心房颤动与心房重构研究进展

心房颤动是临床常见心律失常。心房颤动的发生率、致残率和病死率随人口老龄化而增加。心房重构是心房颤动发生、维持重要影响的因素,故对其发生机制的了解有利于寻找治疗心房颤动的新方法。     

2型糖尿病及其药物对心房颤动的影响

糖尿病作为心血管疾病的重要风险因素,也是老年人群中常见的慢性疾病之一。大部分心血管疾病如冠心病、高血压、心肌病等随着病程的进展往往可发展为心房颤动。已有证据显示,糖尿病可通过影响心脏的自主神经重构、电重构及结构重构诱发心房颤动;而在糖尿病患者中,心房颤动也是其全因死亡率和心血管发病率的独立危险因素。了解糖尿病在心房颤动发病中的作用及各种降糖药对心房颤动的影响将有助于理解糖尿病和心房颤动的相关性,并更好地对合并心房颤动的糖尿病患者进行管理。     

糖尿病并发心房颤动机制的研究进展

<正>除心脏本身原因如心脏瓣膜病及心力衰竭外,经典的心血管危险因素如高血压、糖尿病均可促进心房颤动的发生。糖尿病是心房颤动发生的危险因素,糖尿病患者心房颤动的发生风险较非糖尿病患者高约40%~([1])。糖尿病患者常合并心房颤动,在有研究显示13%糖尿病患者合并有心房颤动~([2])。ADVANCE研究也表明糖尿病患者中心房颤动的发生率明显增高,且接近8%糖尿病患者合并有心房颤动,同时其相关全因死亡风险增加61%,心血管事件增加77%,脑血管事件增加68%,心力衰竭风险增     

糖尿病患者的院内管理

<正>近年来,随着糖尿病发病率不断上升,住院患者中糖尿病患者的比例也逐渐增加。美国住院患者中,高血糖的发生率ICU为32.2%,非ICU为32.0%[1]。国内ICU约26.3%~29.0%伴有高血糖,住院患者中10%~15%伴有糖尿病[2-3]。在这些入院治疗的糖尿病患者中,大多数是因并发症或其他疾病就诊,因此,根据疾病优先治疗的原则,他们常分散在除内分泌代谢科以外的其他临床科室治疗。有研究发现高血糖会增加住院时间、感染发生率及非重症住院患者死亡率     

内科重症监护病房住院患者高血糖临床资料分析——上海仁济医院2002至2009年资料回顾

目的 调查并探讨内科首症监护病房(ICU)住院患者高血糖发生率及高血糖管理与病情、预后的关系.方法 利用病案查询系统检索上海交通大学医学院附属仁济医院2002至2009年内科ICU住院患者病历,对所有资料进行同顾性分析.结果 (1)共纳入2 631例患者,2 168例患者在住院期间测定血糖至少一次,高血糖发生率26.3%,其中既往有糖尿病病史者占12.9%,无糖尿病病史的高血糖患者占13.4%.既往有糖尿病病史合并高血糖的患者中,93.2%住院期间给予了降糖治疗,降糖方案以口服药物(53.0%)和皮下注射胰岛素(24.9%)为主;在既往无糖尿病病史的高血糖患者中,84.4%的患者住院期间没有给予任何降糖治疗;与既往有糖尿病病史合并的高血糖组相比,该组死亡率明显升高(30.4%对13.9%,P<0.01).(2)在既往有糖尿病病史组中,与组内血糖≤7.0 mmol/L亚组相比,血糖>10 mmol/L亚组的死亡率升高(20.5%对9.9%,P<0.05);既往无糖尿病病史的高血糖患者,当血糖>7.0 mmol/L时,则死亡率就开始升高(P<0.01).(3)多元逐步回归分析显示平均血糖是死亡的独立危险因素(OR:1.26).结论 内科ICU住院患者高血糖发生率高,其血糖管理及治疗须引起重视;危重患者高血糖水平可能是死亡率增加的独立危险因素.     

急性心肌梗死急性早期空腹高血糖与住院新发心房颤动的关系及其对预后的影响

目的:探讨急性心肌梗死(AMI)急性早期空腹高血糖与住院新发心房颤动(房颤)的关系及其对预后的影响.方法:AMI病例563例,按空腹血糖水平分空腹高血糖组(空腹血糖≥7 mmol/L,n=250)与对照组(空腹血糖<7 mmol/L,n=313),在不同的心功能Killip分级下比较两组房颤发生率的差异;分别比较两组中糖尿病与非糖尿病患者房颤发生率的差异.根据住院期间是否合并空腹高血糖或房颤,入选患者分既无高血糖亦无房颤亚组、合并高血糖亚组、合并房颤亚组、同时合并高血糖与房颤亚组4个亚组,比较4个亚组住院死亡率的差异.结果:在心功能Killip Ⅰ级、Ⅱ级时,空腹高血糖组房颤发生率明显高于对照组(16.4% vs 6.5%,P=0.005及21.4% vs 12.2%,P=0.037);在心功能Killip Ⅲ~Ⅳ级时两组房颤发生率差异无统计学意义(P=0.761).Logestic回归分析显示高血糖是AMI患者住院房颤发生的独立危险因素(OR=2.6,95%CI 1.59~4.30).无论空腹高血糖组还是对照组,糖尿病与非糖尿病患者房颤发生率差异均无统计学意义(P=0.436,0.441); 既无高血糖亦无房颤亚组住院死亡率0.4%,同时合并高血糖与房颤亚组住院死亡率31.5%,后者是前者的79倍.结论:AMI患者合并空腹高血糖住院期间房颤发生率增高,高血糖可能是房颤发生的独立危险因素,而与是否合并糖尿病无关;AMI同时合并空腹高血糖与房颤,住院死亡率进一步增高,预后不良.     

老年阻塞性睡眠呼吸暂停综合征患者房颤发生机制和治疗的研究进展

阻塞性睡眠呼吸暂停(OSA)是老年常见的睡眠呼吸异常综合征。近年研究发现,OSA患者心房颤动(AF)的发生率明显增加,OSA可能通过代谢异常、组织重构、炎症反应和自主神经失衡等机制诱发心房结构改变和电重构,促进AF发生和发展。OSA患者AF的非药物治疗包括持续气道正压(CPAP)通气治疗、神经刺激、口腔装置和悬雍垂腭咽成形术等,药物治疗包括抗心律失常药物、抗炎药物等;OSA的早期发现和积极治疗可降低AF的发生率。     

《中国成人住院患者高血糖管理目标》专家共识解读

住院患者中高血糖可增加其并发症的发生率、病死率及医疗费用开支,并延长住院时间。为安全、有效地控制住院患者的高血糖,中华医学会内分泌学分会组织相关专家制定了关于中国成人住院患者高血糖管理的共识原则：强调个体化原则,根据不同患者和不同病情制定分层血糖控制目标;糖尿病患者住院期间血糖不一定要求达标;一般不应该快速降糖;降糖治疗应尽量避免低血糖及超重和肥胖者体重增加;避免宽松血糖管理增加感染和高血糖危象的风险。     

糖尿病、心房重构与心房颤动——分子机制和治疗进展

心房颤动是临床最常见的心律失常之一,糖尿病促进心房颤动的发生近年引起重视;但糖尿病导致心房颤动的分子机制仍不清楚。对于在心房颤动发生发展中发挥关键作用的心房重构,目前仍不清楚是糖尿病直接影响心房组织还是通过其他途径参与了心房重构。既往,糖尿病对心肌重构的影响主要是集中于左心室,对左心房影响的研究很少。新近,左心房功能对左心室舒张功能不全的影响以及左心房在心房-心室偶联中的作用,引起了广泛关注。随着电生理技术的进步,新的超声技术如二维斑点跟踪成像技术的应用,为研究左心房功能提供了更精确、更敏感和更可靠的信息,使进一步阐明糖尿病时心房重构和相关心房颤动的发生机制成为可能。现就近年来糖尿病致心房重构的分子机制及临床治疗进展进行综述。     

糖尿病对心房颤动的作用

糖尿病是心房颤动(房颤)发生的主要危险因素之一。在糖尿病状态下,自主神经重构、电重构、电机械重构、结构重构是引起房颤的主要病理生理机制。该文阐述糖尿病与房颤的密切联系,讨论其主要的病理生理机制,并针对糖尿病引起的心房重构提出可能的上游治疗靶点。     

60例老年心房颤动患者资料的临床分析

目的：探讨老年心房颤动（简称房颤）的病因及临床特点。方法：对我院老年病房2003年1月～2007年6月期间住院的60例男性房颤患者的临床资料进行回顾性分析。结果：患者中阵发性房颤、持续性和永久性房颤分别占12％、22％、66％；冠心病、高血压和糖尿病是引起房颤的主要病因（发病率分别占65％、52％、47％）；持续性／永久性房颤心功能明显差于阵发性房颤心功能（P〈0.01）；其左房内径显著大于阵发性房颤患者的左房内径，而射血分数显著低于阵发性房颤的射血分数（P均〈0.01）；慢性房颤患者均合并有不同类型的其它心律失常（如病窦综合征，房室传导阻滞等）；60例老年房颤患者均用过抗凝剂，仅有5例患者使用过华法林，24例患者发生脑栓塞，2例患者发生下肢或上肢动脉栓塞。结论：冠心病、高血压和糖尿病是引起房颤的主要病因；随着房颤的发展，左房内径增大、心功能逐渐恶化、左室射血分数降低；房颤常合并其它形式的心律失常；脑栓塞发生较高．应加强防治。     

Peripheral Arterial Disease in Patients with Atrial Fibrillation: The AFFIRM Study

BackgroundPeripheral arterial disease has been linked with worse outcomes in patients with atrial fibrillation. The aim of this study is to assess the impact of peripheral arterial disease on mortality and stroke in a cohort of patients with atrial fibrillation.MethodsThis was an ancillary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A comparison of baseline characteristics was made between patients with atrial fibrillation with and without diagnosed peripheral arterial disease. Multivariate cox regression analysis was performed to compare the risk of stroke, death, and cardiovascular death among the two groups.ResultsThe prevalence of peripheral arterial disease in the whole cohort of 4060 patients with atrial fibrillation was 6.7%. Patients with peripheral arterial disease tended to be older; had higher prevalence of diabetes mellitus, hypertension, and smoking; and were more likely to have a history of coronary artery disease, heart failure, cardiac surgery or cardiac intervention, and stroke or transient ischemic attack (all P < .05). After multivariate adjustment, peripheral arterial disease was significantly associated with overall higher mortality (hazard ratio 1.34, 95% confidence interval 1.06-1.70, P = .016) in patients with atrial fibrillation, but the rates of ischemic stroke were similar in the two groups (3.9% vs 3.5%, P = 0.874).Subgroup analysis confined to the patients with non-anticoagulated atrial fibrillation showed that peripheral arterial disease was an independent predictor of ischemic stroke (hazard ratio 3.37, 95% confidence interval 1.25-9.09, P < .016).ConclusionPeripheral arterial disease predicts higher mortality in atrial fibrillation, and was an independent predictor of ischemic stroke in patients with non-anticoagulated atrial fibrillation. Proactive surveillance and optimization of medical management in this group of patients is warranted, given the high risks associated with peripheral arterial disease where atrial fibrillation is also present.     

心房颤动患者复发性缺血性卒中的危险因素

目的 探讨心房颤动患者复发性缺血性卒中的危险因素.方法 回顾性纳入合并心房颤动的缺血性卒中患者,收集其人口统计学和临床资料,对首发卒中组与复发性卒中组的卒中相关危险因素进行比较,采用多变量logistic回归分析确定心房颤动患者复发性缺血性卒中的独立危险因素.结果 共纳入504例合并心房颤动的缺血性卒中患者,其中男性245例(48.6%),女性259例(51.4%),平均年龄(76.67±8.26)岁;首发卒中组314例(62.3%),复发性卒中组190例(37.7%).复发卒中组高血压(78.9%对69.4%;χ2=5.446,P=0.020)、糖尿病(38.9%对26.8%;χ2=8.181,P=0.004)和年龄>75岁(68.9%对60.2%;χ2=3.915,P=0.048)的患者比例以及基线收缩压[(153.30±26.02)mmHg对(148.13±26.40)mmHg,1 mmHg=0.133 kPa;t=-2.141,P=0.033]均显著高于首发卒中组.多变量logistic回归分析表明,高血压[优势比(odds ratio, OR)1.734,95%可信区间(confidence interval, CI)1.121~2.682;P=0.013]、糖尿病(OR 1.757,95% CI 1.188~2.597;P=0.005)、年龄>75岁(OR 1.680,95% CI 1.132~2.494;P=0.010)是心房颤动患者复发性缺血性卒中的独立危险因素.结论 高血压、糖尿病和年龄>75岁是心房颤动患者复发缺血性卒中的独立危险因素.     

非瓣膜性心房颤动患者的卒中危险因素分析

卒中是非瓣膜性心房颤动(以下简称为房颤)的主要并发症。心力衰竭、高龄、高血压、糖尿病及卒中或短暂性脑缺血发作史与房颤患者卒中的风险相关,此外,临床上其他原因所致的缺血性卒中的危险因素也与房颤患者的卒中风险相关。筛选房颤患者并发卒中的危险因素,并采取有效方法评估其卒中的危险性,无论是对于抗凝治疗预防卒中事件,还是对于减少抗凝治疗引起的出血风险,都具有十分重要的意义。     

中国人非瓣膜性心房颤动脑卒中危险因素的病例-对照研究

目的　本研究通过回顾性病例对照研究分析中国人心房颤动 (房颤 )脑卒中的危险因素。方法　在全国 1 8家医院共登记房颤患者 4 51 1例 ,其中风湿瓣膜性房颤 1 0 86例 ,非瓣膜性房颤 342 5例。通过比较房颤合并脑卒中与房颤无脑卒中患者 ,筛选房颤发生脑卒中的危险因素。结果　中国人房颤脑卒中的患病率 2 4 81 % ,房颤合并脑卒中组年龄明显高于对照组 (P <0 0 0 1 ) ,且患病率随年龄增长而明显增加。多因素Logistic分析显示 :年龄≥ 75岁 (OR 1 76 ,95 %CI 1 0 8～ 2 98) ,高血压病史 (OR 1 52 ;95 %CI 1 2 8～ 1 80 ) ,糖尿病史 (OR 1 39,95 %CI 1 1 1～ 1 76) ,动脉收缩压升高(OR 1 71 ,95 %CI1 2 1～ 2 2 8) ,左房血栓 (OR 2 77,95 %CI 1 2 5～ 6 1 3)是脑卒中的独立危险因素。结论　中国人非瓣膜性房颤脑卒中的独立危险因素为年龄、高血压病史、糖尿病史、左房血栓、动脉收缩压升高 ,上述因素对决定房颤患者的抗栓治疗策略具有重要意义     

Low cardiovascular event rate and high atrial fibrillation recurrence rate one year after electrical cardioversion

BackgroundElectrical cardioversion is widely used to restore sinus rhythm in patients with atrial fibrillation. However, the long term clinical event and sinus rhythm maintenance rates following electrical cardioversion still remains unclear. This study evaluated one year incidence and risk factors for cardiovascular events and atrial fibrillation recurrence in a single center clinical practice.MethodsIn a prospective study 188 patients with atrial fibrillation who underwent electrical cardioversion were enrolled. Patients and their primary care physicians were followed up one year after cardioversion and patient clinical and arrhythmic event rate was evaluated. Data obtained from patients and general practitioners were combined and the results were analyzed with PSPP 0.8.5 software.ResultsElectrical cardioversion success rate was 90.4%. Within a year after cardioversion one patient (0.6%) suffered myocardial infarction, three patients (1.9%) had a stroke/transitory ischemic attack (TIA), three patients (1.6%) died and three patients (1.9%) had a bleeding event that required hospitalization. The presence of diabetes mellitus was the only factor with a tendency to increase the risk of combined event of myocardial infarction, stroke/TIA and bleeding (P = 0.096). At follow up 30.0% of patients reported having atrial fibrillation and within a year 62.2% had suffered at least one atrial fibrillation paroxysm. The proportion of patients who underwent additional cardioversions after the initial hospitalization was 32.5%. The factors that significantly increased the risk of atrial fibrillation recurrence were history of stroke/TIA (P = 0.014) and increased left atrial volume index on echocardiography (P = 0.039). Greater left atrial diameter had a tendency toward an increased risk (P = 0.087).ConclusionsCardiovascular event rate one year after electrical cardioversion was low. Electrical cardioversion had a high immediate success rate, however, maintenance of stable sinus rhythm in the long term was low.     

Underuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review

Background

Atrial fibrillation is associated with substantial mortality and morbidity from stroke and thromboembolism. Despite an efficacious oral anticoagulation therapy (warfarin), atrial fibrillation patients at high risk for stroke are often under-treated. This systematic review compares current treatment practices for stroke prevention in atrial fibrillation with published guidelines.

Methods

Literature searches (1997-2008) identified 98 studies concerning current treatment practices for stroke prevention in atrial fibrillation. The percentage of patients eligible for oral anticoagulation due to elevated stroke risk was compared with the percentage treated. Under-treatment was defined as treatment of <70% of high-risk patients.

Results

Of 54 studies that reported stroke risk levels and the percentage of patients treated, most showed underuse of oral anticoagulants for high-risk patients. From 29 studies of patients with prior stroke/transient ischemic attack who should all receive oral anticoagulation according to published guidelines, 25 studies reported under-treatment, with 21 of 29 studies reporting oral anticoagulation treatment levels below 60% (range 19%-81.3%). Subjects with a CHADS₂ (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ≥2 also were suboptimally treated, with 7 of 9 studies reporting treatment levels below 70% (range 39%-92.3%). Studies (21 of 54) using other stroke risk stratification schemes differ in the criteria they use to designate patients as “high risk,” such that direct comparison is not possible.

Conclusions

This systematic review demonstrates the underuse of oral anticoagulation therapy for real-world atrial fibrillation patients with an elevated risk of stroke, highlighting the need for improved therapies for stroke prevention in atrial fibrillation.     

Diabetes mellitus – Risikofaktor für Vorhofflimmern

The relationship between atrial fibrillation and diabetes mellitus type 2 is controversial, and various studies have demonstrated conflicting results. However, the majority of larger prospective studies published during recent years demonstrated a positive correlation. After multivariate adjustment diabetes increased the risk for atrial fibrillation at least two fold. This combination is associated with substantially increased risks of death and cardiovascular events (stroke and heart failure). Atrial fibrillation in patients with diabetes mellitus type 2 identifies individuals who are likely to obtain greater benefits from glycemic control and anticoagulants as well as antihypertensive therapy.     

非瓣膜病房颤缺血性脑卒中的预防

非瓣膜病房颤缺血性脑卒及体动脉栓塞的发病率很高,预防这一事件的发生现已成为国内外研究的热题。抗凝治疗无疑是卒中预防中重要环节之一,新型口服抗凝剂相较华法林可能对亚洲房颤人群血栓栓塞的预防效果更好,不良事件发生率更低,正在成为一种全新的选择。随着左心耳封堵技术日渐成熟,给不适合抗凝治疗的房颤患者带来了福音。许多大型临床研究显示射频消融不仅可以恢复窦律,还可以降低房颤负荷,减少血栓栓塞事件的发生,对于栓塞风险较高的病人来说,新型口服抗凝药联合射频消融对卒中预防效果可能会更好。肥胖、吸烟、嗜酒、高血压、糖尿病等危险因素在房颤病程进展中扮演了重要角色,包括房颤危险因素在内的综合管理对缺血性脑卒中的预防效果更佳。     

老年脑梗死患者牛津郡社区脑卒中项目分型与危险因素的关系

目的探讨老年脑梗死患者牛津郡社区脑卒中项目(Oxfordshire community stroke project,OCSP)分型与危险因素的关系。方法将来源于南京脑卒中注册项目的478例患者分为完全前循环梗死组(TACI组,79例)、部分前循环梗死组(PACI组,125例)、后循环梗死组(POCI组,111例)和腔隙性脑梗死组(LACI组,163例),分析各危险因素在OCSP亚型中的分布。结果在4组患者中,高血压、高TC血症、吸烟、饮酒、颈动脉狭窄和短暂性脑缺血发作的发生率差异无显著性意义(P>0.05);TACI组发生心房颤动的比例高于LACI组和POCI组(P<0.01),并高于PACI组(P<0.05);LACI组的糖尿病发生率高于其他3组(P<0.05)。高血压合并糖尿病、高血压合并心房颤动、糖尿病合并心房颤动的患者在OCSP亚型间差异无显著性意义(P>0.05)。结论心房颤动与前循环梗死密切相关,糖尿病更多见于LACI。