围手术期不同抗凝策略对病窦综合征合并心房颤动患者起搏器植入术后囊袋相关并发症及血栓栓塞事件的影响

目的观察围手术期不同抗凝策略对病窦综合征(SSS)合并心房颤动(AF)患者起搏器植入术后囊袋相关并发症及血栓栓塞事件的影响。方法将84例应用华法林抗凝的SSS合并AF需要接受起搏器植入的患者分为3组。A组:围手术期不中断华法林;B组:停用华法林,低分子肝素桥接治疗;C组:停用华法林。观察术后1年内囊袋相关并发症及血栓栓塞事件的发生情况。结果 A组出现囊袋血肿2例;B组出现囊袋血肿3例,其中1例囊袋破溃并拔除起搏系统;C组囊袋血肿2例。A、B组均无血栓栓塞事件发生;C组围手术期出现急性脑梗塞2例。结论 SSS合并持续性AF卒中中高危患者起搏器植入不停用华法林未明显增加囊袋相关并发症,未出现明显血栓栓塞事件。     

抗凝药物不足与过量对高危心房颤动患者的预后孰好孰坏

欧洲心脏病调查小组通过对心房颤动（AF）患者抗凝治疗的资料分析发现，对于高危AF患者来说，抗凝药物用量不足可导致恶性心血管事件发生，然而过量使用则不会增加出血的风险。该小组以2001年ACC／AHA／ESC制定的AF控制指南规定的抗凝药物用量作为标准，通过对2003至2004年AF患者1年内的抗凝治疗及并发血栓栓塞、出血、卒中等资料进行整理和统计学分析。其中有3634例（占总病例数的89％）患有AF的高危患者：抗凝药用量不足964例（28％），     

长期抗凝者植入心脏植入装置围手术期抗凝策略

大量需要植入心脏植入装置的患者正在接受长期抗凝治疗,围手术期面临出血和血栓栓塞事件的双重风险,多数指南推荐根据患者血栓栓塞危险度决定抗凝方案。围手术期进行肝素桥接或双联抗血小板治疗可显著增加囊袋血肿发生的风险,而不间断华法林可能是平衡利弊的优秀策略。现对长期抗凝者心脏植入型电子装置植入围手术期抗凝策略的现状和进展进行综述。     

心房颤动患者心脏植入型电子装置围术期抗凝研究进展

对需要植入心脏植入装置的心房颤动患者,围手术期暂停华法林并使用肝素桥接可增加囊袋血肿发生的风险,目前,建议不间断华法林治疗。而新型口服抗凝药虽具有低出血及栓塞风险、剂量稳定、监测便捷等优点,其在围手术期间的应用策略仍存在诸多争议。如何平衡出血及血栓栓塞事件的风险,制定房颤患者的起搏器围术期抗凝策略,仍是一个亟待解决的问题。     

心脏植入电子装置的患者围手术期的抗栓治疗

近年来,越来越多接受心脏植入电子装置(CIED)患者围手术期需要抗凝(AC)和/或抗血小板(AP)治疗。目前指南多推荐血栓中高危患者围手术期采用肝素桥接策略(HBS),但临床观察及荟萃分析显示HBS导致出血风险显著增加,而不中断口服抗凝疗法并不增加血栓事件发生率;双联AP与单联AP相比,前者明显增加术后出血风险。因此,围手术期对接受CIED植入的易栓患者应选择口服AC疗法或单联AP疗法的方案。     

合并慢性肾脏疾病的心房颤动患者的治疗

心房颤动（atrial fibrillation,AF）和慢性肾脏病（chronic kidney disease,CKD）存在双向作用。CKD增加AF患者卒中/血栓栓塞风险和出血风险,不同口服抗凝药、左心耳封堵术在合并CKD的AF人群中的有效性及安全性尚需更多研究数据支持。是否合并CKD不影响AF患者心率控制或节律控制策略的选择,而导管消融的有效性和安全性数据尚不充分。本文就合并CKD的AF人群抗凝策略、心率控制或节律控制策略等方面的研究进展做一综述。     

心房颤动患者卒中预防中的抗凝治疗：安全性和依从性

心房颤动（atrial fibrilation, AF）最主要的危害是卒中和体循环栓塞事件。最新的资料表明,高达1/3的卒中患者的病因可能为AF ,其导致的卒中致残率和致死率均高于其他类型卒中。因此,对AF患者的卒中预防至关重要。抗凝治疗是AF患者卒中预防的核心策略,文章就AF患者抗凝治疗的安全性和依从性研究进展进行了综述。     

房颤并发冠心病的抗栓策略

栓塞和血栓形成是房颤(AF)和冠心病的常见并发症,所以对于AF并发冠心病患者进行抗栓治疗就至关重要。治疗AF需要口服抗凝剂以减少缺血性卒中,而对冠心病患者则需要长期抗血小板治疗以减少冠状动脉事件。对于AF并发冠心病的患者,如何平衡抗凝或（联合）抗血小板的获益与出血风险？已成为临床讨论的焦点。本文结合2010年《ESC心房颤动治疗指南》及当前的询证学依据,详细综述了AF并发冠心病这一类栓塞高危人群的抗栓治疗策略。     

房颤卒中高风险患者PCI术后的抗栓策略

心房颤动（简称房颤）是临床常见的心律失常,房颤卒中高危人群的抗凝治疗已被证实为有效控制血栓风险的治疗方法。一旦房颤卒中高危人群合并冠心病,而需要接受冠状动脉介入（PercutaneousCoronaryIntervention,PCI）治疗,须植入支架时,为防止支架内血栓形成,需双联抗血小板治疗。     

高频心房事件的临床意义以及对抗凝治疗的指导价值

心房颤动(AF)增加卒中和死亡的风险。心脏植入式电子装置(CIED)对高频心房事件(AHRE)的记录为发现AF提供了诊断依据。研究表明AHRE与卒中风险增高有关。但对于AHRE患者是否需要抗凝治疗尚缺乏证据。由于栓塞风险不仅与AHRE有关,还需关注患者的其它临床情况,因此专家建议抗凝治疗应个体化,将AHRE负荷与CHA_2DS_2-VASC评分相结合是一种恰当的卒中危险分层的方法。目前正在进行的临床研究将为AHRE患者的抗凝治疗决策提供循证依据。     

Left ventricular thrombus

Opinion statement Left ventricular thrombus (LVT) is a frequent complication in patients with acute anterior myocardial infarction (MI) and in those with dilated cardiomyopathy (DCM). The clinical importance of LVT lies in its potential to embolize. The current treatment of patients with acute MI centers on reperfusion, and although controversial, the incidence of LVT complicating acute anterior MI is probably reduced when compared with historical controls. Nevertheless, stroke continues to be a clinically important complication of acute MI and is most common in patients with anterior MI, in part secondary to embolization of LVT. Therapeutic anticoagulation during acute MI reduces the incidence of LVT, and long-term anticoagulation has been associated with a reduction in recurrent infarction and ischemic stroke, but carries hemorrhagic risk. Primary treatment strategies for patients with acute MI center on reperfusion therapy followed by antiplatelet agents and pharmacologic blockade of abnormal neurohumoral mechanisms. Strategies to prevent stroke following infarction include risk stratification for development of LVT and embolism. For patients with anterior MI, particularly those with apical akinesis or dyskinesis, therapeutic anticoagulation reduces the number of LVT and cardioembolic strokes. However, the absolute number of ischemic strokes prevented with this strategy may only be marginal, given the anticoagulation risk, particularly if antiplatelet agents are used concurrently. An attractive alternative strategy is echocardiographic evaluation following anterior infarction with therapeutic anticoagulation reserved for those with demonstrable thrombus. The efficacy of this strategy, however, never has been proven in a clinical study. Primary prevention of cardioembolic stroke through therapeutic anticoagulation is controversial in patients with DCM; the greatest benefit would be expected for those with severe left ventricular dysfunction. If LVT is detected during the course of MI or DCM, therapeutic anticoagulation is usually indicated with the expectation that the majority of thrombi will resolve without clinical evidence of systemic embolism. Additional therapeutic intervention is rarely needed.     

低强度华法林抗凝治疗高出血风险房颤患者的有效性及安全性临床研究

目的：应用2010年欧洲心脏病学协会（ESC）房颤新指南提出的新的评分系统卒中危险评分（CHA2DS2-VASc）和首次推出的出血风险评分法（HAS-BLED）,观察CHA2DS2-VASc积分≥1分且HAS-BLED出血风险积分≥3分时,低强度华法林抗凝治疗高出血风险房颤患者的抗栓疗效和安全性。方法2011年1月至2012年1月我院非瓣膜性房颤患者99例,其CHA2DS2-VASc卒中危险评分≥1分且HAS-BLED出血风险积分≥3分。全部病例分成两组,标准强度华法林治疗组[2.0＜国际标准化比值（INR）≤3.0]和低强度华法林治疗组（1.6≤INR≤2.0）。观察两组患者的血栓栓塞率及出血发生率。结果卡方检验结果显示,两组患者的血栓栓塞率差异无统计学意义（P＞0.05）;标准强度华法林治疗组的出血发生率高于低强度华法林治疗组患者,差异有统计学意义（P＜0.05）。结论 CHA2DS2-VASc卒中危险评分≥1分且HAS-BLED出血风险积分≥3分的高出血风险的房颤患者可以采用低强度华法林抗凝,能有效减少血栓栓塞事件的发生,同时不增加严重出血事件,使用安全可靠。     

Percutaneous left atrial appendage transcatheter occlusion (PLAATO system) to prevent stroke in high-risk patients with non-rheumatic atrial fibrillation: results from the international multi-center feasibility trials

OBJECTIVES: These studies were conducted to evaluate the feasibility of percutaneous left atrial appendage (LAA) occlusion using the PLAATO system (ev3 Inc., Plymouth, Minnesota). BACKGROUND: Patients with atrial fibrillation (AF) have a five-fold increased risk for stroke. Other studies have shown that more than 90% of atrial thrombi in patients with non-rheumatic AF originate in the LAA. Transvenous closure of the LAA is a new approach in preventing embolism in these patients. METHODS: Within two prospective, multi-center trials, LAA occlusion was attempted in 111 patients (age 71 +/- 9 years). All patients had a contraindication for anticoagulation therapy and at least one additional risk factor for stroke. The primary end point was incidence of major adverse events (MAEs), a composite of stroke, cardiac or neurological death, myocardial infarction, and requirement for procedure-related cardiovascular surgery within the first month. RESULTS: Implantation was successful in 108 of 111 patients (97.3%, 95% confidence interval [CI] 92.3% to 99.4%) who underwent 113 procedures. One patient (0.9%, 95% CI 0.02% to 4.9%) experienced two MAEs within the first 30 days: need for cardiovascular surgery and in-hospital neurological death. Three other patients underwent in-hospital pericardiocentesis due to a hemopericardium. Average follow-up was 9.8 months. Two patients experienced stroke. No migration or mobile thrombus was noted on transesophageal echocardiogram at one and six months after device implantation. CONCLUSIONS: Closing the LAA using the PLAATO system is feasible and can be performed at acceptable risk. It may become an alternative in patients with AF and a contraindication for lifelong anticoagulation treatment.     

Empirical anticoagulation for patients in sinus rhythm at high risk of ischaemic stroke:A review of current literature

Ischaemic stroke is one of the commonest causes of morbidity and mortality worldwide and around a fifth of events can be attributed to a cardioembolic source. This is typically due to atrial fibrillation(AF), the most common sustained cardiac arrhythmia. However, AF can, at times, be difficult to detect due to a relative lack of symptoms and the fact that it can be paroxysmal in nature. Studies have shown that diagnosis of AF improves as the length of cardiac monitoring increases. However, prolonged cardiac monitoring is not a costeffective way of diagnosing AF. Therefore, an alternative approach may be to empirically anticoagulate individuals who are at high risk of stroke. This article summarises current evidence surrounding stroke risk prediction, the use of anticoagulation in the secondary prevention of stroke and its use in the primary prevention of stroke in high risk groups with the aim of determining whether empirical anticoagulation is a safe and effective strategy.     

急性心肌梗死合并左心室附壁血栓患者经皮冠状动脉介入术后的抗栓治疗

目的分析急性心肌梗死（AMI）并发左心室附壁血栓（LvT）行经皮冠脉介入治疗（PCI）患者的临床特征及抗栓治疗。方法收集煤炭总医院2005年8月至2012年2月确诊为急性心肌梗死并发左室附壁血栓并行PCI治疗的12例患者的临床资料,对其进行回顾性分析。结果广泛前壁心肌梗死、前壁心肌梗死9例（75％）,左室射血分数低于40％共7例（58％）,冠脉造影检查三支及以上血管病变7例（58％）。6例给予华法林、阿司匹林、氯吡格雷三联抗栓,2例给予西洛他唑、阿司匹林及氯吡格雷三联抗血小板治疗,随访期间血栓均消失。4例双联抗血小板治疗者l例发生脑梗死后加用华法林,3例患者血栓消失,1例血栓机化。12例患者均未出现严重出血现象。结论急性心肌梗死并发左心室附壁血栓并接受PCI治疗患者,充分衡量获益及出血风险,按照个体化原则给予抗栓治疗安全有效。     

The Multiple Causes of Stroke in Atrial Fibrillation: Thinking Broadly

Atrial fibrillation (AF) is numerically the most important risk factor for stroke. It is well established that patients with AF have a 5-fold increased risk of stroke relative to those without and that anticoagulation reduces the risk of stroke by approximately two-thirds. Definitively attributing the mechanism of an individual stroke to AF is more problematic, however. In fact, there is no way to reliably establish the etiology of any ischemic infarction. This necessitates screening for all potential stroke risk factors and treating accordingly. The pattern of infarction is often used to classify the presumed mechanism of infarction as thrombotic or embolic, although even this is approach is based on association and increasingly is recognized as not completely reliable. Furthermore, it should not dictate management—patients with perforating arterial territory infarcts with AF also require and benefit from anticoagulation. Likewise, if other potential embolic sources beyond AF are identified, anticoagulation remains the standard of care. The traditional conceptual model of the mechanistic link between AF and cardioembolic infarction is likely oversimplified. Long-term cardiac rhythm recording studies indicate an inconsistent temporal relationship between AF and infarction. This suggests that cardioembolic stroke in patients with AF may result from the underlying atrial cardiopathy, rather than the rhythm disturbance leading to atrial stasis and thromboembolism. We reviewed traditional and current concepts, as well as evidence for the role of AF in ischemic stroke.     

Stroke and the total artificial heart: neurologic considerations

Neurologic complications, particularly brain infarction (ischemic stroke), are frequent and serious sequelae of total artificial heart (TAH) implantation. Most strokes that occur in TAH patients are due to embolism of thrombotic fragments originating on prosthetic surfaces. The emboli tend to lodge in the middle cerebral artery or its cortical branches and cause cortical syndromes. Cardioembolic strokes are characteristically heralded by the abrupt onset of a maximal neurologic deficit in an awake, often active patient. Cardioembolic strokes have a tendency to undergo hemorrhagic transformation. Anticoagulation is a major issue in stroke management: In anticoagulated patients, hemorrhagic transformation often results in major neurologic worsening; therefore, this risk must be weighed against the danger of recurrent embolism in the absence of anticoagulation. We recommend avoiding anticoagulation during the initial 24 to 48 hours after a stroke, especially in patients with large cardioembolic infarcts. Because of the many invasive procedures producing bacteremia in TAH patients, combined with the large area of prosthetic surfaces, infective endocarditis is a potential concern. Weighing the risks and benefits of anticoagulation in patients with infective endocarditis is likely to produce a controversial choice. Anticoagulation should probably be continued in such patients if they have total artificial hearts. The following article discusses the foregoing issues and presents recommendations for managing acute stroke in TAH patients.     

Causes of death in atrial fibrillation: Challenges and opportunities

Atrial fibrillation (AF) is an age-related arrhythmia associated with several co-morbidities and significant mortality. Most AF patients are in need of anticoagulation due to increased risk of stroke. Despite anticoagulation, AF patients still have a significant risk of death (about 5%/y). Approximately half of deaths in AF are due to heart-related causes (i.e., sudden death, heart failure, and myocardial infarction), one-third of deaths are due to non-vascular causes (i.e., cancer, respiratory diseases, and infections) and the remaining AF patients die from stroke or hemorrhage (about 6% each), or other causes. This review describes current situations related to causes of death in AF, the challenges in the management of AF (e.g., frequent presence of cardiovascular risk factors and co-morbidities, physicians adherence to clinical guidelines and patients adherence to cardiovascular medications in AF) as well as the opportunities for intervention.     

Risk of thromboembolic complications in patients with permanent atrial fibrillation undergoing cardioverter-defibrillator implantation

BACKGROUND: Cardioversion of atrial fibrillation (AF) carries the risk of thromboembolic complications and, therefore, anticoagulation therapy is routinely administered before and after this procedure. In patients with permanent AF who undergo implantation of cardioverter-defibrillator (ICD), anticoagulants are usually withdrawn during the perioperative period. However, in some patients sinus rhythm may be restored during defibrillation threshold (DFT) testing which potentially may increase the risk of thromboembolic complications. AIM: To assess the frequency of sinus rhythm restoration during ICD implantation in patients with permanent AF and the rate of both thromboembolic events and local bleeding complications which may occur due to temporary withdrawal of anticoagulation therapy and its re-initiation early after the procedure. METHODS: Permanent AF was present in 23 (12%) of 193 patients selected for ICD implantation. All patients received prolonged oral anticoagulation according to the generally accepted standards. Anticoagulation therapy was stopped few days before the procedure and replaced by low molecular weight heparin which was administered up to 24 hours before ICD implantation and re-initiated 12-24 hours afterwards. RESULTS: During DFT testing sinus rhythm was restored in 5 (21.7%) patients with AF. Clinical and DFT characteristics were similar in those who were converted to sinus rhythm and those who remained in AF. No thromboembolic events were noted in either group. Local haematoma at the site of ICD implantation occurred in two (8%) patients. CONCLUSIONS: Sinus rhythm was restored in 21.7% of patients with permanent AF who underwent ICD implantation. Temporary withdrawal of anticoagulation therapy did not increase the risk of thromboembolic complications, however, its early re-initiation after implantation resulted in an increase in local bleeding complication rate.     

Pulmonary vein antrum isolation for atrial fibrillation on therapeutic coumadin: special considerations

Pulmonary vein antrum isolation (PVAI) has emerged as an effective treatment for drug-refractory atrial fibrillation (AF). However, thromboembolic events are important complications of this approach. Management of anticoagulation is essential to prevent thromboembolic complications and avoid bleeding complications. The purpose of this review is to outline the general principles followed at our AF centers to address the important issue of pre-, peri-, and postprocedural anticoagulation strategies during PVAI of AF. We initiate warfarin therapy prior to the ablation procedure and continue it through the procedure. Prior work has demonstrated that continuation of therapeutic warfarin during the radiofrequency catheter ablation reduces the risk of periprocedural stroke/transient ischemic attack without increasing the risk of hemorrhagic events. In fact, a strategy that interrupts warfarin anticoagulation may increase the risk of stroke, even with bridging with enoxaparin. Data from our work have shown that minor bleeding was more frequent in the patients bridged with heparin or enoxaparin. There was no significant difference in incidence of major bleeding complications among the patients with a therapeutic level of international normalized ratio (INR) compared with patients for whom bridging therapy was used. Furthermore, the strategy of ablation during a therapeutic INR could be more economical compared with bridging therapy with enoxaparin. Continuation of therapeutic warfarin during ablation of AF may be the best strategy, especially in patients with nonparoxysmal AF, patients with higher thromboembolic risk scores, and patients who require extensive ablation during PVAI of AF.