《心房颤动的治疗新的循证医学证据英文课件(1)》由会员分享，可在线阅读，更多相关《心房颤动的治疗新的循证医学证据英文课件(1)（33页珍藏版）》请在金锄头文库上搜索。
1、Management of Atrial Fibrillation： Update in the EBM proof,Prevalence of AF is increasing,Go: JAMA, 2001：2370,Miyasaka.Circulation.2006:119,Year,Prevalence of AF is increasing,Prevalence %,Age,Prevalence of AF:the Rotterdam study,Heerinaga.Eur Heart J,2006,949,6808 pts., F/U 6.9 yrs，prevalence 5.5%,
2、Incidence ,Age,Incidence of AF:the Rotterdam study,Heerinaga.Eur Heart J,2006,949,6808 pts., F/U 6.9 yrs，Incidence 9.9,Identified AF：the tip of the iceberg,14802 pts aged 65 or over，randomized to systemic screening and opportunistic screeningSystemic screening group:9866 pts.Opportunistic screening
3、group: 4936 pts. F/U 12 monsRate of new AF case in systemic screening 1.63%，Rate of new AF case in opportunistic screening 1.04%,Fitzmaurice.BMJ.2007,383,Risk for stroke increased in lone AF,Jahangir. Circulation. 2007:3050,Meta-analysis: antithrombotic therapy of AF,Hart.Ann Intern Med,2007,857,Rea
4、l world of warfarin in the elderly,The first 90 days associated with major hemorrhage 21% pts withdrawn warfarin for safety issue The higher risk of stroke, the higher incidence of major hemorrhage,Hylek. Circulation.2007,2689,HR for ICH was 4.06 for Asians,Asians were at greater risk for warfarin-r
5、alated ICH,Shen. JACC.2007:309,Prospective，randomize，control 973 pts 75 years old with AF Randomized into warfarin arm (INR 2.0-3.0) and Aspirin arm(75mg/d) Mean F/U 2.7 yrs Primary outcome：fatal or disabling stroke, intracranial haemorrhage, or arterial embolism,Warfarin versus aspirin for stroke p
6、revention in the elderly with AF,(The Birmingham Atrial Fibrillation Treatment of the Aged Study,BAFTA study),Mant.Lancet,2007,493,Warfarin versus aspirin for stroke prevention in the elderly with AF,Mant.Lancet,2007,493,Mant.Lancet,2007,493,Warfarin versus aspirin for stroke prevention in the elder
7、ly with AF,Anticoagulation in clinical practice,2.03/100person-yrs,1.17/100person-yrs,Go.JAMA 2003:2685,Rivaroxaban,Enoxaparin,873 pts Endpoints included DVT,PE,all cause mortality Safety：major hemorrhage,Endpoints,Safety,Eriksson. Circulation. 2006: 2374,%,Rivaroxaban New promise of anticoagulation
8、？,Prospective RIKS-HIA 60764 pts，AF 21459 pts,CHF 22345 pts,AF+CHF16960 pts F/U 1 yr Higher 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 study,Hallberg.Euro J Clin Ph
9、armacol,2007,959,Hallberg.Euro J Clin Pharmacol,2007,959,Digoxin and mortality in AF: A prospective cohort study,Adverse effects of oral amiodarone,Zimetbaum.NEJM.2007:935,Nichol G . Heart. 2002:535 J Am Coll Cardiol. 2003:20,AADs is insufficient tomaintain sinus rhythm,Amiodarone increased mortalit
10、y of HF SCDHeFT研究,Bardy. NEJM,2005: 225,Dronedarone：Substitution of amiodarone？,Derivative of amiodarone, not composed of iodine Eliminate the effects of amiodarone on thyroid and pulmonary functions Half-time 24 hours,22.6% discontinuation because of GI tract complications,Touboul.PACE.2002:574(A),
11、Dronedarone for maintenance of SR in AF：multicenter, double-blind, randomized trials,Singh.NEJM.2007,987,Catheter ablation is superior to antiarrhythmic durg,A prospective, multicenter, randomized, controlled study,ablation+AADs,AADs,137 AF pts (CAF 33%) RandomizationCPVA+isthmus ablation Transtelep
12、honic ECG ，Holter F/U 1 yr Ablation +AADsuccess rate 55.9% Success rate of AADs 8.7%,Stabile.Eur Heart J.2006:216,APAF Trial,29%,Pappone. JACC. 2006:2340,86%,22%,Oral.NEJM.2006:934,146 CAF Event recorder F/U CPVA:74% AAD:4%,Catheter ablation decrease the incidence of stroke,755 pts The incidence of
13、stroke/TIA was 1.1% 0.9% occurred whithin 2 weeks of RFCA 79% of pts without risk factor for stroke and 68% of pts with 1 risk factor in sinus discontinued warfarin Patients with sinus rhythm was thromboembolic event free after the procedure,Oral.Circulation.2006:759,Pappone . JACC.2003:185,N=589,N=
14、582,Catheter ablation reduce stroke,Pappone . JACC.2003:185,Catheter ablation improve prognosis,No risk factor： ASA 81- 325mg One moderate risk factor：ASA 81- 325mg or warfarin Any high risk factor or more than one moderate risk factor: warfarin,Principles of anticoagulation,AmiodaroneAblation ！,No
15、OHD yes HTN yes（concomitanc with LVH amiodaroneablation ） CAD yes HF amiodaroneablation,Maintain Sinus Rhythm,Catheter ablation is a reasonable alternative to pharmacological therapy to prevent recurrent AF (IIa,C),Fuster. Circulation.2006 :e257,Indications for catheter ablation,The presence of symp
16、tomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication in rare clinical situations, it may be appropriate to perform catheter ablation of AF as first line therapy selected symptomatic patients with heart failure and/or reduced ejection fraction LA thrombus is a contraindication,HRS/EHRA/ECAS Expert Consensus Statement,
