胡大一孫藝紅北京大學(xué)人民醫(yī)院

1、胡大一 孫藝紅北京大學(xué)人民醫(yī)院,中國(guó)心房顫動(dòng)流行病學(xué)現(xiàn)實(shí)與問(wèn)題,心房顫動(dòng) (AF),最常見(jiàn)的心律失常 發(fā)病率隨年齡增長(zhǎng)和器質(zhì)性心臟病的發(fā)展而增加卒中常見(jiàn)的病因之一 (占所有卒中10-15%)明顯增加心血管死亡和致殘即使經(jīng)過(guò)抗心律失常藥物治療，半數(shù)患者有復(fù)發(fā)傾向,,,,,,,,,,,AF占心律失常出院診斷1/3,Bialy D. J Am Coll Cardiol. 1992; 19: 41A.,18% Unspecif

2、ied,,Percent of subject died in follow-up,years,AF 死亡率,Benjamin EJ, Circulation 1998; 946-952,10%,30%,50%,,,,,Women, No AF,Men, AF,Women, AF,Men, No AF,Odds Ratio for Death,,Dorian P et al. J Am Coll Cardiol. 2000; 36:

3、 1303-1309 .,生活質(zhì)量,Higher scores = better QQL,*,*,*,*,?,?,,,,AF,CAD,Controls,* P<0.05, patients with AF compared to healthy controls? P<0.05, patients with AF compared to those with CAD,?,?,Framingham 研究: AF危險(xiǎn)因素,B

4、enjamin EJ, et al. JAMA, 1994; 271: 840-844,Ryder KM, et al. Am J Cardiol 1999; 84: 131R-138R.,AF患病率的地理差異,5.5%,5.4%,≥ 50 yrs, USA (CHS), single ECG≥ 65 yrs, UK, single ECG≥ 60 yrs, Netherlands, single ECG & medical

5、 record ≥ 50 yrs, UK, single ECG ≥ 55 yrs, Netherlands, single ECG≥ 35 yrs, USA, medical record≥ 50 yrs, UK, single ECG Review results≥ 60 yrs, Australia, triennial survey≥ 40 yrs, Japan, single ECG ≥ 60 yrs, Hong

6、 Kong, single ECG≥ 35 yrs, Denmark, single ECG25 - 64 yrs, west German, single ECG≥ 15 yrs, India, single ECG,,,,,,,,,,,,,,0.1%,5.1%,3.7%,3.0%,2.8%,2.4%,1.5%,1.3%,1.3%,0.60%,0.28%,Estimate of prevalence of AF vary bas

7、ed on the characteristics of population studied and how AF is ascertained.,% of hospitalization,7.65%,7.90%,8.16%,,,,,1999,2000,2001,,,,,,,,6.0%,6.5%,7.0%,7.5%,8.0%,9.0%,Qi W, et al. Chinese J Cardiol, 2003；31：913-916,A

8、F住院率增加：中國(guó),,Average,7.90%,中國(guó)AF的流行病學(xué) 14個(gè)自然人群, 13 個(gè)省,中國(guó)心房顫動(dòng)的流行病學(xué)調(diào)查,中國(guó)自然人群國(guó)際標(biāo)準(zhǔn)化方法 29079 人年齡> 35 歲連續(xù)采樣,Hu D, et al. 2004 Chin J Intern Med; in press.,方法,中國(guó)AF患病率 ---年齡/性別分層,Age Group, y,Rate per 100,30-39,40-49,50-59,6

9、0-69,Overall,,,Men (n=13358),Women (n=15521),0.3,0.2,0.5,0.6,1.4,1.1,3.6,2.6,7.5,7.4,70-79,≥80,0.9,0.7,Data collected from 13 natural populations from 14 different provinces across China,Hu D, et al. 2004 Chin J Int

10、ern Med; in press.,P<0.05,0.77,不同國(guó)家患病率比較,FHS: the Framingham study. Wolf PA et al. Sroke 1991; 22: 983-988Australia: Lake FR, et al. Aust NZ Med 1989; 19: 321-326UK: Hill JD et al. J R Coll Gen Pract 1987; 37: 172-1

11、73,,AF患病率：中國(guó)及其他地區(qū),,陣發(fā)性/持續(xù)性AF的趨勢(shì),Hu D, et al. 2004 Chin J Intern Med; in press.,陣發(fā)性AF的轉(zhuǎn)歸,64例17.9％,住院病人回顧分析 陣發(fā)性心房顫動(dòng) 358例平均5年后 64例（17.96%）變?yōu)槌掷m(xù)性房顫,2004 中國(guó)心臟起搏與心電生理雜志,中國(guó)AF卒中的患病率,%,12.95%,24.81%,17.5%,,,,,Hu D, 2004,Qi

12、W, 2003,,,,,,,,0,5%,10%,15%,20%,25%,Hu D, 2003,Hu D, et al. 2004 Chin J Intern Med; in press. Random sample of populationQi W, et al. 2003 Chin J Cardiol; 31: 913-916. Case-control study. Hospitalized patientsHu D, et

13、al. 2003 Chin J Intern Med; 42: 157-161. Case-control study. Hospitalized patients,,,,,,,,,,,,,,,,,0,5,10,Ma C, et al. Chin J cardiol 2002; 30: 165-167,<60,60–69,70–79,>80,AF患者卒中發(fā)生率：每年5.3%,%,Without risk factor,Wit

14、h risk factor,,,Age Range (years),1.0,1.6,3.1,5.1,4.0,8.8,,,7.7,7.9,520 consecutive nonvalvular AF patients without taking warfarin were followed 6.75±4.03 years. Hypertension, diabetes and ischemic stroke history

15、has a positive correlation with incidence of AF related stroke.,中國(guó)AF卒中危險(xiǎn)因素: 病例對(duì)照研究,回顧性研究, 18家醫(yī)院，2年,RVD: rheumatic valvular disease,HU D, et al. Chin J Intern Med, 2003; 42: 157-161,AF住院患者一般情況,,,Idiopathic AF,RVD,CHF,CAD,

16、Advanced age,58.1%,,56.3%,,Hypertension,,,,,caidiomyopathy,34.8%,33.1%,24.1%,7.4%,5.4%,,4.1%,Diabetes,CAD: coronary artery disease; CHF: congestive heart failure; RVD: rheumatic valve disease,HU D, et al. Chin J Intern M

17、ed, 2003; 42: 157-161,NVAF患者卒中患病率：年齡分層,,,,,,,years,,,0,5,10,15,20,25,Prevalence (%),,,,,,,,30,>40,40～49,60～69,50-59,70～79,,>80,HU D, et al. Chin J Intern Med, 2003; 42: 157-161,4.9,9.7,15.2,21.0,28.9,32.1,NVAF卒中危險(xiǎn)

18、:病例對(duì)照研究,HU D, et al. Chin J Intern Med, 2003; 42: 157-161,%,Lone AF,PersistenceAF,Control of heart rate,75.2,2.3,97.7,P<0.001,,,,,,,,0,25,Paroxymal AF,,Conversion,50,75,,24.8,51.9,,,,P=0.21,,,,,,100,None valve AF,P

19、=0.009,18.8,NVAF患者卒中危險(xiǎn)因素,AGE >76 yrs,Hypertension,Diabetes,LA thrombi,SBP,,,,,,,,,,1.76 (1.08-2.89),,,1.52 (1.28-1.80),,,1.39 (1.11-1.76),,,,1.71 (1.21-2.28),1,2,3,4,5,2.77 (1.25-6.13),,HU D, et al. Chin J Intern Med,

20、 2003; 42: 157-161,,,,,,,,,,,,,,,,,,,,,,,,,,,,0,2,4,6,8,AFASAK58%7– 81,SPAF67%27– 85,BAATAF86%51– 96,CAFA42%- 68– 80,SPINAF79%52– 90,TOTAL68%50–79,Risk reduction,AF Investigators. Arch Intern Med 1994;154:144

21、9-1457.Atwood et al. Herz 1993;18:27-38.,Stroke Incidence (%),95% CI,AF Investigators: Meta-analysisWarfarin for Stroke Prevention,p < 0.03,p < 0.01,p < 0.02,p > 0.2,p < 0.002,p < 0.001,老年人心房顫動(dòng) 年齡是抗

22、凝的禁忌嗎?,老年人禁忌癥多出血并發(fā)癥多對(duì)華法林敏感嚴(yán)密監(jiān)測(cè)INR，年齡不是危險(xiǎn)因素,Fihn SD, et al; Ann Int Med; 1996; 124: 970-979,抗栓治療明顯降低住院AF患者的卒中,Number of Strokes Prevented,Qi W, et al. Chinese J Cardiol, 2003；31：913-916,,,,,,,,,,0,5%,10%,15%,20%,25%,No

23、 Therapy,Anticoagulation,5.5%,24.2%,P<0.001,,stroke rate,華法林抗凝 433例（9.64％）平均年齡 61.48±12.44歲治療時(shí)間中位數(shù)為 7個(gè)月（1個(gè)月—3年）平均劑量 2.77±0.83mg（1-6mg）,,Hu D, et al. 2004 Chin J Intern Med;,中國(guó)住院AF病人華法林抗凝

24、治療,,非瓣膜性心房顫動(dòng)華法林年齡分層,Hu D, et al. 2004 Chin J Intern Med;,,,華法林抗凝監(jiān)測(cè)INR分布情況,中國(guó)住院AF病人INR監(jiān)測(cè)情況,24％,Hu D, et al. 2004 Chin J Intern Med;,華法林 阿司匹林 非抗栓,P=0.001,抗栓治療總出血發(fā)生率,中國(guó)住院AF病人華法林抗凝的安全性,Hu D, et al. 2004 Chin J Inter

25、n Med;,輕微出血（84%）嚴(yán)重出血（16%）,出血事件 31例 嚴(yán)重出血 5例 腦出血 2例 嚴(yán)重上消化道出血 2例

26、 硬膜下腔出血 1例輕微出血 26例 鼻出血 6例 齒齦出血 6例 血尿 5例 皮膚粘膜瘀斑 5例 黑便 3例 球結(jié)

27、膜出血 1例,中國(guó)住院AF病人華法林抗凝的安全性,p=0.259,65 62,OR=3.73 (p=0.001),華法林抗凝并發(fā)出血的危險(xiǎn)因素,中國(guó)住院AF病人華法林抗凝的安全性,,,,56% Rhythm control,20% Rate control,24% NO therapy,,Amiodarone 31.0%,Cedilanid 29.6%,β-Blocker

28、 18.3%,Propafenone 14.3%,陣發(fā)性AF住院患者 — 治療現(xiàn)狀,Qi W, et al. Chinese J Cardiol, 2003；31：913-916,,,,Rate Control 83%,Rhythm Control 14%,No treatment3%,持續(xù)性AF住院患者 — 治療現(xiàn)狀,Qi W, et al. Chinese J Cardiol, 2003；31：913-916,,2% Warfar

29、in,60% None,Aspirin38%,AF患者抗栓治療現(xiàn)狀：人群流調(diào),Hu D, et al. 2004 Chin J Intern Med; in press,,,9.64% Warfarin,90.36% No anticoagulation,Sun Y, Hu D, et al. Chinese J Cardiol, 2004；43：258-260,AF住院患者抗凝治療的現(xiàn)狀,N=4511,INR was monit

30、ored in 77.2% patients treated with warfarin Thirty one (7.11%) confirmed bleeding events CHF and HT increased the risk of bleeding during warfarin treatment INR between 1.5 and 3.0 is safe and effective,結(jié) 論,AF的流行病學(xué)危