高血压与心房颤动

高血压和心房颤动均是目前心血管领域面临的重大课题。且发病率随着年龄增长而增加。心房颤动作为高血压的共患病,是临床上最常见的心律失常,并且有很高的发病率和病死率。心房颤动的危险因素众多,由于高血压患病率高,已成为心房颤动最重要的危险因素。高血压增加心房颤动患者的心脑血管事件和死亡风险。血管紧张素转换酶抑制剂和血管紧张素受体拮抗剂类药物对高血压合并心房颤动患者的治疗效果越来越受到人们的重视。现将高血压与心房颤动的关系、高血压合并心房颤动的发病机制、危害以及治疗的最新研究进展进行阐述。     

肾素-血管紧张素-醛固酮系统抑制与心房颤动

心房颤动(房颤)是临床最常见的心律失常之一,大多数房颤复律后容易反复发作,部分转为永久性房颤。积极地控制房颤,不仅在于消除患者心悸等不适症状,而且对防止血栓栓塞等并发症的发生有重要意义。近年来,大量研究显示通过抑制肾素-血管紧张素-醛固酮系统可对房颤有一定的预防作用。因此,应用血管紧张素转换酶抑制剂和血管紧张素受体阻断剂抑制肾素-血管紧张素-醛固酮系统预防房颤,可望成为控制房颤的一条新途径。     

肾素-血管紧张素-醛固酮系统基因多态性与心房颤动

心房颤动(房颤)的病因多认为是由心脏的组织结构及电活动的改变引起,近年来研究表明遗传因素也可能参与了房颤的发生:家族性房颤的遗传背景已较明确;非家族性房颤遗传因素的相关研究也取得了进展,其中肾素-血管紧张素-醛固酮系统基因多态性与房颤的相关性研究就取得了部分进展.有研究认为血管紧张素原基因多态性及血管紧张素转换酶基因多态性与房颤的发病有关,但也有相反观点;而血管紧张素受体基因多态性则多认为与房颤的发病无关;肾素和醛固酮合酶的基因多态性与房颤的相关性问题尚无明确报道.     

他汀类药物抗心房颤动作用

他汀类药物可以减少心房颤动的发生率,其确切作用机制不明,可能与改变心肌离子通道与载体; 抗炎作用;延缓心肌组织、电重构; 改善自主神经功能等有关.     

心房颤动抗凝治疗进展

心房颤动是最常见的心律失常之一,心房颤动患者脑卒中发生风险显著增高,且较其他原因所致的脑卒中有更高的致残率与病死率,故预防脑卒中是心房颤动治疗的重要环节,抗凝治疗在心房颤动患者管理中的地位及重要性逐渐提高.近年来,在心房颤动抗凝治疗方面有重要进展,现对心房颤动患者脑卒中与出血风险评估、抗凝策略选择及抗凝药物研究最新进展进行综述.     

心房颤动患者的抗凝治疗

心房颤动是临床实践中最常见且危害严重的心律失常,是缺血性脑卒中的最主要危险因素之一。有效的抗凝治疗可显著降低心房颤动患者缺血性脑卒中的发生率,成为心房颤动患者治疗策略的重中之重。新型口服抗凝剂为心房颤动患者的抗凝治疗提供了更多选择。现结合近年发表的相关文献对心房颤动患者的抗凝治疗进行综述。     

心房颤动的治疗进展

心房颤动是临床最常见的持续性心律失常,也是目前的研究热点。其治疗的方法包括药物、导管消融及外科手术等。对于其方式的选择也有争论。现就心房颤动的当前相关治疗进行综述。     

Confounding Factors in Rate Versus Rhythm Control Trials in Patients with Atrial Fibrillation: Lessons from the Strategies of Treatment of Atrial Fibrillation (STAF) Pilot Study

Background: The Strategies of Treatment of Atrial Fibrillation (STAF) multicenter pilot trial was one of five completed clinical studies to compare two treatment strategies in patients with atrial fibrillation: the strategy of rhythm control (restoration and maintenance of sinus rhythm) and the strategy of rate control (pharmacologic or invasive rate control and anticoagulation). Methods: In STAF 200 patients (100 per group) with persistent atrial fibrillation were randomized to rhythm or rate control. The combined primary endpoint was a combination of death, cardiopulmonary resuscitation, cerebrovascular event, and systemic embolism. Results: After 19.6 ± 8.9 (0–36) months there was no difference in the primary endpoint between rhythm control (9/100; 5.54%/year) and rate control (10/100; 6.09%/year; p = 0.99). The percentage of patients in sinus rhythm in the rhythm control group after up to four cardioversions during the follow-up period was 23% at 36 months compared to 0% in the rate control group. Eighteen primary endpoints occurred in atrial fibrillation, only 1 occurred in sinus rhythm (p = 0.049). Conclusions: The STAF pilot trial did not show any differences between the two treatment strategies in common with other trials of rhythm versus rate control. These data suggest that there is no benefit in attempting rhythm control in this group of patients with a high risk of arrhythmia recurrence. It remains unclear whether the results in the group of rhythm control would have been better if sinus rhythm had been maintained in a higher proportion of patients since all but one endpoint occurred during atrial fibrillation.Atrial fibrillation; Electric Countershock; Anti-Arrhythmia Agents; Clinical trial, randomized clinical trial     

The Impact of New and Emerging Clinical Data on Treatment Strategies for Atrial Fibrillation

AF Treatment Strategies . Introduction: The Atrial Fibrillation (AF) Exchange Group, an international multidisciplinary group concerned with the management of AF, was convened to review recent advances in the field and the potential impact on treatment strategies. Methods: Issues discussed included epidemiology and the impact of the rising incidence of AF on health care systems, developments in pharmacological and surgical interventions in the management of arrhythmias and thromboprophylaxis, the potential to affect treatment strategies, and barriers to implementing them. Results: The incidence of AF and the associated burden on health care systems are increasing with aging populations, prevalence of comorbidities and more effective treatment of cardiovascular diseases. Advances in available medical treatments, in particular dronedarone and dabigatran, with other products in development, offer the possibility of changes in treatment paradigms and a greater emphasis on reducing hospitalizations and improvement in long‐term outcomes instead of a symptom/safety‐driven approach in which the priority is symptom suppression without provoking drug toxicity. Developments in catheter ablation techniques may mean that, in experienced centers, ablation may be offered as first‐line treatment in selected patient populations. Barriers to optimal treatment include underdiagnosis, lack of recognition as a serious condition and as a risk factor for stroke, limited access to care, inadequate implementation of guidelines, and poor adherence to treatment. Conclusions: The focus of the management of AF may be changing as a consequence of new treatments based on the outcome improvements they offer. However, the benefits will not be fully realized if guidelines and guidance are not observed in routine clinical practice. (J Cardiovasc Electrophysiol, Vol. 21, pp. 946‐958, August 2010)     

左心耳在预测心房颤动发生脑卒中的作用

成为公共健康沉重负担的心房颤动和相关的血栓栓塞性脑卒中事件仍在以惊人的速度增长。心房颤动导致脑卒中的风险增加了5倍．．因此,预防脑卒中的心房颤动管理仍然是最关键的一方面。现在公认的重点预防措施就是规范抗凝,包括已使用很广泛的华法林和现在出现的新抗凝药如利伐沙班等。而且抗凝药的使用已有据可查。由于左心耳在心房鲡动血栓的发生中起关键作用,所以有目的性地去除或结扎左心耳来预防发生脑卒中就成了一种可替代的治疗方法,尤其是适用于那些不适合口服抗凝药的患者,,现就左心耳预测心房颤动发生脑卒中进行介绍。     

及早节律干预——刻不容缓

心房颤动（房颤）是临床上最常见的心律失常。房颤的治疗在当下仍是一大挑战。研究显示,长时间的心动过速会导致心肌结构重构,电重构和神经体液重构,即所谓的心动过速性心肌病。流行病学的调查证实,房颤是心力衰竭、脑卒中、死亡的独立危险因素。毫无疑问,尽早的转复并维持窦性心律给患者来带的血流动力学及其他方面的益处是室率控制策略不可比拟的,但是目前抗心律失常的治疗措施仍然不尽人意。十几年来,对房颤治疗的两种基本策略——室率控制和节律控制,结合抗栓治疗的临床研究一直没有停歇,然而这些研究似乎都得出一个结论：两种治疗策略对于整体房颤人群的预后没有显著性的差异。但是对这些临床研究的深层解读告诉我们：对房颤患者进行早期节律干预仍是我们的治疗目标。     

Medical Management of Atrial Fibrillation: State of the Art

Predominantly a disease of advancing age, atrial fibrillation (AF) is the most common sustained arrhythmia. Its prevalence is rising as the proportion of elderly people in the population continues its inexorable rise. Without more effective therapeutic interventions, AF-related cardiovascular and cerebrovascular morbidity and mortality will also continue to rise. Antiarrhythmic drugs are an essential tool in the management of AF and may be used as premedication before cardioversion; together with cardioversion to help or assist cardioversion; or given afterward to prevent recurrence. If AF recurs after one or two cardioversions, then it is usual to adopt a rate control strategy; highly symptomatic patients who fail cardioversion may benefit from ablation therapy. We are already on the threshold of a large expansion in the use of ablation therapy, a strategy that has potential to deliver dramatic improvements in outcome. Not only can AF be cured by ablative therapy, but there is also evidence that it confers functional improvement as well. It will not, however, be appropriate for all AF patients and pharmacological therapies will continue to have an important place in the management of AF. The plethora of antiarrhythmic drugs currently available for the treatment of AF is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability. Improved class III antiarrhythmic agents, such as dronedarone; new classes of antiarrhythmic agents, such as atrial repolarization delaying agents; and upstream therapies dealing with substrate represent potential sources of new pharmacological therapies for AF.     

Pharmacological Conversion of Atrial Fibrillation of Ten-Years Duration with Flecainide

A case of idiopathic atrial fibrillation of ten-years duration refractory to quinidine therapy, but successfully converted to sinus rhythm following flecainide therapy is presented. With the availability of newer more potent antiarrhythmic drugs, such as flecainide, conversion of previously refractory atrial fibrillation may be possible.     

心房颤动的药物抗栓治疗进展

心房颤动是临床常见的心律失常,血栓形成是其主要并发症。目前临床上常用的抗凝药物主要有非甾体抗炎药类、香豆素类、吡啶类和其他新型抗凝药物。现将介绍目前临床常用的几类抗凝药的药理作用及在临床上的应用。     

心房颤动的药物治疗进展

心房颤动是临床上最常见的心律失常类型,患病率随年龄增长而增加,药物是心房颤动治疗的首选,由于传统抗心律失常药物潜在的致心律失常作用及心脏外的不良反应,故而在心房颤动的治疗中受限。近年一些新药的研制给心房颤动的治疗带来了新的希望,也为临床医生提供了更多的选择。现就心房颤动药物治疗进展做一综述。     

心房颤动的外科治疗

心房颤动是临床最常见的心律失常,严重威胁患者的生活质量,现就心房颤动的外科治疗作一综述。     

心房颤动的上游治疗新进展

心房颤动是最常见的持续性心律失常之一,目前一致认为心房颤动是发病率、病死率都很高的疾病之一。心房颤动的上游治疗受到重视,上游治疗通常包括血管紧张素转换酶抑制剂、血管紧张素受体拮抗剂、醛固酮拮抗剂、他汀类和多聚不饱和脂肪酸（Polyunsaturated fatty acid,PuFA）。这些非抗心律失常药物的抗心律失常作用对心房颤动的一、二级预防可起到一定的作用。     

Management of Atrial Fibrillation in Elderly Adults

Driven in large part by the aging of the population and the increasing prevalence of cardiovascular comorbidities associated with atrial fibrillation (AF), there is a burgeoning epidemic of AF in elderly adults. Although there is a large body of literature to guide management of people with AF, elderly adults with AF are frequently underrepresented in clinical trials. This review provides a contemporary update on management of elderly adults with AF with a particular focus on the two main clinical challenges that AF poses: stroke risk reduction and control of symptoms. The evidence to support novel AF treatment strategies in elderly adults is reviewed, including novel oral anticoagulants and left atrial appendage closure for stroke risk reduction and catheter ablation for control of symptoms.     

New Antiarrhythmic Agents for the Prevention and Treatment of Atrial Fibrillation

Rhythm control could become the preferred treatment strategy for atrial fibrillation (AF) if the available antiarrhythmic agents were more effective and safe. A subanalysis of the AFFIRM trial data suggested that rhythm control, if achieved without the adverse effects related to antiarrhythmic medications, may offer a significant survival advantage over rate control. This article reviews the new investigational pharmacologic and dietary agents being considered for the prevention and treatment of AF. Dronederone is a benzofurane similar to amiodarone, but without the iodine component, and is devoid of many of the amiodarone systemic toxicities. Azimilide is a delayed rectifier potassium channel blocker with use-dependent effects. Agents that target the ultra rapid component of the delayed rectifier potassium current (I_Kur) have atrial myocyte specific properties and may be devoid of QT prolongation and torsade de pointes in clinical usage. Newer agents being studied also include fish oil, gap junction modulators, 5HT4 receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and HMG CoA reductase inhibitors. There is considerable hope that at least some of these agents will ultimately be available for more effective and safe clinical treatment and prevention of AF.