老年人心瓣膜病合并房颤及心衰的处理原则课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,整理ppt,*,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,整理ppt,老年人心瓣膜病合并房颤及心衰的处理原则整理ppt,1,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,整理ppt,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,2,整理ppt,整理ppt,3,整理ppt,整理ppt,4,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,整理ppt,国外报道的发病率明显高于国内。Pomerance 等 尸检1,5,整理ppt,整理ppt,6,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,整理ppt,The incidence and etiological,7,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,整理ppt,Mitral stenosis was found in 2,8,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,整理ppt,Aortic stenosis was noted in 3,9,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,整理ppt,Etiological classification rev,10,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.,整理ppt,A total of 458 cases (11.5%) w,11,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.,整理ppt,an etiology of the valvular di,12,整理ppt,整理ppt,13,整理ppt,整理ppt,14,仍关注对老年人风心病,整理ppt,仍关注对老年人风心病整理ppt,15,。,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,整理ppt,。山西医科大学第一临床医学院心内科从1979 - 0119,16,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。,整理ppt,老年风心病215 例,所占比例为17.5 %。逐年住院比例由,17,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,整理ppt,老年退行性心脏瓣膜病又称老年钙化性心脏瓣膜病(SCHVD),18,A Novel Role of the Sympatho-Adrenergic System in Regulating Valve Calcification,Recent 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 ,2006,整理ppt,A Novel Role of the Sympatho-A,19,Salmeteroltereatment 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,整理ppt,In elderly patients (arbitrari,29,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,整理ppt,Another serious challenge in t,30,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).,整理ppt,关于抗血栓治疗(瓣膜病)antithrombotic the,31,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).,整理ppt,Among the key recommendations,32,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,整理ppt,In people with mitral valve pr,33,(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).,整理ppt,(房颤)This chapter about antithr,34,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).,整理ppt,Among the key recommendations,35,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 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,整理ppt,手术的最佳时机:是慢性代偿期到失代偿期整理ppt,60,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。,整理ppt,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、,61,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(医学科学版) Vo l14 No12 2006 年6 月,整理ppt,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,62,整理ppt,整理ppt,63,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,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(医学科学版) Vo l14 No12 2006 年6 月,整理ppt,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,64,整理ppt,整理ppt,65,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(医学科学版) Vo l14 No12 2006 年6 月,整理ppt,美托洛尔的心衰死亡率(4. 3%) , 明显低于总死亡(9,66,.,青岛管氏,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（2006）04-0135-02,整理ppt,.青岛管氏,血液透析治疗老年心瓣膜病所致顽固性心力衰竭临床疗,67,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（2006）04-0135-02,整理ppt,对1994年-2005 年入院的36 例老年心瓣膜病顽固性,68,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（2006）04-0135-02,整理ppt,男性1 6 例，女性2 0 例，平均年龄69.6 6.1,69,3 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（2006）04-0135-02,整理ppt,3 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,70,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（2006）04-0135-02,整理ppt,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,71,谢谢大家!,整理ppt,谢谢大家!,72,