,心房颤动治疗进展 最新指南解读,Atrial Fibrillation Update 2012,Philadelphia 1.5 million,San Francisco 700,000,Miami 400,000,Los Angeles 3.8 million,6.4 million,11.800.000,心房颤动（房颤）的临床与基础研究领域积累了大量的循证医学证据，极大地促使了房颤指南的更新。2010年欧洲心脏病学会（ESC）发布了欧洲房颤诊疗指南，随后美国心脏病学会基金会（ACCF）/美国心脏协会（AHA）/心律学会（HRS）联合更新了美国房颤诊疗指南。深层次解读最新欧美房颤指南的建议是规范我国房颤诊疗的迫切需要。,Atrial Fibrillation (AF),Atrial fibrillation. http:/www.health-res.com/EX/07-29-05/atrial-fibrillation-lg.jpg. Accessed November 2009.,Atrial fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis.,2% VF,Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.,34% Atrial Fibrillation,18% Unspecified,6% PSVT,6% PVCs,4% Atrial Flutter,9% SSS,8% Conduction Disease,3% SCD,10% VT,Arrhythmia as principal diagnosis,8,Hospitalization from AF,150,110,410,900,100,300,Cardiac arrest,VF,VT,Atrial fibrillation,Atrial flutter,Sick sinus syndrome,0,200,400,600,800,1000,1200,Bialy et al, J Am Coll Cardiol 92,Hospital days,9,AF Is the Leading Cause of Hospitalizations for Arrhythmia,Hospital Days (thousands),N=517,699 (representing 10% of CV admissions).,Hospital Admissions in US,VT,VF,Unspecified,Sick sinus,Premature beats,Junctional,Conduction disease,Cardiac arrest,AFL,AF,0,200,400,600,800,1000,VF, ventricular fibrillation; VT, ventricular tachycardia.Adapted from Waktare JE, et al. J Am Coll Cardiol. 1998;81(suppl 5A):3C-15C.,10,Prevalence of Diagnosed AF,Go AS, et al. JAMA. 2001;285:2370-2375.,Prevalence (%),0,2,4,6,8,10,12,7 days,Both paroxysmal and persistent AF can become permanent,aTermination with pharmacologic therapy or direct-current cardioversion does not change the designation.,Fuster V, et al. Circulation. 2006;114(7):e257-e354.,17,（1）首次诊断的房颤（first diagnosed AF）：第一次心电图发现为房颤，无论持续时间或房颤相关临床状况的严重程度。 （2）阵发性房颤（paroxymal AF）：房颤持续小于48小时，可自行终止。虽然房颤发作可能持续到7天，但48小时是个关键的时间点，有重要的临床意义。超过48小时，房颤自行终止的可能性会降低，需考虑抗凝治疗。 （3）持续性房颤（persistent AF）：房颤持续超过7天，或者需要转复治疗（药物转复或者直接电转复）。 （4）长程持续性房颤（long-standing persistent AF）：房颤持续时间超过1年，拟采用节律控制策略，即接受导管消融治疗。长程持续性房颤是在导管消融时代新出现的名词，导管消融使房颤治愈成为可能，因此，房颤已不再是“永久性”。 （5）永久性房颤（permanent AF）：是指房颤已为患者及其经治医师所接受，从而不再考虑节律控制策略的类型；换言之，一旦决定采取节律控制策略，该型房颤将重新定义为长程持续性房颤。 静寂性房颤（Silent AF，或无症状性房颤）：是分类外较为特殊的一种情况，患者可能以缺血性卒中或心动过速心肌病为首发症状，可以是上述五种类型中的任何一种。,18,Pathophysiology,19,Pathophysiology of AF,?Inflammation,Left ventricular hypertrophy Diastolic dysfunction,Mitral regurgitation,Atrial dilatation/stretch,?Inflammation,Stretch-activated channels Dispersion of refractoriness Pulmonary vein focal/discharges?,Increased vulnerability to AF?,Compliance,HTN and/or vascular disease,Adapted with permission from Gersh BJ, et al. Eur Heart J Suppl. 2005;7(suppl C):C5-C11.,20,What Happens When AF Persists?,Remodeling explains why “AF begets AF”,LA and LAA dilatationFibrosis,Decrease in Ca+ currents Shortening of atrial action potential Increased importance of early activating K+ channels: IKur, IKto,Structural Remodeling,Electro- physiologic Remodeling,21,22,Structural abnormalities associated with AF,Conditions Frequently Associated With Nonvalvular AF1-4,Wattigney WA, et al. Circulation. 2003;108(6):711-716. Gersh BJ, et al. Eur Heart J Suppl. 2005;7(suppl C):C5-C11. Fuster V, et al. J Am Coll Cardiol. 2006;48(4):854-906. Mozaffarian D, et al. Circulation. 2008;118(8):800-807.,Hypertension Aging Male sex Obesity/metabolic syndrome/diabetes Ischemic heart disease Heart failure/diastolic dysfunction Obstructive sleep apnea Physical inactivity Thyroid disease Inflammation?,24,Initiation of AF,PACs,bradykardia,25%,30%,8%,32%,5%,tachycardia,reinitiation,sudden onset,25,Clinical Evaluation,26,27,EHRA score of AF- related symptoms,AF = atrial fibrillation; EHRA = European Heart Rhythm Association,Clinical Evaluation for AF Patients: Etiology, AAD Risk, Embolic Risk,Treatment of AF is dependent on etiologic (cause, severity, reversible/modifiable) as well a patient factors (embolic risk, concomitant disorders) Some anatomic or functional disorders pose risks from AAD treatment (eg, organ toxicity and ventricular proarrhythmia) At a minimum, an evaluation requires History Echocardiogram Physical Blood chemistries ECG Stress test (if CAD is suspected) Chest x-ray (and possibly PFTs) if pulmonary disease is suspect and/or HF is a consideration Current guidelines emphasize the prospectively determined CHADS2 risk-scoring system for embolic risk,