房顫患者腦卒中的預防（英文）課件

AtrialFibrillation–asimplepulsechecktopreventastroke?DrKnealeMetcalfOverviewAtrialfibrillationStrokeandatrialfibrillationDetectingatrialfibrillationManagingatrialfibrillationWhatisatrialfibrillation(AF)?“Atrialfibrillationisanatrialtachyarrhythmiacharacterisedbypredominantlyuncoordinatedatrialactivation”“Afast/irregularheart”Whathappensintheheart?SinusrhythmAFECGMostcommonlydiagnosedbyanECG:ClassificationofAFPermanentPersistent

(notself-terminating)Paroxysmal

(self-terminating–usuallywithin7days)FirstDetectedRecurrentif

≥2episodesTheIncidenceofAFisIncreasingintheUnitedKingdomIn1995,0.9%oftheUnitedKingdompopulationwereaffectedbyAF2By2006thisfigurehadrisento

1.3%1

TheprevalenceofAFwillcontinuetoriseastheproportionofelderlypatientsincreasesBy2050,itisestimatedthatAFwillbepresentin2%ofthegeneralpopulation,andinafarhigherproportionofelderlypatients2NICEClinicalGuideline36costingreport.Availableat:.uk/nicemedia/pdf/CG036costingreport.pdf.AccessedJanuary14,2010StewartS,etal.Heart2004;90:286–92;3.SavelievaI,etal.Europace

2008;10:647–65

OtherpointsaboutAFCanbesymptomaticorasymptomaticIfasymptomaticthenhowdoyoupickitup?CoremessageAtrialfibrillationiscommonandgettingcommonerAFandstrokeWolfetal.Stroke1991;22:983-988OnesixthofallstrokesareattributabletoAF

%AFprevalence

StrokesattributabletoAFAgeRange(years)FraminghamStudy010203050–5960–6970–7980–89AFisanIndependentRiskFactorforStrokeAFpatientshavenearlyafivefoldincreasedriskofstrokecomparedwithpatientswithoutAF11.WolfPA,etal.Stroke1991;22:983–850–5960–6970–7980–89432105Age(years)4.02.63.34.5Relativeriskofstrokecompared

topatientswithoutAFp<0.001forallagegroupsTheImpactofAFonStrokeOutcomesSurvivalispoorerandstrokerecurrenceratesarehigherfollowingAF-relatedstrokeAF=atrialfibrillation;OR=oddsratio;CI=confidenceinterval1.LinHJ,etal.Stroke1996;27:1760–4;2.DulliDA,etal.Neuroepidemiology2003;22:118–23AFpatients

(n=30)Non-AFpatients(n=120)1-yearpoststrokerecurrence23%8%30-daypoststrokemortality30%17%1-yearpoststrokemortality63%34%Framingham(10-yearfollowupfrom1981)AF=atrialfibrillation;OR=oddsratio;CI=confidenceintervalDulliDA,etal.Neuroepidemiology2003;22:118–23Patientsbedriddenonadmission(%)p<0.00054030201005041.2%23.7%WithAF

(n=194)WithoutAF

(n=867)FunctionaloutcomesofstrokearesignificantlyworseinpatientswithAF,andmorepatientsremainbedriddenORforbedriddenstatefollowingstrokeduetoAFwas2.23(95%CI:1.87,2.59)TheImpactofAFonStrokeOutcomesCoremessageAtrialfibrillationcausesstroke

DetectingAFDetectingAFPulseECG24hrECGFancykitAF–howcanitbediagnosed?ECG(preferably12-lead)StillthecornerstoneofAFdiagnosisOpportunisticscreeningTakenupby2PBCConsortiathisyearinNorfolkduringfluvaccinationIDEALsettingHighriskpatientsNursevaccinationDonetoprotocolGPpaid!EvidenceofeffectivnessNEssexscreened30000in6weeks361patientsnewlydiagnosedwithAFProtocolPatientsagedover65years,whohavenorecordofAF,willhavetheirpulsecheckedforatleast30secondstolookforirregularity.Ifirregularityisidentified,thentheywillbefollowedupwith:?resting12-leadECG?bloodtestsforlipidprofile,renalfunction,fastingglucose,fullbloodcount,thyroidfunction?bodymassindex?urinalysis?clinicalassessmentofcardiovascularsystem?overallevaluationofcardiovascularriskManagementoptionswillinclude:?warfarin(orantiplateletagentsifwarfarincontraindicated)?pulseratecontrol?considerationofreferralforcardioversion.24hrECG(andlonger)AsAFcanbeparoxysmalthenoneoffpulseorECGmaymiss!24hrECGmayhaveabetterpickupEffectivenessofdifferentrhythmdetectorsECG24hourtape7daymonitor7%5%6%JabaudonD,SztajzelJ,SievertKetal.Usefulnessofambulatory7-dayECGmonitoringforthedetectionofatrialfibrillationandflutterafteracutestrokeandtransientischemicattack.Stroke.2004;35(7):1647–1651.CARDISTTrialPatientswithstrokeorTIANoHxAF24hrECG,7dayautomateddevice,wristwatchdeviceComparingAFpickuprateCoremessageAFcanbedetectedbyasimplepulsecheckManagingAFBloodthinningAntiplateletsAnticoagulationRhythmcontrolRateStabalisationOperationsTheCHADS2ScoringSystemCHADS2isapoints-basedsystemforpredictingriskofstrokeinAFbasedonkeyriskfactors1Congestiveheartfailure 1pointHypertension 1pointAge>75years 1pointDiabetesmellitus 1pointStrokeorTIA 2pointsNumberofpointsRecommendation0Aspirin1Anti-plateletoranti-coagulanttherapy

2OralvitaminKantagonist,suchaswarfarinAspirinStroke

reductionof19%(95%CI2%to34%)WarfarinRiskreductionof62%(95%CI48%to72%)versusplaceboRE-LYTrial(Dabigatran)DabigatranDirectthrombininhibitorNONMONITOREDANTICOAGULATION18000patients,comparedtowarfarin150mgbetterthanwarfarin(RRR34%)Rate/rhythmcontrolBetablockersAmiodarone