新发房颤的急诊处理.ppt

新发房颤的急诊处理 房颤分类 初发房颤 阵发性房颤 持续性房颤 持久性房颤 慢性房颤 除此之外，因脑血栓或其他原因住院而发现房颤，患者无明显症状的房颤定义为沉默性房颤。名称 临床特点 心律失常类型 初发房颤 有 症 状 的（首 次 发 作）无 症 状 的（首 次 发 现）发生时间不明（首次发现）可复发，也可不 复发 阵发性房颤 持续时间 7d（常 7d 非自限性 反复发作 持久性房颤 持续时间1年 永久性房颤 不能终止的 终止后又复发的 没有转复愿望的 持续永久性 AF发病率 Framingham研究表明，在50岁60岁、60岁70岁及70岁80岁人群中房颤发病率分别为0.7%、3.5%和6.6%，而在80岁人群中发病率高达 16.3%。同时，男性发病率远高于女性，7080岁男性发病率为9.1%，为该年龄组女性的2倍；80岁男性发病率高达21.9%，而女性为 12.5%。P A Wolf,et.al,Atrial fibrillation as an independent risk factor for stroke:the Framingham Study.房颤，脑部的潜在威胁 Compared with subjects free of these conditions,the age-adjusted incidence of stroke was more than doubled in the presence of coronary heart disease(p less than 0.001)and more than trebled in the presence of hypertension(p less than 0.001).There was a more than fourfold excess of stroke in subjects with cardiac failure(p less than 0.001)and a near fivefold excess when atrial fibrillation was present(p less than 0.001).In persons with coronary heart disease or cardiac failure,atrial fibrillation doubled the stroke risk in men and trebled the risk in women.With increasing age the effects of hypertension,coronary heart disease,and cardiac failure on the risk of stroke became progressively weaker(p less than 0.05).Advancing age,however,did not reduce the significant impact of atrial fibrillation.For persons aged 80-89 years,atrial fibrillation was the sole cardiovascular condition to exert an independent effect on stroke incidence(p less than 0.001).The attributable risk of stroke for all cardiovascular contributors decreased with age except for atrial fibrillation,for which the attributable risk increased significantly(p less than 0.01),rising from 1.5%for those aged 50-59 years to 23.5%for those aged 80-89 years.While these findings highlight the impact of each cardiovascular condition on the risk of stroke,the data suggest that the elderly are particularly vulnerable to stroke when atrial fibrillation is present.(ABSTRACT TRUNCATED AT 250 WORDS)1/3未曾接受治疗的未曾接受治疗的AF病人会出现脑卒中病人会出现脑卒中 AF患者出现脑卒中的风险是无患者出现脑卒中的风险是无AF患者的患者的4倍倍 伴随心衰或者冠心病患者中，伴随心衰或者冠心病患者中，AF使男性发使男性发生脑卒中的风险增加生脑卒中的风险增加1倍，使女性发生脑卒倍，使女性发生脑卒中的风险增加中的风险增加2倍。倍。AF是唯一随年龄递增的脑卒中特特异心血是唯一随年龄递增的脑卒中特特异心血管危险性因素。管危险性因素。急性脑栓塞 心源性占60-70%起病急骤，以秒计；既往有各种类型的心脏病、心房纤颤、心肌病、心肌梗死等病史，需注意特发性房颤造成脑栓塞占2.7；昏迷约占33，抽搐高达 25，偏瘫常较完全；有时可发现其他内脏或肢体的栓塞；脑脊液检查压力正常或略高，常规检查可能有红细胞，说明有栓塞性出血的可能性；头颅CT扫 描检查和脑血栓形成相仿，但有时脑水肿较明显；有时在低密度区中有高密度灶存在，说明有栓塞性出血；有时可见多个低密度区，说明有多发性脑栓塞。AF合并脑卒中患者预后 Saposnik G,et,al,Atrial Fibrillation in Ischemic Stroke:Predicting Response to Thrombolysis and Clinical Outcomes.Stroke.2012 Nov 20.Among 12 686 patients with an acute ischemic stroke,2185(17.2%)had AF.Overall,AF patients had higher risk of death at 30 days(22.3%versus 10.2%;P0.0001),1 year(37.1%versus 19.5%;P0.0001)and death or disability at discharge(69.7%versus 54.7%;P0.0001)compared with non-AF patients.After adjustment,thrombolysis was associated with a favorable outcome for patients without AF(relative risk,1.18;95%CI,1.10-1.27),but no benefit was observed for patients with AF(relative risk,0.91;95%CI,0.71-1.17).There was a modestly increased risk of intracranial hemorrhage(any type)(16.5%versus 11.6%;relative risk,1.42;95%CI,1.05-1.91)after thrombolysis among AF compared with non-AF patients.In the logistic regression analysis,there was an interaction between tPA and iScore for a favorable outcome(P-value interaction 0.001).The interaction also was significant(P0.0012)among patients without AF,but did not reach significance(P=0.17)in patients with AF.在缺血性脑卒中患者，17.2%有AF病史 在脑卒中患者中，对比于无AF的病人，AF患者发病一月，一年内死亡率更高。在脑卒中患者中，对比于无AF的病人，伴有AF的患者致残率更高。在脑卒中患者中，由于改善了溶栓治疗，可以使无合并AF患者相关风险减低，但是这对合并AF的患者并没有明显改善。在溶栓治疗后，合并AF的患者出现颅内出血的风险较其他患者升高。“低危”患者并不真正低危 在使用20年后，ChADS2 的限制性日益受到重视。某些脑卒中高危因素并未曾纳入到ChADS2评分中。很多被认为是低危的人群（ChADS2 =0）患者，发生脑卒中的危险为1.5%/年。因此，ChADS2 =0的“低危”患者并不真正低危。Gage BF,et al,Validation of clinical classification schemes for predicting stroke:results from theNational Registry of Atrial Fibrillation.JAMA.2001 Jun 13;285(22):2864-70.血管病作为一个独立脑卒中影响因子，在旧的ChADS2 中并没有体现。AF患者发生中风的概率会在65岁之后会增高，在75岁之后，出现中风的风险甚至会更高，但在CHADS2中，没有体现年龄分级。Olesen JB et al,Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation:nationwide cohort study.BMJ.2011 Jan 31;342:d124.doi:10.1136/bmj.d124.CHADS2 CHA2DS2-VASc Congestive HF or LVEF 40%1 1 Hypentension 1 1 Age 75 years 1 2 Diabetes mellitus 1 1 Stoke,TIA,or thrombo-embolisom 2 2 Vascular diseasev(previous myocardial infarction,peripheral artery disease,or aortic plaque)1 Age 6574 years 1 Sex category(i.e.female sex)1 关于女性作为新的脑卒中危险因素的几点说明 有研究表明女性作为一个独立高危因素 但有其他的证据表明若“年龄少于65，并且没有其他并发症”，则女性不作为一个独立的危险因素。同时，在满足“年龄少于65，并且没有其他并发症”这个标准的人群中，无论其性别的如何，脑卒中的发生率都很低，因此，不推荐在这类人群中使用抗血栓治疗（即使她们的CHA2DS2-VAS 评分为“1”）由于CHA2DS2-VASc评分较CHADS2评分纳入血管疾病，年龄（大于65）以及女性等风险因素，更加精细地评估房颤患者中风的风险。CHA2DS2-VASc评分更加精细，能够辨别那些“真正低风险（truly low-risk）”的患者，避免过度治疗。由于纳入更多的风险评估因素，在辨别“真正低风险”同时，对于那些“假低风险”的人群，CHA2DS2-VASc能够识别并且提供使用抗血栓治疗的依据。房颤的治疗 对于阿司匹林，指南提出其在防止脑卒中的地位下降。Olesen JB在跟踪对比研究132,372例房颤分别使用VKA,阿司匹林以及没有使