心房顫動(dòng)的治療新的循證醫(yī)學(xué)證據(jù)——英文

1、Management of Atrial Fibrillation：Update in the EBM proof,ChangSheng Ma Department of Cardiology, Beijing Anzhen Hospital Capital Medical University, P.R. China,Prevalence of AF is increasing,,Go: JAMA, 2001：2370,Miya

2、saka.Circulation.2006:119,Year,,Prevalence of AF is increasing,Prevalence %,Age,Prevalence of AF:the Rotterdam study,Heerinaga.Eur Heart J,2006,949,6808 pts., F/U 6.9 yrs，prevalence 5.5%,Incidence ‰,Age,Incidence of AF:t

3、he Rotterdam study,Heerinaga.Eur Heart J,2006,949,6808 pts., F/U 6.9 yrs，Incidence 9.9‰,Identified AF：the tip of the iceberg,14802 pts aged 65 or over，randomized to systemic screening and opportunistic screening S

4、ystemic screening group:9866 pts. Opportunistic screening group: 4936 pts.F/U 12 mons Rate of new AF case in systemic screening 1.63%， Rate of new AF case in opportunistic screening 1.04%,Fitzmaurice.BMJ.2007,3

5、83,Risk for stroke increased in lone AF,Jahangir. Circulation. 2007:3050,Meta-analysis:antithrombotic therapy of AF,Hart.Ann Intern Med,2007,857,Real world of warfarin in the elderly,The first 90 days associated with ma

6、jor hemorrhage21% pts withdrawn warfarin for safety issueThe higher risk of stroke, the higher incidence of major hemorrhage,Hylek. Circulation.2007,2689,HR for ICH was 4.06 for Asians,Asians were at greater risk for

7、 warfarin-ralated ICH,Shen. JACC.2007:309,Prospective，randomize，control973 pts ?75 years old with AFRandomized into warfarin arm (INR 2.0-3.0) and Aspirin arm(75mg/d)Mean F/U 2.7 yrsPrimary outcome：fatal or disabling

8、 stroke, intracranial haemorrhage, or arterial embolism,Warfarin versus aspirin for stroke prevention in the elderly with AF,(The Birmingham Atrial Fibrillation Treatment of the Aged Study,BAFTA study),Mant.Lancet,2007,4

9、93,Warfarin versus aspirin for stroke prevention in the elderly with AF,Mant.Lancet,2007,493,Mant.Lancet,2007,493,Warfarin versus aspirin for stroke prevention in the elderly with AF,Anticoagulation in clinical practice,

10、2.03/100person-yrs,1.17/100person-yrs,,Go.JAMA 2003:2685,Rivaroxaban,Enoxaparin,,,873 ptsEndpoints included DVT,PE,all cause mortality Safety：major hemorrhage,,,Endpoints,Safety,Eriksson. Circulation. 2006: 2374,%,Riva

11、roxaban —New promise of anticoagulation？,Prospective RIKS-HIA60764 pts，AF 21459 pts,CHF 22345 pts,AF+CHF16960 ptsF/U 1 yrHigher mortality rate in AF without CHF pts taking digoxin (RR1.42)Similar mortality rate in C

12、HF or AF+CHF pts with or without digoxin,Digoxin and mortality in AF:A prospective cohort study,Hallberg.Euro J Clin Pharmacol,2007,959,Hallberg.Euro J Clin Pharmacol,2007,959,Digoxin and mortality in AF:A prospective

13、cohort study,Adverse effects of oral amiodarone,Zimetbaum.NEJM.2007:935,Nichol G . Heart. 2002:535J Am Coll Cardiol. 2003:20,AADs is insufficient to maintain sinus rhythm,Amiodarone increased mortality of HF SCD－HeFT研究

14、,Bardy. NEJM,2005: 225,,Dronedarone：Substitution of amiodarone？,Derivative of amiodarone, not composed of iodineEliminate the effects of amiodarone on thyroid and pulmonary functionsHalf-time 24 hours,22.6% discontinua

15、tion because of GI tract complications,Touboul.PACE.2002:574(A),Dronedarone for maintenance of SR in AF：multicenter, double-blind, randomized trials,Singh.NEJM.2007,987,Catheter ablation is superior to antiarrhythmic dur

16、g,A prospective, multicenter, randomized, controlled study,ablation+AADs,AADs,137 AF pts (CAF 33%) Randomization CPVA+isthmus ablationTranstelephonic ECG ，Holter F/U 1 yrAblation +AAD success rate 55.9%Success

17、 rate of AADs 8.7%,Stabile.Eur Heart J.2006:216,,,,APAF Trial,29%,Pappone. JACC. 2006:2340,,86%,22%,Oral.NEJM.2006:934,146 CAFEvent recorder F/UCPVA:74% > AAD:4%,Catheter ablation decrease the incidence of st

18、roke,755 ptsThe incidence of stroke/TIA was 1.1%0.9% occurred whithin 2 weeks of RFCA79% of pts without risk factor for stroke and 68% of pts with ≥ 1 risk factor in sinus discontinued warfarinPatients with sinus rh

19、ythm was thromboembolic event free after the procedure,,,Oral.Circulation.2006:759,Pappone . JACC.2003:185,N=589,,N=582,Catheter ablation reduce stroke,Pappone . JACC.2003:185,,Catheter ablation improve prognosis,No risk

20、 factor： ASA 81- 325mg One moderate risk factor：ASA 81- 325mg or warfarinAny high risk factor or more than one moderate risk factor: warfarin,Principles of anticoagulation,Amiodarone＝Ablation

21、！,No OHD yesHTN yes（concomitanc with LVH amiodarone>ablation ）CAD yesHF amiodarone>ablation,Maintain Sinus Rh

22、ythm,Catheter ablation is a reasonable　alternative to　pharmacological therapy to prevent recurrent　AF (IIa,C),Fuster. Circulation.2006 :e257,Indications for catheter ablation,The presence of symptomatic AF refractory or

23、intolerant to at least one Class 1 or 3 antiarrhythmic medicationin rare clinical situations, it may be appropriate to perform catheter ablation of AF as first line therapyselected symptomatic patients with heart failu

24、re and/or reduced ejection fractionLA thrombus is a contraindication,HRS/EHRA/ECAS Expert Consensus Statement,AF Ablation as first-line therapy?(Catheter Ablation vs. Antiarrhythmic Drug Therapyfor Atrial Fibrillation

25、 Trial, CABANA),Ongoing NIH sponsored CABANA study: mortality study of AF ablation vs. antiarrhythmics vs. rate control/coumadin as first-line therapy for AFMain study to enroll 3,000 patients at 100 centersPatients wi