终点:卒中或全身性栓塞发生率
RR 0.65 (95% CI: 0.52–0.81)
卒中
/全身
性栓
塞
(%/年
)
事件数量 : 183/6015 134/6076 202/6022
达比加群110 mg BID
达比加群150 mg BID
华法林0.0
0.3
0.6
0.9
1.2
1.5
1.8
1.54
1.11
1.71
P<0.001 (Sup)
P<0.001 (NI)
RR 0.90 (95% CI: 0.74–1.10)
Connolly SJ et al. N Engl J Med 2010;363:1875–6
BID = 每日两次 ; NI = 非劣效性 ; RR = 相对危险度 ; RRR = 相对危险降幅 ; Sup = 优效性
35%
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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RE-LY 主要终点:卒中或全身性栓塞发生率
BID = 每日两次 ; NI = 非劣效性 ; RR = 相对危险度 ; RRR = 相对危险降幅 ; Sup = 优效性
华法林达比加群 110 mg BID
达比加群 150 mg BID
RR 0.90(95% CI: 0.74–1.10)P<0.001 (NI)P=0.30 (Sup)
RR 0.65(95% CI: 0.52–0.81)P<0.001 (NI)P<0.001 (Sup)
Connolly SJ et al. N Engl J Med 2010;363:1875–6
RRR 35%
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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出血性卒中发生率
Connolly SJ et al. N Engl J Med 2009;361:1139–51; Connolly SJ et al. N Engl J Med 2010;363:1875–6
BID = 每日两次 ; RR = 相对危险度 ; RRR = 相对危险降幅 ; Sup = 有效性
出血
性卒
中
(事
件数
量)
n: 6015 6076 6022
达比加群110 mg BID
达比加群150 mg BID
华法林0
10
20
30
40
50
14
0.12%12
0.10%
45
0.38%
RR 0.31 (95% CI: 0.17–0.56)
P<0.001 (Sup)RR 0.26 (95% CI: 0.14–0.49)
P<0.001 (Sup)
69%74%
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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大出血发生率
BID = 每日两次 ; RR = 相对危险度 ; RRR = 相对危险降幅 ; Sup = 优效性
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
大出
血
(%/年
)
达比加群110 mg BID
达比加群150 mg BID
华法林
事件 / 数量 342/6015 399/6076 421/6022
RR 0.80 (95% CI: 0.70–0.93)
P=0.003 (Sup) RR 0.93 (95% CI: 0.81–1.07)
P=0.32 (Sup)
2.87
3.323.57
Connolly SJ et al. N Engl J Med 2010;363:1875–6
20%
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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危及生命的出血发生率
BID = 每日两次 ; RR = 相对危险度 ; RRR = 相对危险降幅 ; Sup = 优效性
1.24
1.49
1.85
事件 / 数量 : 147/6015 179/6076 218/6022
达比加群110 mg BID
达比加群150 mg BID
华法林0.0
0.5
2.0
危及
生命
的出
血(%
/年)
1.5
1.0
RR 0.67 (95% CI: 0.54–0.82)
P<0.001 (Sup)RR 0.80 (95% CI: 0.66–0.98)
P=0.03 (Sup)
RRR20%
Connolly SJ et al. N Engl J Med 2010;363:1875–6
33%
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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颅内出血发生率
事件 / 数量 : 27/6015 38/6076 90/6022
达比加群110 mg BID
达比加群150 mg BID
华法林0
0.6
0.9
颅内
出血
(%/年
)
0.8
0.7
0.5
0.4
0.3
0.2
0.10.23
0.32
0.76
RR 0.30 (95% CI: 0.19–0.45)
P<0.001 (Sup)RR 0.41 (95% CI: 0.28–0.60)
P<0.001 (Sup)
Connolly SJ et al. N Engl J Med 2010;363:1875–6
BID = 每日两次 ; RR = 相对危险度 ; RRR = 相对危险降幅 ; Sup = 优效性
70% 59%
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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总体出血事件
14.7416.56
18.37
事件 / 数量 : 1754/6015 1993/6076 2166/6022
达比加群110 mg BID
达比加群150 mg BID
华法林0
10
25
总体
出血
事件
(%
/年) 20
15
5
RR 0.78 (95% CI: 0.73–0.83)
P<0.001 (Sup) RR 0.91 (95% CI: 0.85–0.96)
P=0.002 (Sup)
Connolly SJ et al. N Engl J Med 2010;363:1875–6
BID = 每日两次 ; RR = 相对危险度 ; RRR = 相对危险降幅 ; Sup = 优效性
22%
Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke prevention for patients with atrial fibrillation in China
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Stroke or Systemic EmbolismStroke or Systemic Embolism
0.50 0.75 1.00 1.25 1.50
Dabigatran 110 vs. Warfarin
Dabigatran 150 vs. Warfarin
Non-inferiorityp-value
<0.001
<0.001
Superiorityp-value
0.34
<0.001
Margin = 1.46
HR (95% CI)Warfarin betterDabigatran better
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达比加群酯与华法林的比较达比加群酯与华法林的比较
达比加群酯 华法林
类型 直接凝血酶抑制剂 维生素 K 拮抗剂
起效 快 (2 小时内达峰 ) 较慢 ( 达峰时间个体差异大 )
INR 监测 不需要 需要,治疗窗窄 (INR2-3)
药物 - 药物相互作用
很少 常见
药物 - 食物相互作用
无 常见
剂量调整 不需要 需要
遗传代谢性 无明显影响 有Dabigatran etexilate is in clinical development and not licensed for clinical use in stroke
prevention for patients with atrial fibrillation in China
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对无人工心脏瓣膜、无血流动力学改变瓣膜病、无严重肝肾(肌酐清除率对无人工心脏瓣膜、无血流动力学改变瓣膜病、无严重肝肾(肌酐清除率
<15ml/min)<15ml/min) 损害的阵发性、持续性、永久性房颤及伴有卒中和体循环损害的阵发性、持续性、永久性房颤及伴有卒中和体循环
栓塞风险的患者,达比加群可替代华法林用来预防卒中和体循环栓塞。 栓塞风险的患者,达比加群可替代华法林用来预防卒中和体循环栓塞。
( ( II 类推荐,类推荐, BB 级证据)级证据)
2011 年 ACCF/AHA/HRS 房颤指南更新
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WATCHMAN LAA Closure Device in situWATCHMAN LAA Closure Device in situ
3000838-18
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持续时间持续时间 <48<48 小时房颤小时房颤转复前也需抗栓转复前也需抗栓
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心室率控制:严格 心室率控制:严格 vs vs 宽松宽松
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RACE IIRACE II
持久性房颤持久性房颤 614614 例,随机入组例,随机入组– 宽松控制组 宽松控制组 (( 静息静息 HR <110bpm) HR <110bpm)
– 严格控制组 严格控制组 (( 静息静息 HR <80 bpmHR <80 bpm ;中等运动 ;中等运动 <110 bpm) <110 bpm)
一级终点:心血管死亡、心衰住院、卒中、一级终点:心血管死亡、心衰住院、卒中、
动脉栓塞、出血、致命性心律失常事件动脉栓塞、出血、致命性心律失常事件
随访随访 2~32~3 年年
Van Gelder, et.al, for the RACE II Investigators NEJM April 15, 2010, No. 15, Vol 362: 1363-1373
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RACE IIRACE II
Van Gelder, et.al, for the RACE II Investigators NEJM April 15, 2010, No. 15, Vol 362: 1363-1373
0
2
4
6
8
10
12
14
16
一级终点
宽松组严格组
12.9%14.9%
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RACE IIRACE II
Van Gelder, et.al, for the RACE II Investigators NEJM April 15, 2010, No. 15, Vol 362: 1363-1373
0
20
40
60
80
100
HR达标率
宽松组严格组
97.7%
67%
P<0.001
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RACE IIRACE II
Van Gelder, et.al, for the RACE II Investigators NEJM April 15, 2010, No. 15, Vol 362: 1363-1373
0
100
200
300
400
500
600
700
总访视率
宽松组严格组
75
684P<0.001
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老年、症状轻微:首选心率控制
反复发作 AF :心率控制贯穿节律控制始终
症状性房颤( EHRA≥ 2 ):心率控制满意仍推荐节律控制
房颤心衰:节律控制以改善症状
年轻症状性 AF :消融前先尝试节律控制
继发性 AF :在缺血、甲亢纠正后节律控制
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无预激:静脉 β阻滞剂或钙拮抗剂(注意低血压与心衰)
低血压与心衰:洋地黄、胺碘酮
预激伴 AF : I类 AAD 、胺碘酮
预激伴 AF :洋地黄、 β阻滞剂、钙拮抗剂、 ATP
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阵发性、持续性、持久性:药物心率控制,个体化,防止心动过缓
活动相关症状:运动评估疗效生理变时反应、防止心动过缓
预激伴 AF :普罗帕酮、胺碘酮
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宽松心率控制: RHR<100bpm
严格心率控制: RHR<80bpm ,中等运动<110bpm 。宽松控制后症状持续或心动过速心肌病。应用 Holter 评估
Dronedarone 可用于非持久性 AF 的心率控制(除外 NYHA III-IV 或不稳定心衰)
地高辛可用于心衰或活动少的患者
其他药物无效或禁忌时可应用口服胺碘酮
阵发性 AF 不能单独应用地高辛控制心率
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Β阻滞剂首选
合用洋地黄
血流动力学不稳定:胺碘酮
排除旁路后,可用洋地黄代替胺碘酮
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20122012 年年《《 HRS/EHRA/ECASHRS/EHRA/ECAS心房颤动导管和外科消融专家心房颤动导管和外科消融专家
共识共识》》
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建 议
2012HRS/EHRA/ECAS共识
2011ACCF/AHA/HRS 指
南
2010ESC
指南
在有经验的中心,抗心律失常药物治疗无效、有明显症状的阵发性房颤,推荐行导管消融 Ⅰ
A Ⅰ
A Ⅱ a
A
抗心律失常药物治疗无效、有明显症状的持续性房颤,导管消融是合理的
Ⅱ a
B
Ⅱ a
A
Ⅱ a
B
抗心律失常药物治疗无效、有明显症状的长程持续性房颤,考虑行导管消融
Ⅱ b
B
Ⅱ a
A
Ⅱ b
C
未行抗心律失常治疗、有明显症状的阵发性房颤,导管消融是合理的
Ⅱ a
B
NA Ⅱ b
B
未行抗心律失常治疗、有明显症状的持续性房颤或长程持续性房颤,考虑行导管消融
Ⅱ b
C
NA NA
适应证的变迁
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房颤导管和外科消融操作和终点的房颤导管和外科消融操作和终点的专家建议专家建议
以肺静脉或肺静脉前庭作为消融靶点是大多数房颤消融术式的基础
如果消融策略将肺静脉或肺静脉前庭作为消融靶点,则肺静脉电隔离应作为消融终点,至少应证实肺静脉传入阻滞
实现肺静脉电隔离至少 20min 后观察肺静脉是否传导恢复
外科消融后应证实肺静脉传入阻滞和 /或传出阻滞
避免肺静脉内消融
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房颤导管和外科消融操作和终点的房颤导管和外科消融操作和终点的专家建议专家建议
如果在房颤导管消融过程中,发现肺静脉外局部触发灶,应尽可能消融
如果行心房线性消融,应保证心房消融线完整、连续,尽可能达到双向阻滞
有典型房扑病史或术中出现典型房扑时应行下腔静脉 - 三尖瓣环峡部消融
长程持续性房颤应采取线性消融或复杂碎裂心房电位消融等结合的心房内广泛消融
尽量避开心房后壁消融以免损伤食管
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即刻成功实现所有肺静脉的电隔离,判定电隔离标准中至少应包括传入阻滞,若加入其他标准如传出阻滞、异丙肾或腺苷诱发等则应注明。同时,临床研究
中需注明实现电隔离后观察早期传导恢复的时间 1 年治疗成功
消融 3 个月后到 1 年时,不使用抗心律失常药物而无房颤 /房扑 /房速发作
临床 /部分成功
消融后使用或不使用术前无效的抗心律失常药物时房颤发作次数、持续时间或房颤负荷减少 75%以上
远期成功 消融 3 个月后到至少 36 个月时,不服用Ⅰ类或Ⅲ类抗心律失常药物无房颤 /房扑 /房速发作
成功标准
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早期复发消融后 3 个月内发生的房颤 /房扑 /房速,如持续时间≥ 30 s ,视为早期复发,早期复发不应认为是治疗失败
复发 消融 3 个月后发生的房颤 /房扑 /房速,如持续时间≥ 30 s ,视为复发
远期复发 消融 12 个月后发生的房颤 /房扑 /房速,如持续时间≥ 30 s ,视为远期复发
复发判定
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谢 谢!谢 谢![email protected]