血管紧张素受体拮抗剂抗房颤的作用——事实与争议

大量的基础研究证实,肾素-血管紧张素-醛固酮（RAAS）系统参与了促心律失常的病理生理过程。一些前瞻性临床试验也提示,使用血管紧张素受体拮抗剂（ARBs）阻断RAAS系统,在心房颤动（房颤）的一、二级预防中均能获益。近年来意大利多中心房颤试验（GISSI—AF）却报道了使用缬沙坦药物并不能预防房颤复发。该文对ARBs抗房颤的作用作一综述。     

血管紧张素受体拮抗剂抗房颤的作用——事实与争议

大量的基础研究证实,肾素-血管紧张素-醛固酮（RAAS）系统参与了促心律失常的病理生理过程。一些前瞻性临床试验也提示,使用血管紧张素受体拮抗剂（ARBs）阻断RAAS系统,在心房颤动（房颤）的一、二级预防中均能获益。近年来意大利多中心房颤试验（GISSI—AF）却报道了使用缬沙坦药物并不能预防房颤复发。该文对ARBs抗房颤的作用作一综述。     

非杓型EH患者RAAS及靶器官损害指标测定与分析

目的研究原发性高血压患者（EH）血压昼夜节律与肾素—血管紧张素—醛固酮系统（RAAS）及靶器官损害的关系。方法研究对象为同期收治的49例EH患者,其中血压昼夜节律为非杓型23例（A组）、杓型26例（B组）,分别检测两组RAAS指标包括血浆肾素、血管紧张素、醛固酮水平;行超声心动图检查,测量左室舒张末期内径（LVDD）、舒张期室间隔厚度（IVST）、左室后壁厚度（PWT）;留取清晨中段尿,测定24 h尿蛋白定量、血肌酐（SCr）、血尿素氮（BUN）。结果 A组血浆肾素、血管紧张素、醛固酮水平均明显高于B组,LVDD、IVST、24 h尿蛋白定量均明显大于B组（P均〈0.05）。结论非杓型分布EH患者发生RAAS异常及靶器官并发症的危险性更高。     

血清肾素-血管紧张素醛固酮水平与代谢综合征的相关性

目的:研究血清肾素-血管紧张素醛固酮水平与代谢综合征(MS)及其组分的相关性。方法:198例体检者采空腹静脉血查血糖(FPG)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)、总胆固醇(TC)及肾素、血管紧张素、醛固酮水平、行糖耐量(OGTT)检测,测血压、身高及体重,计算体重指数(BMI)及醛固酮肾素比值,相关回归分析血清RAAS水平与血脂、血压、血糖、BMI及MS的相关性。根据是否患有MS分为MS组及对照组,比较2组的肾素、血管紧张素、醛固酮水平及醛固酮肾素比值大小。结果:血管紧张素Ⅱ与血脂组分TC(r=0.329)、TG(r=0.936)及BMI(r=0.29)正相关,与HDL-C(r=-0.256)负相关,与LDL-C(r=0.116,P=0.111)无明显相关性,Logestic回归分析血管紧张素Ⅱ与高血压、高血糖、高血脂及代谢综合征均有明显相关性(P0.001),其中与MS回归系数最高(Exp(B)=1.082),MS组血清肾素、血管紧张素Ⅰ、血管紧张素Ⅱ、醛固酮水平均明显高于对照组(P=0.000),2组醛固酮肾素比值无差异。结论:RAAS水平与MS密切相关。     

高血压合并心房颤动的机制及危险因素

高血压与心房颤动(AF)的发生密切相关,约60%~80%的AF患者会同时并存高血压。目前无论从流行病学还是临床研究角度,高血压患者AF发生风险增加的致病机制和风险因素均尚不明确。高血压合并AF风险增加可能与左房、左室功能和结构重构以及肾素-血管紧张素-醛固酮系统(RAAS)活跃有关。高血压患者新发AF的相关风险因素可能与高血压水平、心动过速、脉压差大、血压控制程度及抑制RAAS有关。     

房颤患者脑钠肽与心功能及肾素、血管紧张素、醛固酮系统的关系

目的探讨持续性房颤患者的血浆脑钠肽(BNP)水平与心功能及肾素、血管紧张素Ⅱ、醛固酮系统的关系。方法把55例持续性房颤患者分为心功能正常组35例与心衰组20例,和50例对照组进行血浆BNP、肾素、血管紧张素、醛固酮水平检测,并经胸心脏超声检查测定左房内径(LAD)、左室射血分数(LVEF)等。结果房颤组无论心功能正常组还是心衰组,BNP水平均明显高于对照组,肾素、血管紧张素、醛固酮水平也明显高于对照组。多元线性逐步回归分析,BNP与LAD和血管紧张素Ⅱ高度相关,心衰组BNP与LVEF明显相关。结论房颤患者BNP明显升高,与心房重构及肾素、血管紧张素、醛固酮系统密切相关。     

肾素-血管紧张素-醛固酮系统中单核苷酸多态性与心房颤动的相关性

最近的研究指出,肾素-血管紧张素-醛固酮系统(RAAS)的生理作用可增加心房颤动(简称房颤)发生的风险,其中认为RAAS中的单核苷酸多态性在房颤发生的过程中起着重要的作用。目前的研究表明,肾素与房颤的相关性尚无明确报道,血管紧张素原、血管紧张素转化酶、血管紧张素转化酶2、血管紧张素II-1型受体、醛固酮合酶等基因与房颤的发生有着一定的影响,但结果存在着争议。     

原发性醛固酮增多症患者血浆肾素-血管紧张素-醛固酮系统异常对糖代谢的影响

目的探讨原发性醛固酮增多症（PA）患者血浆肾素血管紧张素-醛同酮系统变化对糖代谢的影响及其可能的机制。方法收集55例PA患者以及年龄和BMI相匹配的原发性高血压（EH）患者50例的I临床资料进行分析,PA患者根据血糖水平分为正常血糖组、空腹血糖受损和糖耐量减低组和糖尿病组。结果PA组的糖代谢异常发生率高于EH组（43．6％vs20．0％,P〈0．05）。PA患者中糖尿病组的血浆卧、立位醛固酮水平低于血糖正常组（P〈0．05）,而肾素活性和血管紧张素水平组间比较均无显著差异,立位醛固酮与肾素比值也无显著差异。结论PA患者糖代谢异常发生率高于EH患者。在血浆肾素-血管紧张素醛固酮系统中,糖代谢异常与醛固酮水平明显相关,与血管紧张素水平无关。     

高血压合并房颤时如何选择降压药？

匡培清(江阴市疾病预防控制中心慢性病防所,江苏 江阴 21400) 肾素血管紧张素醛固酮系统(RAAS)在房颤(AF)的发生发展中有重要作用.血管紧张素Ⅱ(Ang Ⅱ)能:     

血浆肾素、血管紧张素II和醛固酮与肝纤维化关系的实验研究

肾素-血管紧张素-醛固酮系统（RAAS）是机体调节血管张力和钠水代谢的内分泌系统。肝硬化患者常有。肾素-血管紧张素系统活性增高和醛固酮增多，一般认为系肝脏对醛固酮的灭活减少等引起的。但近年来的研究表明，多种器官和组织都能合成肾素和血管紧张素系统的成分，参与器官纤维化。肝脏也存在局部肾素．血管紧张素系统。为深入了解血浆肾素、血管紧张素和醛固酮水平与肝纤维化的关系。     

Clinical and Prognostic Significance of Atrial Fibrillation in Acute Myocardial Infarction

The clinical significance of the time of onset of atrial fibrillation (AF) was investigated in patients with acute myocardial infarction (AMI). Among 1,039 patients with AMI, 100 (9.6%) had AF. These patients were divided into 3 groups: AF group 1 (n = 45), who developed AF within 24 hours of the onset of AMI; AF group 2 (n = 41), who developed AF>24 hours after the onset of AMI; and AF group 3 (n = 14), who developed AF before the onset of AMI. The infarct-related lesion was most frequent (67%) in the proximal right coronary artery in AF group 1 (p <0.01). Right atrial pressure was most significantly increased in AF group 1. The left atrial dimension and pulmonary arterial wedge pressure were most significantly increased, and left ventricular ejection fraction was most significantly decreased in AF group 2. In the acute phase, the frequencies of heart failure, cardiogenic shock, and in-hospital mortality were higher for all 3 AF groups than the sinus group (p <0.01). The long-term survival rate was significantly lower in AF group 1 and AF group 2 than in the sinus group. AF was an independent predictor of cardiac death in both AF group 1 (odds ratio 2.5; 95% confidence interval 1.2 to 5.0; p = 0.0012) and AF group 2 (odds ratio 3.7; 95% confidence interval 1.8 to 7.5; p = 0.0005), but not in AF group 3. The onset time of AF appears to be a useful parameter for evaluating the cardiac status and prognosis of patients with AMI.     

急性心肌梗死并发心房颤动的临床意义

目的 观察急性心肌梗死并发心房颤动的临床意义。方法 比较急性心肌梗死心房颤动组20例和非心房颤动组132例的心力衰竭发生率及死亡率。结果 急性心肌梗死心房颤动组心力衰竭发生率（90．0％），及死亡率（60．0％）均明显高于非心房颤动组（31．1％，15．1％，P〈0．01）。结论 急性心肌梗死并发心房颤动预后较差。     

Prognostic Significance of Newly Diagnosed Atrial Fibrillation After Acute Myocardial Infarction: A Study of 184,980 Medicare Patients

We aimed to determine whether newly diagnosed atrial fibrillation (AF) predicted cardiovascular events and death after myocardial infarction (AMI) in a large nationwide cohort of patients. All Medicare beneficiaries aged >65 years who were discharged alive after a diagnosis of AMI between January 1, 2007 and December 31, 2008 were identified. Main exposure was a diagnosis of AF during admission or within 90 days after discharge. Primary outcome was a composite of recurrent AMI, stroke and all-cause mortality. Secondary outcomes were each of recurrent AMI, stroke and all-cause mortality. We used Cox proportional hazards regression to assess the relationship between AF and time-to-event outcomes with follow up ending at 3 years. Of 184,980 patients, 9.1 % had AF; 40.6 % were male; 82.8 % were non-Hispanic whites. Mean age was 79.1 ± 8.1 years. Overall, 15.7 % had subsequent AMI, 5.7 % had stroke and 43.9 % died during a mean follow up of 26.4 months. AF was associated with a significantly increased risk of the primary outcome (Hazard ratio (HR) = 1.10; 95 % confidence interval (CI): 1.07–1.12). AF was also separately associated with significantly increased risk of recurrent AMI (HR = 1.09; 95 % CI: 1.04–1.14), stroke (HR = 1.29; 95 % CI: 1.21–1.37), and death (HR = 1.09; 95 % CI: 1.06–1.12). Neither age, race nor sex modified the effects of AF on primary or secondary outcomes. In conclusion, AF is a significant predictor of adverse cardiovascular outcomes and mortality after AMI. Further studies are needed to understand mechanisms by which AF alters outcomes in survivors of AMI.     

急性心肌梗死并发心房颤动/心房扑动的影响因素及预后分析

目的分析急性心肌梗死(AMI)患者合并心房颤动(atrial fibrillation,Af)/心房扑动(atria flutter,AF)的发病率、临床特点、影响因素及其对院内死亡的影响。方法将我院收治的653例AMI患者分为Af/AF组(61例)及无Af/AF组(592例),分析发生Af/AF的相关危险因素;再根据是否在院内死亡分为院内死亡组(64例)及未死亡组(589例),评估Af/AF对AMI患者院内死亡的影响。结果AMI患者初发Af/AF的发生率为9.3%。单因素分析显示,Af/AF组与无Af/AF组在年龄、性别、入院时心率、心肌梗死范围、Killip分级、左心室射血分数、入院时血肌酐水平及血红蛋白水平均有显著性差异(P<0.05)。Af/AF组与无Af/AF组多因素logistic回归分析显示,多部位心肌梗死、女性是影响AMI患者发生Af/AF的最主要独立危险因素;院内死亡组与未死亡组多因素lo-gistic回归分析显示,Af/AF是影响AMI患者院内死亡的独立危险因素。结论Af/AF是AMI患者常见的并发症,合并Af/AF的患者住院期间的预后更差。     

Prognostic significance of atrial fibrillation/atrial flutter in patients with acute myocardial infarction treated with percutaneous coronary intervention

Atrial fibrillation (AF) is a frequent complication after acute myocardial infarction (AMI) that has been associated with increased in-hospital and long-term mortality rates in the prethrombolytic and thrombolytic eras. Current therapies, including percutaneous coronary intervention (PCI), are effective in reducing mortality in patients with AMI. However, little is known concerning the incidence and prognostic significance of AF in patients with AMI who are treated with PCI. We evaluated 2,475 consecutive patients with AMI who underwent PCI within 24 hours after onset and who were enrolled in the Osaka Acute Coronary Insufficiency Study. Patients were categorized into 2 groups according to the presence of AF or atrial flutter. The incidence of AF was 12.0%. Patients with AF were older, were in higher Killip classes, had higher rates of previous myocardial infarction and previous cerebrovascular disease, had systolic blood pressure of <100 mm Hg and heart rates of > or =100 beats/min, multivessel disease, and had poorer reperfusion of the infarct-related artery than those without AF. Patients with AF had higher in-hospital (16.0% vs 6.7%, p <0.001) and 1-year (18.9% vs 7.9%, p <0.001) mortality than those without AF. Multivariate Cox regression analysis revealed that AF was an independent predictor of 1-year mortality (hazard ratio 1.64, 95% confidence interval 1.05 to 2.55) but was not a predictor of in-hospital mortality. AF is a common complication in patients with AMI who are treated with PCI and independently influences 1-year mortality.     

P Wave Dispersion and P Wave Duration on SAECG in Predicting Atrial Fibrillation in Patients with Acute Myocardial Infarction

Background: Atrial fibrillation (AF) is a frequent complication of acute myocardial infarction (AMI), with reported incidence of 7% to 18%. The incidence of congestive heart failure, in‐hospital mortality, and long‐term mortality is higher in AMI patients with AF than in AMI patients without AF. P wave duration on signal‐averaged ECG (PWD) and P wave dispersion on standard ECG (Pd) are noninvasive markers of intra‐atrial conduction disturbances, which are believed to be the main electrophysiological cause of AF. Methods: In the present study we investigated prospectively whether P wave duration on SAECG and P wave dispersion on standard ECG can predict development of AF in a group of patients with AMI. One hundred and thirty patients (100 men and 30 women, aged 56.9 ± 12) with AMI were investigated. PWD, Pd, their clinical and hemodynamic characteristics were collected. Results: During the observation up to 14 days, 22 patients (16.9%) developed AF. Univariate analysis variables associated with development of AF: age > 65 years, Killip class III‐IV, PWD > 125 ms, and Pd > 25 ms. Stepwise logistic regression analysis showed that age > 65 years, PWD > 125 ms, and Pd > 25 ms were independently associated with AF. Conclusions: PWD and Pd both measured in a very early period of AMI are useful in predicting AF. A.N.E. 2002;7(4):363–368     

急性心肌梗塞合并心房纤颤的冠状动脉血管病变分析

目的通过分析急性心肌梗塞并发心房纤颤患者的冠状动脉病变的特点,探讨冠脉病变的不同程度对急性心肌梗塞时房颤发生的影响。方法回顾性分析了急性心肌梗塞并发房颤的患者（８７例）,与同期无房颤发生的心肌梗塞患者（６００例）的冠状动脉造影、急诊ＰＴＣＡ和静脉溶栓的临床资料。结果两组患者的梗塞相关血管发生的部位差别无显著性。而三支血管病变的发生率房颤组（３１．４％）显著高于非房颤组（１８．８％）;梗塞相关血管的再通率非房颤组（６９．６％）显著高于房颤组,在房颤组中,早期组的冠脉再通率（７３．６％）又显著高于后期组（１６．６％）。结论冠脉血管的多支病变和灌注不良与急性心肌梗塞后房颤的发生密切相关。急性心肌梗塞后早期发生房颤者冠脉血管再通率高,提示ＡＭＩ发病后早期房颤的发生可能与再灌注损伤有关。     

Prognostic risk of atrial fibrillation in acute myocardial infarction complicated by left ventricular dysfunction: the OPTIMAAL experience.

AIMS: The present study aimed to determine the frequency and the impact on clinical outcome of atrial fibrillation (AF) in patients with acute myocardial infarction (AMI) and left ventricular dysfunction. METHODS AND RESULTS: In the OPTIMAAL trial, 5477 patients with AMI and signs of left ventricular dysfunction were included. At baseline, 655 patients (12%) had AF, and 345 (7.2%) developed new-onset AF during follow-up (2.7 +/- 0.9 years). Older patients, patients with history of angina and worse Killip class had and developed AF more frequently (P < 0.001). Patients with AF at baseline were at increased risk relative to those without AF for mortality [adjusted hazard ratio (HR) of 1.32, P = 0.001] and for stroke (HR 1.77, P < 0.001). New-onset AF was associated with increased subsequent mortality for the first 30 days following randomization (HR 3.83, P < 0.001) and the entire trial period (HR 1.82, P < 0.001). Risk of stroke was increased for the first 30 days (HR 14.6, P < 0.001) and for the whole trial period (HR 2.29, P < 0.001). CONCLUSION: AF is frequently observed in patients with AMI complicated by heart failure. Current AF, and the development of new AF soon after AMI, is associated with increased risk of death and stroke.     

Predicting new onset atrial fibrillation post acute myocardial infarction: Echocardiographic assessment of left atrial size

Background

Atrial fibrillation (AF) commonly occurs following acute myocardial infarction (AMI). Left atrial (LA) size has been reported to predict new onset AF in this cohort, however, the optimal metric of left atrial size for risk stratification following AMI is unknown.

Methods

Patients presenting to a tertiary hospital with incident AMI (NSTEMI or STEMI) and no history of AF were recruited. All patients underwent guideline-based workup and management for AMI, including transthoracic echocardiographic assessment. Three alternative metrics of left atrial size were determined: LA area, maximal and minimal LA volume indexed to body surface area (LAVImax and LAVImin). The primary endpoint was new onset AF diagnoses.

Results

Four hundred thirty three patients were included in the analysis, of which 7.1% had a new diagnosis of AF within a median follow-up of 3.8 years. Univariate predictors of incident AF included age, hypertension, revascularization with CABG, NSTEMI presentation, right atrial area, and all three metrics of LA size. Among three multivariable models created for the prediction of new onset AF utilizing alternate metrics of LA size, LAVImin was the only LA size metric found to be an independent predictor.

Conclusions

LAVImin is an independent predictor of new onset AF post AMI. LAVImin outperforms echocardiographic assessment of diastolic dysfunction and alternative metrics of LA size (including LA area and LAVImax) for risk stratification. Further studies are needed to validate our findings in post AMI patients, and evaluate whether LAVImin holds similar advantages over LAVImax in other cohorts.     

Predictive Value of P‐Wave Signal‐Averaged Electrocardiogram for Atrial Fibrillation in Acute Myocardial Infarction

Background: Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) with a reported incidence of 7–18%. Recently, P‐wave signal‐averaged electrocardiogram (P‐SAECG) has been used to assess the risk of paroxysmal AF attacks in some diseases. The aim of this study was to determine prospectively whether patients with AMI at risk for paroxysmal AF would be identified by P‐SAECG and other clinical variables. Methods: A total of 100 patients (mean age: 59 ± 12 , 77 male, 23 female) with ST segment elevation AMI were enrolled in this study. Patients with chronic AF were excluded. At entry, all patients underwent standard 12‐lead ECG and in the first 24 hours, P‐SAECG was taken, and echocardiography and coronary angiography were performed on the patients. Patients are followed for a month in terms of paroxysmal AF attacks and mortality. Results: AF was determined in 19 patients (19%). In patients with AF, abnormal P‐SAECG more frequently occurred than in patients without AF (37% vs 15%, P < 0.05) . Patients with AF were older (70 ± 14 vs 56 ± 10, P < 0.001) and had lower left ventricular ejection fraction (42%± 8 vs 49%± 11, P < 0.05) . AF was less common in thrombolysis‐treated patients (47% vs 74%, P <0.05) . Thirty‐day mortality was higher in patients with AF (16% vs 2%, P = 0.05) . Conclusions: An abnormal P‐SAECG may be a predictor of paroxysmal AF in patients with AMI. Advanced age and systolic heart failure were detected as two important clinical risk factors for the development of AF.