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1、,心房颤动治疗进展 最新指南解读,Atrial Fibrillation Update 2012,Philadelphia 1.5 million,San Francisco 700,000,Miami 400,000,Los Angeles 3.8 million,6.4 million,11.800.000,心房颤动（房颤）的临床与基础研究领域积累了大量的循证医学证据，极大地促使了房颤指南的更新。2010年欧洲心脏病学会（ESC）发布了欧洲房颤诊疗指南，随后美国心脏病学会基金会（ACCF）/美国心脏协会（AHA）/心律学会（HRS）联合更新了美国房颤诊疗指南。深层次解读最新欧美房颤指南的建
2、议是规范我国房颤诊疗的迫切需要。,Atrial Fibrillation (AF),Atrial fibrillation. http:/www.health- Accessed November 2009.,Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis.,2% VF,Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.,34% Atrial Fibrillation,18% U
3、nspecified,6% PSVT,6% PVCs,4% Atrial Flutter,9% SSS,8% Conduction Disease,3% SCD,10% VT,Arrhythmia as principal diagnosis,8,Hospitalization from AF,150,110,410,900,100,300,Cardiac arrest,VF,VT,Atrial fibrillation,Atrial flutter,Sick sinus syndrome,0,200,400,600,800,1000,1200,Bialy et al, J Am Coll C
4、ardiol 92,Hospital days,9,AF Is the Leading Cause of Hospitalizations for Arrhythmia,Hospital Days (thousands),N=517,699 (representing 10% of CV admissions).,Hospital Admissions in US,VT,VF,Unspecified,Sick sinus,Premature beats,Junctional,Conduction disease,Cardiac arrest,AFL,AF,0,200,400,600,800,1
5、000,VF, ventricular fibrillation; VT, ventricular tachycardia.Adapted from Waktare JE, et al. J Am Coll Cardiol. 1998;81(suppl 5A):3C-15C.,10,Prevalence of Diagnosed AF,Go AS, et al. JAMA. 2001;285:2370-2375.,Prevalence (%),0,2,4,6,8,10,12,7 days,Both paroxysmal and persistent AF can become permanen
6、t,aTermination with pharmacologic therapy or direct-current cardioversion does not change the designation.,Fuster V, et al. Circulation. 2006;114(7):e257-e354.,17,（1）首次诊断的房颤（first diagnosed AF）：第一次心电图发现为房颤，无论持续时间或房颤相关临床状况的严重程度。 （2）阵发性房颤（paroxymal AF）：房颤持续小于48小时，可自行终止。虽然房颤发作可能持续到7天，但48小时是个关键的时间点，有重要的
7、临床意义。超过48小时，房颤自行终止的可能性会降低，需考虑抗凝治疗。 （3）持续性房颤（persistent AF）：房颤持续超过7天，或者需要转复治疗（药物转复或者直接电转复）。 （4）长程持续性房颤（long-standing persistent AF）：房颤持续时间超过1年，拟采用节律控制策略，即接受导管消融治疗。长程持续性房颤是在导管消融时代新出现的名词，导管消融使房颤治愈成为可能，因此，房颤已不再是“永久性”。 （5）永久性房颤（permanent AF）：是指房颤已为患者及其经治医师所接受，从而不再考虑节律控制策略的类型；换言之，一旦决定采取节律控制策略，该型房颤将重新定义为长程
8、持续性房颤。 静寂性房颤（Silent AF，或无症状性房颤）：是分类外较为特殊的一种情况，患者可能以缺血性卒中或心动过速心肌病为首发症状，可以是上述五种类型中的任何一种。,18,Pathophysiology,19,Pathophysiology of AF,?Inflammation,Left ventricular hypertrophy Diastolic dysfunction,Mitral regurgitation,Atrial dilatation/stretch,?Inflammation,Stretch-activated channels Dispersion of re
9、fractoriness Pulmonary vein focal/discharges?,Increased vulnerability to AF?,Compliance,HTN and/or vascular disease,Adapted with permission from Gersh BJ, et al. Eur Heart J Suppl. 2005;7(suppl C):C5-C11.,20,What Happens When AF Persists?,Remodeling explains why “AF begets AF”,LA and LAA dilatationF
10、ibrosis,Decrease in Ca+ currents Shortening of atrial action potential Increased importance of early activating K+ channels: IKur, IKto,Structural Remodeling,Electro- physiologic Remodeling,21,22,Structural abnormalities associated with AF,Conditions Frequently Associated With Nonvalvular AF1-4,Watt
11、igney WA, et al. Circulation. 2003;108(6):711-716. Gersh BJ, et al. Eur Heart J Suppl. 2005;7(suppl C):C5-C11. Fuster V, et al. J Am Coll Cardiol. 2006;48(4):854-906. Mozaffarian D, et al. Circulation. 2008;118(8):800-807.,Hypertension Aging Male sex Obesity/metabolic syndrome/diabetes Ischemic hear
12、t disease Heart failure/diastolic dysfunction Obstructive sleep apnea Physical inactivity Thyroid disease Inflammation?,24,Initiation of AF,PACs,bradykardia,25%,30%,8%,32%,5%,tachycardia,reinitiation,sudden onset,25,Clinical Evaluation,26,27,EHRA score of AF- related symptoms,AF = atrial fibrillatio
13、n; EHRA = European Heart Rhythm Association,Clinical Evaluation for AF Patients: Etiology, AAD Risk, Embolic Risk,Treatment of AF is dependent on etiologic (cause, severity, reversible/modifiable) as well a patient factors (embolic risk, concomitant disorders) Some anatomic or functional disorders p
14、ose risks from AAD treatment (eg, organ toxicity and ventricular proarrhythmia) At a minimum, an evaluation requires History Echocardiogram Physical Blood chemistries ECG Stress test (if CAD is suspected) Chest x-ray (and possibly PFTs) if pulmonary disease is suspect and/or HF is a consideration Current guidelines emphasize the prospectively determined CHADS2 risk-scoring system for embolic risk,
