最新心房颤动的治疗 新的循证医学证据——英文课件PPT课件 34页

'心房颤动的治疗新的循证医学证据——英文课件 PrevalenceofAFisincreasingAdultswithAFib(millions)Year2.082.262.442.662.943.333.804.784.345.165.425.61%363753YearProportionAged80YrGo:JAMA,2001：2370 Realworldofwarfarinintheelderly13.1%4.7%Thefirst90daysassociatedwithmajorhemorrhage21%ptswithdrawnwarfarinforsafetyissueThehigherriskofstroke,thehigherincidenceofmajorhemorrhageHylek.Circulation.2007,2689 HRforICHwas4.06forAsiansAsianswereatgreaterriskforwarfarin-ralatedICHShen.JACC.2007:309 Prospective，randomize，control973pts≽75yearsoldwithAFRandomizedintowarfarinarm(INR2.0-3.0)andAspirinarm(75mg/d)MeanF/U2.7yrsPrimaryoutcome：fatalordisablingstroke,intracranialhaemorrhage,orarterialembolismWarfarinversusaspirinforstrokepreventionintheelderlywithAF(TheBirminghamAtrialFibrillationTreatmentoftheAgedStudy,BAFTAstudy)Mant.Lancet,2007,493 0.831.155(0.4%)6(0.5%)haemorrhagic0.651.921(0.1%)2(0.2%)OtherICH0.360.323(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%)disablingnonfatal0.00270.4824(1.8%)Total0.530.695(0.4%)unknown0.00040.3010(0.8%)ischemic0.140.5913(1.0%)fatal0.0030.4621(1.6%)StrokepEventwarfarin(n=488)ASA(n=488)N(Riskperyear)N(Riskperyear)warfarinVS.ASARRWarfarinversusaspirinforstrokepreventionintheelderlywithAFMant.Lancet,2007,493 Mant.Lancet,2007,493WarfarinversusaspirinforstrokepreventionintheelderlywithAF Anticoagulationinclinicalpractice2.03/100person-yrs1.17/100person-yrs11,526ptswithAF,54.8%wasonwarfarinRelativeriskforthromb-embolismreduced51%inwarfarintherapyTheintracranialhemorrhagerateincreasedinwarfarin(0.46/100person-yrsVS0.23/100person-yrs）Warfarinwasnotassociatedwithnonintracranialhemorrhage(1.05/100person-yrsVS1.06/100person-yrs）Go.JAMA2003:2685 RivaroxabanEnoxaparin873ptsEndpointsincludedDVT,PE,allcausemortalitySafety：majorhemorrhageEndpointsSafetyEriksson.Circulation.2006:2374%Rivaroxaban—Newpromiseofanticoagulation？ ProspectiveRIKS-HIA60764pts，AF21459pts,CHF22345pts,AF+CHF16960ptsF/U1yrHighermortalityrateinAFwithoutCHFptstakingdigoxin(RR1.42)SimilarmortalityrateinCHForAF+CHFptswithorwithoutdigoxinDigoxinandmortalityinAF:AprospectivecohortstudyHallberg.EuroJClinPharmacol,2007,959 Hallberg.EuroJClinPharmacol,2007,959DigoxinandmortalityinAF:Aprospectivecohortstudy AdverseeffectsoforalamiodaroneZimetbaum.NEJM.2007:935Bradycardia5%ProlongedQTInmostTdp<1%Hepatic15%Hyperthyroidism3%Hypothyroidism20%Pulmonary<3%Dermatology25-75%Neurologic3-30%Cornealdeposits100%Opticneuritis<1% NicholG.Heart.2002:535JAmCollCardiol.2003:20AADsisinsufficienttomaintainsinusrhythm AmiodaroneincreasedmortalityofHFSCD－HeFT研究Bardy.NEJM,2005:225 Dronedarone：Substitutionofamiodarone？Derivativeofamiodarone,notcomposedofiodineEliminatetheeffectsofamiodaroneonthyroidandpulmonaryfunctionsHalf-time24hours22.6%discontinuationbecauseofGItractcomplicationsTouboul.PACE.2002:574(A) 64.1%75.2%DronedaroneformaintenanceofSRinAF：multicenter,double-blind,randomizedtrialsSingh.NEJM.2007,987 CatheterablationissuperiortoantiarrhythmicdurgAprospective,multicenter,randomized,controlledstudyablation+AADsAADs137AFpts(CAF33%)RandomizationCPVA+isthmusablationTranstelephonicECG，HolterF/U1yrAblation+AADsuccessrate55.9%SuccessrateofAADs8.7%Stabile.EurHeartJ.2006:216 APAFTrial29%Pappone.JACC.2006:2340198ptswithPAFRandomizationF/U1yrsSuccess：ATafree86%22% Oral.NEJM.2006:934146CAFEventrecorderF/UCPVA:74%>AAD:4% Catheterablationdecreasetheincidenceofstroke755ptsTheincidenceofstroke/TIAwas1.1%0.9%occurredwhithin2weeksofRFCA79%ofptswithoutriskfactorforstrokeand68%ofptswith≥1riskfactorinsinusdiscontinuedwarfarinPatientswithsinusrhythmwasthromboemboliceventfreeaftertheprocedureOral.Circulation.2006:759 Pappone.JACC.2003:185N=589N=582Catheterablationreducestroke Pappone.JACC.2003:185Catheterablationimproveprognosis Noriskfactor：ASA81-325mgOnemoderateriskfactor：ASA81-325mgorwarfarinAnyhighriskfactorormorethanonemoderateriskfactor:warfarinPrinciplesofanticoagulation Amiodarone＝Ablation！NoOHDyesHTNyes（concomitancwithLVHamiodarone>ablation）CADyesHFamiodarone>ablationMaintainSinusRhythmCatheterablationisareasonable　alternativeto　pharmacologicaltherapytopreventrecurrent　AF(IIa,C)Fuster.Circulation.2006:e257 IndicationsforcatheterablationThepresenceofsymptomaticAFrefractoryorintoleranttoatleastoneClass1or3antiarrhythmicmedicationinrareclinicalsituations,itmaybeappropriatetoperformcatheterablationofAFasfirstlinetherapyselectedsymptomaticpatientswithheartfailureand/orreducedejectionfractionLAthrombusisacontraindicationHRS/EHRA/ECASExpertConsensusStatement AFAblationasfirst-linetherapy?(CatheterAblationvs.AntiarrhythmicDrugTherapyforAtrialFibrillationTrial,CABANA)OngoingNIHsponsoredCABANAstudy:mortalitystudyofAFablationvs.antiarrhythmicsvs.ratecontrol/coumadinasfirst-linetherapyforAFMainstudytoenroll3,000patientsat100centersPatientswillbefollowedfor2.5-5years ThankYou! 结束语谢谢大家聆听！！！34'