老年人心瓣膜病合并房颤及心衰的处理原则 广州市第一人民医院 刘丰随着人口的老龄化,老年退行性钙化性瓣膜病逐渐占有重要的地位,是目前老年人的特殊疾病。已经成为老年人心力衰竭、心律失常、晕厥、猝死的原因之一。 对冠心病具有重要预测价值国外报道的发病率明显高于国内。Pomerance 等 尸检162 例死于心衰的患者, 分析其原因后发现钙化性瓣膜病变占45 % ,仅次于冠心病。 Wong 等 在78 例65102 岁的患者中 发现瓣膜退行性改变占74 %。 90100 岁年龄组几近100 %Springer. Verlag ,1982 :6367. J AM Geriatir soc ,1983 ,3l :156.国内外报道十分不一致,主要原因有种族差异、也存在方法学的问题The incidence and etiological classification of valvular diseases were examined on 358 cases from 3,000 consecutive autopsies of more than 60 years of age. The incidence of valvular disease was 11.9% (358 out of 3,000 cases) Jpn Circ J. 1982 Apr;46(4):337-45 Mitral stenosis was found in 23 cases (6.4%), of which 21 cases were rheumatic and the remaining 2 were mitral ring calcification (MRC). Mitral regurgitation was observed in 126 cases (35.3%): 69 of papillary muscle dysfunction, 26 of mitral valve prolapse (MVP), 16 of MRC, 9 of ruptured chordae tendineae, 3 of rheumatic and 3 of congenital.Jpn Circ J. 1982 Apr;46(4):337-45 Aortic stenosis was noted in 33 cases (9.2%): 27 of calcified, 5 of rheumatic and one of congenital. Aortic regurgitation was found in 169 cases (47.2%): 112 of degenerative, 47 of syphilitic, 7 of rheumatic and 2 of aortitis syndrome. There were 6 cases (1.7%) of tricuspid regurgitation.Jpn Circ J. 1982 Apr;46(4):337-45 Etiological classification revealed 6 cases (1.7%) of congenital, 36 (10%) of rheumatic, 49 (13.7%) of syphilitic, 27 (7.5%) of MVP, 69 (19.3%) of ischemic and 166 (46.4%) of degenerative valvular disease.Jpn Circ J. 1982 Apr;46(4):337-45 A total of 458 cases (11.5%) with valvular heart diseases in the aged (greater than or equal to 60 years) were found among 4,000 consecutive autopsies. They included 204 cases (45%) of aortic regurgitation (AR), 171 cases (37%) of mitral regurgitation (MR), followed by 45 (10%) of aortic stenosis (AS) and 27 cases (6%) of mitral stenosis (MS). J Cardiol Suppl. 1988;19:29-38. an etiology of the valvular diseases, degenerative type was found in 195 cases (43%), ischemic origin in 91 cases (20%), followed by inflammatory origin such as syphilitic in 51 and infective endocarditis in three, aortitis in two and rheumatic in 49 (11%). Congenital origin was also found in 18 cases (4%).J Cardiol Suppl. 1988;19:29-38. 仍关注对老年人风心病仍关注对老年人风心病。山西医科大学第一临床医学院心内科从1979 - 011998 - 12 共收治风心病1 227 例,其中老年风心病215 例,对其逐年发病情况及95 例资料齐全者临床特点作一回顾分析老年风心病215 例,所占比例为17.5 %。逐年住院比例由1979 年的9 %逐渐增长为1998 年的42.5 %。又从215 例老年风心病患者中取资料齐全者95 例,其中男49 例,女46 例,年龄6080 岁,平均年龄64 岁,平均病程16.8 年。老年退行性心脏瓣膜病老年退行性心脏瓣膜病又称老年钙化性心脏瓣膜病(SCHVD) , 是一种与年龄相关的瓣膜退行性变。随着增龄, 心血管系统逐渐老化, 处于血流不断冲击的瓣膜及其支架易发生退行性变、纤维化和钙化, 造成主动脉瓣和(或) 二尖瓣关闭不全及狭窄, 若病变的心肌扩张和钙化、纤维化涉及传导系统可 以并发各种心律失常A Novel Role of the Sympatho-Adrenergic System in Regulating Valve CalcificationRecent evidence has indicated that the sympathetic nervous system plays an important role inregulating bone deposition and resorption the beta 2-adrenergic receptors(2-AR).In order to test the effect 2-AR on changing the human valve lCs towards osteogenic phenotype cells were treated with the selectlve2-AR agonist ,salmeterol ,in the presence and absence of osteogenic media for 21 days .Supplement circulation vol 114,no 18 october 31 ,2006Salmeteroltereatment in the presence of osteogenic media significantly reduced the ALP activity from 10.22.9nmol/min/mg proteiy in the osteogenic treated cellc ,to 4.71.9nmol/min/mg protein(p75 years), the management of atrial fibrillation varies; it requires an individual approach, which largely depends on comorbid conditions, underlying cardiac disease, and patient and physician preferences. Drugs Aging. 2002;19(11):819-46 Another serious challenge in the management of chronic atrial fibrillation in older individuals is the prevention of stroke, its primary outcome, by choosing an appropriate antithrombotic treatment (aspirin or warfarin). Several risk-stratification schemes have been validated and may be helpful to determine the best antithrombotic choice in individual patients Drugs Aging. 2002;19(11):819-46 关于抗血栓治疗(瓣膜病)antithrombotic therapy in native and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international normalized ratio INR, 2.5; range, 2.0 to 3.0) Grade 1C+. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs at a therapeutic INR, we recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C). CHEST 2004; 126:179S-187S). In people with mitral valve prolapse (MVP) without history of systemic embolism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexplained TIAs, we recommend long-term aspirin therapy, 50 to 162 mg/d (Grade 1A). CHEST 2004; 126:179S-187S(房颤)This chapter about antithrombotic therapy in atrial fibrillation (AF) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following (all vitamin K antagonist VKA recommendations have a target international normalized ratio INR of 2.5; range, 2.0 to 3.0): In patients with persistent or paroxysmal AF (PAF) intermittent AF at high risk of stroke (ie, having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age 75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus), we recommend anticoagulation with an oral VKA, such as warfarin (Grade 1A). In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, we recommend antithrombotic therapy with either an oral VKA or aspirin, 325 mg/d, in this group of patients who are at intermediate risk of stroke (Grade 1A). In patients with persistent AF or PAF 65 years old and with no other risk factors, we recommend aspirin, 325 mg/d (Grade 1B). For patients with AF and mitral stenosis, we recommend anticoagulation with an oral VKA (Grade 1C+). CHEST 2004; 126:179S-187S). Requiring Lower Warfain Dosages to Achieve Therapeutic Anticoagulation is a Strong Risk Factor for Bleeding Event Accumulating evidence suggests some genotypes of enzymes are associated with low maintenance dose requirement and increased risk of major bleeding .Supplement circulation vol 114,no 18 october 31 ,2006METHODS In a prospective cohort from 550 consecutive patients with mechanical valve replacement were studied . Patients were divided into three groups (lower dosages group , warfarin maintenance dose 0.2mg/day/BM).results over 4000 patient-years of follow-up, PT-INR values fell within target range range for 90.2% of the time on treatment .Supplement circulation vol 114,no 18 october 31 ,2006There was no difference between three groups about patient characteristics including anticoagulant intensity . low dosage group have significantly increased risk of bleeding (figure)Supplement circulation vol 114,no 18 october 31 ,20065101500.000.250.500.751.00Not singnificantp=0.0001p=0.0019high dose groupIntermediate dose groupLow dose groupAnalysis time (years)Bleeding event free survival by warfarin dose关于老年瓣膜病合并房颤抗血栓治疗1.注意合并症的情况 2.注意各种危险因素 3.年龄界限对治疗的影响 4.多种药物的相互作用 5.出血在老年中的不同表现和不同后果老年瓣膜病合并心功能不全 SDHVD 者年龄均偏大,由于瓣膜狭窄或反流造成血流动力学的改变,最后可导致心脏扩大 ,可单一左心房扩大或左房、左 室扩大。加之心律失常、左室几何形态学的变形而影响心室收缩导致心功能不全的发生,一旦出现症状,病情会加快发展、加重。广东叶氏,2000 年1 月至2005 年1 月收治的40 例老年退行性心脏瓣膜病合并心力衰竭与同期收治的40 例年龄、性别相匹配的、无瓣膜钙化合并心力衰竭的冠心病患者进行临床对比研究,旨在揭示其潜在危险,提请临床重视。临床和实验医学杂志临床和实验医学杂志2006 年年1 月第月第5 卷第卷第1 期期 瓣膜性心脏病患者,主要问题是瓣膜本身有机械性损害,而任何内科治疗或药物均不能使其消除或缓解,更不能用来替代已有肯定疗效的介入或手术治疗。实验研究表明, 单纯的心肌细胞牵拉刺激就可促发心肌重塑,因而治疗瓣膜性心脏病的关键就是修复瓣膜损害。 目前国内外较一致的意见是:所有有症状的瓣膜性心脏病心力衰竭(NYHA 级及以上) ,以及重度主动脉瓣病变伴有晕厥、心绞痛者,均必须进行介入治疗或手术置换瓣膜或修复瓣膜,因为有充分证据表明介入或手术治疗是有效和有益的,可提高长期存活率。有症状的二尖瓣狭窄(MS) 和主动脉瓣狭窄(AS) 应当考虑手术,手术同样适用于有症状的二尖瓣关闭不全(MR) 和主动脉瓣关闭不全(AR) 。有些反流性病变的患者在出现症状前也可考虑手术,例如左室射血分数降低或心脏明显扩大。外科治疗包括瓣膜的修补术和置换术,单纯MS 可采用经皮球囊二尖瓣成形术。 值得注意的是,如果在瓣膜病的治疗中用药不当,反而可能加重病情。例如血管扩张剂以及ACEI 等具有血管扩张作用的药物,应慎用于瓣膜狭窄的患者,以免后负荷过度降 低致心输出量减少,引起低血压、晕厥等。MS 患者,左心室并无压力负荷或容量负荷过重,因此没有任何特殊的内科治疗洋地黄类无益于单纯MS 伴窦性心率的病人,但可以用于快速心室率的心房颤动治疗,控制心室率效果不好时,可加用小剂量的阻滞剂。AS 患者亦应避免应用阻滞剂等 负性肌力药物。阻滞剂仅适用于心房颤动并快速室率或有窦性心动过速时。 最常受累的是主动脉瓣膜最常受累的是主动脉瓣膜,其发生率远高于其他瓣膜。这主要是由于主动脉瓣膜所承受的机械压力较大,尤其在血压增高时,易引起胶原纤维断裂形成间隙而有利于钙盐沉积。老年瓣膜长期经受血流冲击,瓣叶中糖蛋白与蛋白聚糖的丢失与营养不良,也是钙化形成的可能机制 。主动脉瓣膜又以左冠瓣为多见,右冠瓣次之。因左冠瓣与主动脉 瓣环后缘相连接,此处易形成血流旋涡致瓣膜受损, 使钙盐沉积于此 。右冠瓣因缺少致密牢固的绢织支托,受血流冲击较大亦易受损。AR 的药物治疗的药物治疗:降低后负荷的药物可以改善AR 患者的预后。在一项与地高辛的比较研究中,硝苯地平可以延缓严重无症状AR 患者做主动脉瓣置换术的时机。ACEI 也可通过减轻后负荷,增加前向心输出量而减少返流,可应用于以下情况: (1) 有症状的重度AR 患者,因其他心脏疾病或非心脏因素而不能手术者; (2) 重度心力衰竭患者,在换瓣手术前短期治疗以改善血液动力学异常,此时不能应用负性肌力 药; (3) 无症状AR 患者,已有左室扩大,而收缩功能正常,可长期应用,以延长其代偿期; (4) 已经手术置换瓣膜,但仍有持续左室收缩功能异常AR的手术指征的手术指征:与严重MR 一样,AR 术前左室大小与术后射血分数的改善直接相关,但有两点重要不同:AR 术前心室较大者术后也可以维持正常射血分数。另外,如果射血分数的降低时间小于1214 个月,术后也可能恢复正常。 严重严重AR患者出现下列情况时应当考虑瓣膜患者出现下列情况时应当考虑瓣膜置换置换:出现症状、左室射血分数下降( 5.5 cm) 。 一旦出现明显的左室功能下降,手术结果将不会令人满意。左室收缩末径可以反映左室功能,并且不像射血分数那样受前负荷的影响AS的心导管诊治的心导管诊治:对于超声心动图诊断不明确的患者,可以做心导管检查,心导管检查的主要作用是排除伴发的冠心病,在此比其他瓣膜病更重要,因为主动脉瓣狭窄主要发生在老年人。通过心导管可做经皮球囊瓣膜成形术,但与经皮球囊二尖瓣扩张术(PBMC)治疗二尖瓣狭窄不同,主动脉瓣狭窄的瓣膜成形术常常不成功,其出血和栓塞的发生率较高,6 个月的成功率较低AS的外科治疗的外科治疗:应当认为AS 是一种外科疾病,因为没有药物可以代替手术治疗,也没有药物可以改善生存率。非手术治疗的预后很差。其手术指征为:超声心动图或心导管检查证实严重的主动脉瓣狭窄并伴有心脏症状。有少数患者可做瓣膜修补,但瓣膜置换术的效果更好。手术风险较高的患者可考虑做心导管球囊成形术。MR 的药物治疗的药物治疗:发生MR 后,左房扩大增加了二尖瓣后叶张力,紧拉叶瓣使瓣膜功能失常加重,所以严重MR 常是进展性的。严重MR 非手术治疗应限制体力活动,减少钠摄入,并通过合理应用利尿剂增加钠排泄。血管扩张剂和洋地黄可增加左室衰竭后的前向心输出量。静脉应用硝普钠或硝酸甘油可减少后负荷,减少返流,有助于稳定急性或重度MR 患者病情。无症状慢性MR 且射血分数正常时,并无后负荷增加,尚不清楚应用降低后负荷药物是否有利。ACEI治疗慢性MR 可能有益,特别是有症状或左室增大者,可减少MR 并使左室腔减小,但要注意ACEI 降低后负荷可能掩 盖左室功能不全,而有症状MR 患者则适用于手术治疗。与MS 一样,MR 患者近期心房颤动应考虑转为窦性心律。心力衰竭晚期患者应用抗凝药和下肢绷带,可减少静脉血栓形成和肺栓塞。MR 的手术治疗的手术治疗:必须全面考虑疾病缓慢进展的性质和瓣膜修复以及瓣膜置换所带来的远期及近期风险。没有症状或只在强体力活动受限者病情可稳定多年,不宜外科治疗。左室功能受损者手术治疗风险骤增,远期存活下降,但其保守治疗几乎没有有效的办法,即使在病情晚期,仍可考虑手术治疗。如果临床表现与超声心动图检查不一致时,左心导管检查和心血管造影可能有助于确认严重MR 的存在,还有助于发现相关瓣膜病变、病变严重程度以及发现需同时血管重建的病人手术的最佳时机:是慢性代偿期到失代偿期 的转变阶段。左室射血分数 60 % ,左室收缩末径 4.5 cm时手术效果最好。选择手术时机还要考虑肺动脉高压和心房颤动的情况关于老年瓣膜病合并心功能不全治疗关于老年瓣膜病合并心功能不全治疗1.正确判断瓣膜的受损部位、程度、范围2.把临床症状与病变情况结合考虑3.牢记心功能是病程的分水岭4.对心功能不全的治疗，应因病而治。美托洛尔治疗瓣膜性心脏病心力衰竭的随机对照研究 山西叶氏,经心脏超声确认为瓣膜性心脏病的心力衰 竭284 例中, 拒绝施行介入或手术治疗, 同意参与研究的184例, 其中男性80 例, 女性104 例, 年龄31 73 岁(平均56. 48. 3 岁) , 随机分为两组,A 组美托洛尔组,B 组常规治疗 延安大学学报延安大学学报(医学科学版医学科学版) Vo l14 No12 2006 年年6 月月所有入选患者接诊后均为按慢性收缩性心力衰竭治疗指南常规治疗, 待心功能纠正到 以上, 患者一般情况好转后(心功能分级按美国纽约心脏病学会N YHA 分级法) , 随机分为两组,A 组美托洛尔组,B 组常规治疗组,A 组开始口服美托洛尔12. 5mg/d, 每2w 增加1 次剂量, 最大用量75mg/d , 长期服用,A、B 两组其他用药均按心衰治疗指南 常规处理, 观察时间2 年。观察指标观察指标 死亡率统计两组在观察期内组间死亡率和总死亡率。延安大学学报延安大学学报(医学科学版医学科学版) Vo l14 No12 2006 年年6 月月 美托洛尔的心衰死亡率(4. 3%) , 明显低于总死亡(9.2% ) 和常规治疗组死亡率(14. 3%) , 两组比较有统计学意义(P 0. 05)。对心功能的控制与维持有良好作用,A 组心功能1 2 级者75 例(80. 6%) ,B 组心功能12 者32 例(35.2% ) , 两组比较有统计学意义(P 0. 05)。同时显示美托洛尔 对心衰患者运动与静息时心室率均有良好控制, 减少因心衰加重的住院率延安大学学报延安大学学报(医学科学版医学科学版) Vo l14 No12 2006 年年6 月月.青岛管氏,血液透析血液透析治疗老年心瓣膜病所致顽固性心力衰竭临床疗效评价临床医药（临床医药（2006）04-0135-02对1994年-2005 年入院的36 例老年心瓣膜病顽固性心力衰竭患者，在综合性治疗无效的基础上采用血液透析( H D ) 治疗临床医药（临床医药（2006）04-0135-02男性1 6 例，女性2 0 例，平均年龄69.6 6.1 岁(60-79 岁)，其中联合瓣膜病28 例，B 超检查证 实合并腹水1 1 例，单或双侧胸腔积液1 7 例。选择3 0 例同期未做血液透析的心瓣膜病顽固性心力衰竭患者，男性1 3 例，女性17 例，平均年龄6 9 . 5 6 . 0 岁（6 1 - 7 8 岁），其中联合瓣膜病2 1 例，B 超检查证实合并腹水1 0 例，单或双侧胸腔积液1 8 例。所有入选病人均符合顽固性心力衰竭的诊断标准，按N Y H A 心功能分级均为I I I - - I V 级充血性心力衰竭( C H F )临床医药（临床医药（2006）04-0135-023 6 例老年心瓣膜病顽固性心力衰竭患者，经血液透析治疗纠正心衰存活1 年以上的有1 7 例，其中1 0 例 于心衰纠正后做了瓣膜置换术，存活最长的已达5 年。1 个月内死亡1 9例，死亡的主要原因：7 例 死于难以控制的心源性休克；7 例 死于肾功能衰竭；3 例死于致命性心律失常；2 例死于严重的感染, 总病死率为5 2 . 7 7 % 。同期未做血液透析的心瓣膜病顽固性心力衰竭患者，1 周内3 0 例病人死亡2 1 例，1 个月内3 0例病人全部死亡，病死率为1 0 0 % ，与透析组相比差异十分显著临床医药（临床医药（2006）04-0135-02血液透析治疗老年心瓣膜病顽固性心力衰竭患者有效 可能与以下因素有关：( 1 ) 在短期内脱水，纠正顽固性水肿，减轻了心脏负荷，改善了心功能；（2 ）纠正了电解质紊乱、调整了神经内分泌激素的过度代偿，减少了恶性心率失常的发生；( 3 ) 恢复了可逆性损害的肾功能；( 4 ) 低蛋白血症在心力衰竭的过程中起重要的作用，血液透析中也易引起低血压，因此，及时发现并纠正低蛋白血症，是透析成功的关键。临床医药（临床医药（2006）04-0135-02 谢谢大家谢谢大家!