心瓣膜病合并房顫及心衰的處理原則詳解演示文稿

心瓣膜病合并房顫及心衰的處理原則詳解演示文稿當(dāng)前1頁，總共67頁。（優(yōu)選）心瓣膜病合并房顫及心衰的處理原則當(dāng)前2頁，總共67頁。當(dāng)前3頁，總共67頁。當(dāng)前4頁，總共67頁。國外報道的發(fā)病率明顯高于國內(nèi)。Pomerance等尸檢162例死于心衰的患者,分析其原因后發(fā)現(xiàn)鈣化性瓣膜病變占45%,僅次于冠心病。Wong等在78例65～102歲的患者中發(fā)現(xiàn)瓣膜退行性改變占74%。90～100歲年齡組幾近100%Springer.Verlag,1982:63～67..JAMGeriatirsoc,1983,3l:156.國內(nèi)外報道十分不一致,主要原因有種族差異、也存在方法學(xué)的問題當(dāng)前5頁，總共67頁。當(dāng)前6頁，總共67頁。Theincidenceandetiologicalclassificationofvalvulardiseaseswereexaminedon358casesfrom3,000consecutiveautopsiesofmorethan60yearsofage.Theincidenceofvalvulardiseasewas11.9%(358outof3,000cases)JpnCircJ.1982Apr;46(4):337-45

當(dāng)前7頁，總共67頁。Mitralstenosiswasfoundin23cases(6.4%),ofwhich21caseswererheumaticandtheremaining2weremitralringcalcification(MRC).Mitralregurgitationwasobservedin126cases(35.3%):69ofpapillarymuscledysfunction,26ofmitralvalveprolapse(MVP),16ofMRC,9ofrupturedchordaetendineae,3ofrheumaticand3ofcongenital.JpnCircJ.1982Apr;46(4):337-45

當(dāng)前8頁，總共67頁。Aorticstenosiswasnotedin33cases(9.2%):27ofcalcified,5ofrheumaticandoneofcongenital.Aorticregurgitationwasfoundin169cases(47.2%):112ofdegenerative,47ofsyphilitic,7ofrheumaticand2ofaortitissyndrome.Therewere6cases(1.7%)oftricuspidregurgitation.JpnCircJ.1982Apr;46(4):337-45

當(dāng)前9頁，總共67頁。Etiologicalclassificationrevealed6cases(1.7%)ofcongenital,36(10%)ofrheumatic,49(13.7%)ofsyphilitic,27(7.5%)ofMVP,69(19.3%)ofischemicand166(46.4%)ofdegenerativevalvulardisease.JpnCircJ.1982Apr;46(4):337-45

當(dāng)前10頁，總共67頁。Atotalof458cases(11.5%)withvalvularheartdiseasesintheaged(greaterthanorequalto60years)werefoundamong4,000consecutiveautopsies.Theyincluded204cases(45%)ofaorticregurgitation(AR),171cases(37%)ofmitralregurgitation(MR),followedby45(10%)ofaorticstenosis(AS)and27cases(6%)ofmitralstenosis(MS).

JCardiolSuppl.1988;19:29-38.當(dāng)前11頁，總共67頁。anetiologyofthevalvulardiseases,degenerativetypewasfoundin195cases(43%),ischemicoriginin91cases(20%),followedbyinflammatoryoriginsuchassyphiliticin51andinfectiveendocarditisinthree,aortitisintwoandrheumaticin49(11%).Congenitaloriginwasalsofoundin18cases(4%).JCardiolSuppl.1988;19:29-38.

當(dāng)前12頁，總共67頁。當(dāng)前13頁，總共67頁。當(dāng)前14頁，總共67頁。仍關(guān)注對老年人風(fēng)心病當(dāng)前15頁，總共67頁。。山西醫(yī)科大學(xué)第一臨床醫(yī)學(xué)院心內(nèi)科從1979-01～1998-12共收治風(fēng)心病1227例,其中老年風(fēng)心病215例,對其逐年發(fā)病情況及95例資料齊全者臨床特點作一回顧分析當(dāng)前16頁，總共67頁。老年風(fēng)心病215例,所占比例為17.5%。逐年住院比例由1979年的9%逐漸增長為1998年的42.5%。又從215例老年風(fēng)心病患者中取資料齊全者95例,其中男49例,女46例,年齡60～80歲,平均年齡64歲,平均病程16.8年。當(dāng)前17頁，總共67頁。老年退行性心臟瓣膜病又稱老年鈣化性心臟瓣膜病(SCHVD),是一種與年齡相關(guān)的瓣膜退行性變。隨著增齡,心血管系統(tǒng)逐漸老化,處于血流不斷沖擊的瓣膜及其支架易發(fā)生退行性變、纖維化和鈣化,造成主動脈瓣和(或)二尖瓣關(guān)閉不全及狹窄,若病變的心肌擴(kuò)張和鈣化、纖維化涉及傳導(dǎo)系統(tǒng)可以并發(fā)各種心律失常當(dāng)前18頁，總共67頁。ANovelRoleoftheSympatho-AdrenergicSysteminRegulatingValveCalcificationRecentevidencehasindicatedthatthesympatheticnervoussystemplaysanimportantroleinregulatingbonedepositionandresorptionthebeta2-adrenergicreceptors(β2-AR).Inordertotesttheeffectβ2-ARonchangingthehumanvalvelCstowardsosteogenicphenotypecellsweretreatedwiththeselectlveβ2-ARagonist,salmeterol,inthepresenceandabsenceofosteogenicmediafor21days.Supplementcirculationvol114,no18october31,2006當(dāng)前19頁，總共67頁。Salmeterol tereatmentinthepresenceofosteogenicmediasignificantlyreducedtheALPactivityfrom10.2±2.9nmol/min/mgproteiyintheosteogenictreatedcellc,to4.7±1.9nmol/min/mgprotein(p<0.04,n=3).TherewasnoincreaseintheALPactivitywhenhumanvalaelcsweretreatedwithsalmeterolalone.Supplementcirculationvol114,no18october31,2006當(dāng)前20頁，總共67頁。老年瓣膜病合并房顫老年退行性心臟瓣膜病又稱老年鈣化性心臟瓣膜病(SCHVD),是一種與年齡相關(guān)的瓣膜退行性變。隨著增齡,心血管系統(tǒng)逐漸老化,處于血流不斷沖擊的瓣膜及其支架易發(fā)生退行性變、纖維化和鈣化,造成主動脈瓣和(或)二尖瓣關(guān)閉不全及狹窄,若病變的心肌擴(kuò)張和鈣化、纖維化涉及傳導(dǎo)系統(tǒng)可以并發(fā)各種心律失常當(dāng)前21頁，總共67頁。老年瓣膜病合并房顫

國內(nèi)姜氏:107例鈣化性心臟瓣膜病中檢出各類心律失常者82例,發(fā)生率為76.16%。室上性心律失常居首位,占52.14%;其次為傳導(dǎo)阻滯,占24.13%;室性心律失常占13.14%。當(dāng)前22頁，總共67頁。當(dāng)前23頁，總共67頁。Theriskofthromboembolismiswellknown;otheroutcomesofatrialfibrillationarelesswellrecognised,suchasitsrelationshipwithdementia,depressionanddeath.Suchconsequencesareresponsiblefordiminishedqualityoflifeandconsiderableeconomiccost.DrugsAging.2002;19(11):819-46

當(dāng)前24頁，總共67頁。瓣膜病合并房顫的治療原則當(dāng)前25頁，總共67頁。首先老年瓣膜病合并冠心病、高血壓者居多,其次為糖尿病,表明動脈粥樣硬化的易患因素如高血壓、高膽固醇、高血糖也是導(dǎo)致瓣膜鈣化的重要因素。因此老年人應(yīng)盡早防治各種引起動脈硬化的因素,這樣可能延緩?fù)诵行孕陌昴げ〉陌l(fā)生,從而減少各類心律失常的發(fā)生,降低死亡率當(dāng)前26頁，總共67頁。其次此癥除與心房肌缺血有關(guān)外,一個主要因素是心房肌的退行性變,這與瓣膜的退行性病變是一致的。一些心房纖顫,部分快速性心房纖顫經(jīng)治療轉(zhuǎn)復(fù)竇律后伴有T波倒置外,其余在心室率正常情況下心電圖并無缺性改變,亦無臨床癥狀,并反復(fù)房顫發(fā)作,不易轉(zhuǎn)復(fù),這種心房纖顫可用心肌及瓣膜的退行性變來解釋,因而不宜強(qiáng)行糾正,室性心律失常雖可暫時糾正,但極易復(fù)發(fā),這亦與心肌的退行性變有關(guān)。當(dāng)前27頁，總共67頁。Twoalternativesarepossible:restorationandmaintenanceofsinusrhythm,orcontrolofventricularrate,leavingtheatriainarrhythmia.Pharmacologicaloptionsincludeantiarrhythmicdrugs,suchasclassIIIagents,beta-blockersandclassICagents.Thesedrugshavesomeadverseeffects,andcarefulmonitoringisnecessary.DrugsAging.2002;19(11):819-46

當(dāng)前28頁，總共67頁。Inelderlypatients(arbitrarilydefinedasaged>75years),themanagementofatrialfibrillationvaries;itrequiresanindividualapproach,whichlargelydependsoncomorbidconditions,underlyingcardiacdisease,andpatientandphysicianpreferences.

DrugsAging.2002;19(11):819-46

當(dāng)前29頁，總共67頁。Anotherseriouschallengeinthemanagementofchronicatrialfibrillationinolderindividualsisthepreventionofstroke,itsprimaryoutcome,bychoosinganappropriateantithrombotictreatment(aspirinorwarfarin).Severalrisk-stratificationschemeshavebeenvalidatedandmaybehelpfultodeterminethebestantithromboticchoiceinindividualpatients

DrugsAging.2002;19(11):819-46

當(dāng)前30頁，總共67頁。關(guān)于抗血栓治療(瓣膜病)antithrombotictherapyinnativeandprostheticvalvularheartdiseaseispartoftheSeventhACCPConferenceonAntithromboticandThrombolyticTherapy:EvidenceBasedGuidelines.Grade1recommendationsarestrongandindicatethatthebenefitsdo,ordonot,outweighrisks,burden,andcosts.Grade2suggeststhatindividualpatients'valuesmayleadtodifferentchoices(forafullunderstandingofthegradingseeGuyattetal,CHEST2004;126:179S-187S).當(dāng)前31頁，總共67頁。Amongthekeyrecommendationsinthischapterarethefollowing:Forpatientswithrheumaticmitralvalvediseaseandatrialfibrillation(AF),orahistoryofprevioussystemicembolism,werecommendlong-termoralanticoagulant(OAC)therapy(targetinternationalnormalizedratio[INR],2.5;range,2.0to3.0)[Grade1C+].ForpatientswithrheumaticmitralvalvediseasewithAForahistoryofsystemicembolismwhosuffersystemicembolismwhilereceivingOACsatatherapeuticINR,werecommendaddingaspirin,75to100mg/d(Grade1C).Forthosepatientsunabletotakeaspirin,werecommendaddingdipyridamole,400mg/d,orclopidogrel(Grade1C).CHEST2004;126:179S-187S).當(dāng)前32頁，總共67頁。Inpeoplewithmitralvalveprolapse(MVP)withouthistoryofsystemicembolism,unexplainedtransientischemicattacks(TIAs),orAF,werecommendedagainstanyantithrombotictherapy(Grade1C).InpatientswithMVPanddocumentedbutunexplainedTIAs,werecommendlong-termaspirintherapy,50to162mg/d(Grade1A).CHEST2004;126:179S-187S當(dāng)前33頁，總共67頁。(房顫)Thischapteraboutantithrombotictherapyinatrialfibrillation(AF)ispartoftheSeventhACCPConferenceonAntithromboticandThrombolyticTherapy:EvidenceBasedGuidelines.Grade1recommendationsarestrongandindicatethatthebenefitsdo,ordonot,outweighrisks,burden,andcosts.Grade2suggeststhatindividualpatients'valuesmayleadtodifferentchoices(forafullunderstandingofthegradingseeGuyattetal,CHEST2004;126:179S-187S).當(dāng)前34頁，總共67頁。Amongthekeyrecommendationsinthischapterarethefollowing(allvitaminKantagonist[VKA]recommendationshaveatargetinternationalnormalizedratio[INR]of2.5;range,2.0to3.0):InpatientswithpersistentorparoxysmalAF(PAF)[intermittentAF]athighriskofstroke(ie,havinganyofthefollowingfeatures:priorischemicstroke,transientischemicattack,orsystemicembolism,age>75years,moderatelyorseverelyimpairedleftventricularsystolicfunctionand/orcongestiveheartfailure,historyofhypertension,ordiabetesmellitus),werecommendanticoagulationwithanoralVKA,suchaswarfarin(Grade1A).當(dāng)前35頁，總共67頁。InpatientswithpersistentAForPAF,age65to75years,intheabsenceofotherriskfactors,werecommendantithrombotictherapywitheitheranoralVKAoraspirin,325mg/d,inthisgroupofpatientswhoareatintermediateriskofstroke(Grade1A).InpatientswithpersistentAForPAF<65yearsoldandwithnootherriskfactors,werecommendaspirin,325mg/d(Grade1B).ForpatientswithAFandmitralstenosis,werecommendanticoagulationwithanoralVKA(Grade1C+).CHEST2004;126:179S-187S).當(dāng)前36頁，總共67頁。RequiringLowerWarfainDosagestoAchieveTherapeuticAnticoagulationisaStrongRiskFactorforBleedingEvent

Accumulatingevidencesuggestssomegenotypesofenzymesareassociatedwithlowmaintenancedoserequirementandincreasedriskofmajorbleeding.Supplementcirculationvol114,no18october31,2006當(dāng)前37頁，總共67頁。METHODSInaprospectivecohortfrom550consecutivepatientswithmechanicalvalvereplacementwerestudied.Patientsweredividedintothreegroups(lowerdosagesgroup,warfarinmaintenancedose0.2mg/day/BM).resultsover4000patient-yearsoffollow-up,PT-INRvaluesfellwithintargetrangerangefor90.2%ofthetimeontreatment.Supplementcirculationvol114,no18october31,2006當(dāng)前38頁，總共67頁。Therewasnodifferencebetweenthreegroupsaboutpatientcharacteristicsincludinganticoagulantintensity.lowdosagegrouphavesignificantlyincreasedriskofbleeding(figure)Supplementcirculationvol114,no18october31,2006當(dāng)前39頁，總共67頁。5101500.000.250.500.751.00Notsingnificantp=0.0001p=0.0019highdosegroupIntermediatedosegroupLowdosegroupAnalysistime(years)Bleedingeventfreesurvivalbywarfarindose當(dāng)前40頁，總共67頁。關(guān)于老年瓣膜病合并房顫抗血栓治療1.注意合并癥的情況2.注意各種危險因素3.年齡界限對治療的影響4.多種藥物的相互作用5.出血在老年中的不同表現(xiàn)和不同后果當(dāng)前41頁，總共67頁。老年瓣膜病合并心功能不全SDHVD者年齡均偏大,由于瓣膜狹窄或反流造成血流動力學(xué)的改變,最后可導(dǎo)致心臟擴(kuò)大,可單一左心房擴(kuò)大或左房、左室擴(kuò)大。加之心律失常、左室?guī)缀涡螒B(tài)學(xué)的變形而影響心室收縮導(dǎo)致心功能不全的發(fā)生,一旦出現(xiàn)癥狀,病情會加快發(fā)展、加重。當(dāng)前42頁，總共67頁。廣東葉氏,2000年1月至2005年1月收治的40例老年退行性心臟瓣膜病合并心力衰竭與同期收治的40例年齡、性別相匹配的、無瓣膜鈣化合并心力衰竭的冠心病患者進(jìn)行臨床對比研究,旨在揭示其潛在危險,提請臨床重視。臨床和實驗醫(yī)學(xué)雜志2006年1月第5卷第1期當(dāng)前43頁，總共67頁。當(dāng)前44頁，總共67頁。瓣膜性心臟病患者,主要問題是瓣膜本身有機(jī)械性損害,而任何內(nèi)科治療或藥物均不能使其消除或緩解,更不能用來替代已有肯定療效的介入或手術(shù)治療。實驗研究表明,單純的心肌細(xì)胞牽拉刺激就可促發(fā)心肌重塑,因而治療瓣膜性心臟病的關(guān)鍵就是修復(fù)瓣膜損害。當(dāng)前45頁，總共67頁。目前國內(nèi)外較一致的意見是:所有有癥狀的瓣膜性心臟病心力衰竭(NYHAⅡ級及以上),以及重度主動脈瓣病變伴有暈厥、心絞痛者,均必須進(jìn)行介入治療或手術(shù)置換瓣膜或修復(fù)瓣膜,因為有充分證據(jù)表明介入或手術(shù)治療是有效和有益的,可提高長期存活率。當(dāng)前46頁，總共67頁。有癥狀的二尖瓣狹窄(MS)和主動脈瓣狹窄(AS)應(yīng)當(dāng)考慮手術(shù),手術(shù)同樣適用于有癥狀的二尖瓣關(guān)閉不全(MR)和主動脈瓣關(guān)閉不全(AR)。有些反流性病變的患者在出現(xiàn)癥狀前也可考慮手術(shù),例如左室射血分?jǐn)?shù)降低或心臟明顯擴(kuò)大。外科治療包括瓣膜的修補(bǔ)術(shù)和置換術(shù),單純MS可采用經(jīng)皮球囊二尖瓣成形術(shù)。當(dāng)前47頁，總共67頁。值得注意的是,如果在瓣膜病的治療中用藥不當(dāng),反而可能加重病情。例如血管擴(kuò)張劑以及ACEI等具有血管擴(kuò)張作用的藥物,應(yīng)慎用于瓣膜狹窄的患者,以免后負(fù)荷過度降低致心輸出量減少,引起低血壓、暈厥等。MS患者,左心室并無壓力負(fù)荷或容量負(fù)荷過重,因此沒有任何特殊的內(nèi)科治療當(dāng)前48頁，總共67頁。洋地黃類無益于單純MS伴竇性心率的病人,但可以用于快速心室率的心房顫動治療,控制心室率效果不好時,可加用小劑量的β阻滯劑。AS患者亦應(yīng)避免應(yīng)用β阻滯劑等負(fù)性肌力藥物。β阻滯劑僅適用于心房顫動并快速室率或有竇性心動過速時。當(dāng)前49頁，總共67頁。

最常受累的是主動脈瓣膜,其發(fā)生率遠(yuǎn)高于其他瓣膜。這主要是由于主動脈瓣膜所承受的機(jī)械壓力較大,尤其在血壓增高時,易引起膠原纖維斷裂形成間隙而有利于鈣鹽沉積。老年瓣膜長期經(jīng)受血流沖擊,瓣葉中糖蛋白與蛋白聚糖的丟失與營養(yǎng)不良,也是鈣化形成的可能機(jī)制。主動脈瓣膜又以左冠瓣為多見,右冠瓣次之。因左冠瓣與主動脈瓣環(huán)后緣相連接,此處易形成血流旋渦致瓣膜受損,使鈣鹽沉積于此。右冠瓣因缺少致密牢固的絹織支托,受血流沖擊較大亦易受損。當(dāng)前50頁，總共67頁。AR的藥物治療:降低后負(fù)荷的藥物可以改善AR患者的預(yù)后。在一項與地高辛的比較研究中,硝苯地平可以延緩嚴(yán)重?zé)o癥狀A(yù)R患者做主動脈瓣置換術(shù)的時機(jī)當(dāng)前51頁，總共67頁。。ACEI也可通過減輕后負(fù)荷,增加前向心輸出量而減少返流,可應(yīng)用于以下情況:(1)有癥狀的重度AR患者,因其他心臟疾病或非心臟因素而不能手術(shù)者;(2)重度心力衰竭患者,在換瓣手術(shù)前短期治療以改善血液動力學(xué)異常,此時不能應(yīng)用負(fù)性肌力藥;(3)無癥狀A(yù)R患者,已有左室擴(kuò)大,而收縮功能正常,可長期應(yīng)用,以延長其代償期;(4)已經(jīng)手術(shù)置換瓣膜,但仍有持續(xù)左室收縮功能異常當(dāng)前52頁，總共67頁。AR的手術(shù)指征:與嚴(yán)重MR一樣,AR術(shù)前左室大小與術(shù)后射血分?jǐn)?shù)的改善直接相關(guān),但有兩點重要不同:AR術(shù)前心室較大者術(shù)后也可以維持正常射血分?jǐn)?shù)。另外,如果射血分?jǐn)?shù)的降低時間小于12～14個月,術(shù)后也可能恢復(fù)正常。當(dāng)前53頁，總共67頁。嚴(yán)重AR患者出現(xiàn)下列情況時應(yīng)當(dāng)考慮瓣膜置換:出現(xiàn)癥狀、左室射血分?jǐn)?shù)下降(<55%)、左室嚴(yán)重擴(kuò)大(收縮末徑>5.5cm)。一旦出現(xiàn)明顯的左室功能下降,手術(shù)結(jié)果將不會令人滿意。左室收縮末徑可以反映左室功能,并且不像射血分?jǐn)?shù)那樣受前負(fù)荷的影響當(dāng)前54頁，總共67頁。AS的心導(dǎo)管診治:對于超聲心動圖診斷不明確的患者,可以做心導(dǎo)管檢查,心導(dǎo)管檢查的主要作用是排除伴發(fā)的冠心病,在此比其他瓣膜病更重要,因為主動脈瓣狹窄主要發(fā)生在老年人。通過心導(dǎo)管可做經(jīng)皮球囊瓣膜成形術(shù),但與經(jīng)皮球囊二尖瓣擴(kuò)張術(shù)(PBMC)治療二尖瓣狹窄不同,主動脈瓣狹窄的瓣膜成形術(shù)常常不成功,其出血和栓塞的發(fā)生率較高,6個月的成功率較低當(dāng)前55頁，總共67頁。AS的外科治療:應(yīng)當(dāng)認(rèn)為AS是一種外科疾病,因為沒有藥物可以代替手術(shù)治療,也沒有藥物可以改善生存率。非手術(shù)治療的預(yù)后很差。其手術(shù)指征為:超聲心動圖或心導(dǎo)管檢查證實嚴(yán)重的主動脈瓣狹窄并伴有心臟癥狀。有少數(shù)患者可做瓣膜修補(bǔ),但瓣膜置換術(shù)的效果更好。手術(shù)風(fēng)險較高的患者可考慮做心導(dǎo)管球囊成形術(shù)。當(dāng)前56頁，總共67頁。MR的藥物治療:發(fā)生MR后,左房擴(kuò)大增加了二尖瓣后葉張力,緊拉葉瓣使瓣膜功能失常加重,所以嚴(yán)重MR常是進(jìn)展性的。嚴(yán)重MR非手術(shù)治療應(yīng)限制體力活動,減少鈉攝入,并通過合理應(yīng)用利尿劑增加鈉排泄。血管擴(kuò)張劑和洋地黃可增加左室衰竭后的前向心輸出量。靜脈應(yīng)用硝普鈉或硝酸甘油可減少后負(fù)荷,減少返流,有助于穩(wěn)定急性或重度MR患者病情。當(dāng)前57頁，總共67頁。無癥狀慢性MR且射血分?jǐn)?shù)正常時,并無后負(fù)荷增加,尚不清楚應(yīng)用降低后負(fù)荷藥物是否有利。ACEI治療慢性MR可能有益,特別是有癥狀或左室增大者,可