心房颤动所致心源性脑卒中的早期二级预防

心房颤动所致心源性脑卒中是危害最大的脑卒中类型,严重增加社会负担。心源性脑卒中的预防和治疗往往需要脑血管科医师和心内科医师的共同决策。发病后14 d内是早期阶段,此时既是脑卒中再发的高危时段,同时也是发生脑出血的高危时段。在这个栓塞与出血均高危的矛盾时期,如何进行脑卒中的二级预防,是临床亟待解决的问题。本文总结了心房颤动所致心源性脑卒中二级预防的主要手段,并探讨早期二级预防的可能性。     

心房颤动患者脑卒中预防研究进展

心房颤动是最常见的心律失常,据保守估计,目前国内的心房颤动患者约900万例,绝对数量占世界首位[1];其中阵发性和孤立性心房颤动的患者超过300万例,是需要重点干预的人群[2];预计2050年,全球心房颤动患者总数将比现在至少增加3倍.     

Preventing stroke in patients with atrial fibrillation.

CONTEXT: Atrial fibrillation, a common disorder that affects nearly one sixth of the population aged 75 years and older, is a major risk factor for stroke. OBJECTIVES: To review and evaluate the evidence supporting the use of warfarin and/or aspirin for stroke prevention in patients with atrial fibrillation. DATA SOURCES: Prospective, randomized trials of patients with atrial fibrillation evaluating either warfarin or aspirin or both, from MEDLINE from January 1, 1966, to February 23, 1999. STUDY SELECTION: Five primary prevention placebo-controlled studies, which had been formally pooled, 1 study evaluating secondary prevention of stroke, 1 study comparing warfarin with aspirin, and 3 studies of warfarin in combination with aspirin were identified. DATA SYNTHESIS: The risk of developing stroke is heterogeneous and increases with each decade above 65 years; history of high blood pressure, diabetes mellitus, previous transient ischemic attack, or stroke; poor ventricular function; and in women older than 75 years. For patients younger than 65 years, without risk factors, and not receiving antithrombotic therapy, the risk of stroke is 1%/y; those without risk factors between the ages of 65 and 75 years have a risk of 1.1%/y if taking warfarin and 1.4%/y if taking aspirin. For all other patients, stroke risk is reduced from an untreated rate of between 4.3%/y and more than 12%/y to a rate of 1.2%/y to 4%/y with warfarin use. CONCLUSION: The protection afforded by warfarin is most pronounced in patients at the highest risk for stroke, while aspirin treatment seems adequate in low-risk populations.     

Statement on pertussis immunization. National Advisory Committee on Immunization.

The following recommendations on pertussis vaccine from the National Advisory Committee on Immunization will appear in the fourth edition of the Canadian Immunization Guide, scheduled for publication in autumn 1993. These revised recommendations represent a major change in vaccine usage and take account of the current understanding of adverse events associated with use of pertussis vaccine. Most adverse events are no longer contraindications to further immunization; only anaphylactic reaction to a previous dose remains an absolute contraindication to pertussis immunization. Other adverse reactions for which there are no sequelae or that have not been proven to be caused by the vaccine are no longer considered valid reasons for withholding immunization. It is hoped that simplification of the contraindications will improve vaccine utilization and achieve higher levels of age-appropriate immunization.     

探讨食道超声在防治房颤患者脑卒中的应用价值

目的：分析111例行食道超声和头颅CT检查的房颤患者,了解左房血栓与脑卒中的关系以及食道超声在防治房颤患者脑卒中的应用价值。方法：通过对2006年3月～2008年8月在新疆自治区人民医院心内科住院的房颤患者,行食道超声和头颅CT检查并对住院病例进行回顾性分析,了解左房血栓的发生率,以及左房血栓与脑卒中发生的关系。结果：111例房颤患者均经食道超声检查,发现左房血栓15例,占13.5%。左房血栓组与左房无血栓组在脑卒中发生率方面有统计学意义（X2=10.695P〈0.001）。结论：左房血栓与脑卒中的发生密切相关,食道超声在防治房颤患者脑卒中的方面有重要的应用价值,建议为预防房颤患者脑卒中的发生,对房颤患者行食道超声检查。     

亚临床房颤与卒中的研究进展

亚临床房颤（subclinical atrial fibrillation）是无典型临床症状的心房颤动（atrial fibrillation）,由心脏植入器械（cardiac implantable electronic devices,CIED）记录的高心房率事件（atrial high rate events,AHREs）是一种表现形式。近来的临床研究表明,由CIED记录到的亚临床房颤发生率较高,且此类患者卒中风险增加;在卒中患者中由植入性心电记录器（insertable cardiac monitors,ICMs）随访记录到亚临床房颤发生,亚临床房颤与卒中有关。抗凝治疗降低心房颤动卒中风险,亚临床心房颤动抗凝治疗的有效性与安全性目前暂不清楚。远程心电监测对于亚临床房颤的早期发现有重要意义。本文将对亚临床房颤的流行病学、与卒中关系、是否抗凝治疗、远程心电监测的运用方面展开讨论。     

华法令与阿司匹林预防老年房颤患者脑卒中的临床比较分析

目的 探讨中老年房颤患者脑卒中预防的现状及分析。方法 对我院252例老年房颤患者资料进行回顾性调查,了解不同年龄层高危因素的分布,对比服用华法令和阿斯匹林等抗血栓药物后,患者脑卒中以及出血等并发症的发生率。结果 高龄患者（≥75岁）的患者中,合并其他高危因素的机率比65～75岁组的患者显著增多;其中,48例接受华法令治疗,185例接受阿司匹林治疗;华法令组脑卒中发病率同阿司匹林组比较显著下降;华法令组并发非致死性出血机率显著高于阿司匹林组。结论 老年房颤患者中,年龄本身是个高危因素,随着年龄增大,合并其他高危因素的几率增多;对于持续性老年房颤患者脑卒中的预防,华法令比阿司匹林效果明显,但临床实际应用中,华法令的使用率仍较低,且监测明显不足。     

瓣膜性房颤患者的临床特点、卒中一级预防现状及随访调查

目的 了解2014 ～ 2015 年成都地区瓣膜性心脏病（VHD）伴心房纤颤（AF）患者的一般资料、卒中相关危险因素及卒中一级预防的现状及预后,为进行有效的卒中一级预防提供理论依据和支持。方法 选取2013年12 月-2015 年4 月四川省人民医院收治的VHD 伴颤且未发生脑卒中的233 例住院患者的完整临床资料,按照病因分为风湿性心脏瓣膜病伴AF 组（n =126）、退行性心脏瓣膜病伴AF 组（n =82）以及其他瓣膜性心脏病AF 组（n =25）,对3 组中影响脑卒中的危险因素以及一级预防方法和现状进行分析并随访2 年,观察患者的干预方法是否对脑卒中有预防作用。结果 3 组在年龄分布、性别以及房颤类型等方面差异有统计学意义（P <0.05）。房颤类型以持续性房颤为主;89.3% 的患者有左心房增大;瓣膜性房颤患者的卒中一级预防的干预措施中风湿性VHD 组以抗凝为主,其中（74.8%）使用华法林长期抗凝治疗,退行性VHD 组以抗血小板（57.3%）为主;采用CHA2DS2-VASc 评分来评估房颤患者的卒中风险,高风险人群共173 例（74.3%）;风湿性VHD 组高风险人群以抗凝99% 为主,退行性VHD 高风险人群则以抗血小板为主58.9%。在预防干预后随访2 年,未坚持卒中一级预防的患者中11.1% 出现脑梗死,坚持卒中一级预防的患者中发生脑梗死比例为0.5%。结论 退行性VHD 合并房颤患者比例较前增加。VHD 合并房颤的患者大部分属于高卒中风险人群,使用华法林药物抗凝仍是脑卒中一级预防的主要方法。药物抗凝、手术方式抗凝均能够有效的预防VHD 合并房颤患者的2 年内脑卒中的发生。     

达比加群对非瓣膜性房颤卒中二级预防的疗效及安全性观察

目的：比较达比加群和华法林对非瓣膜性房颤卒中二级预防的疗效及安全性。方法：连续收集2013年1月1日至2015年1月28日在温州医科大学附属第一医院神经内科的非瓣膜性房颤伴缺血性卒中患者并根据其抗凝药物的不同分为达比加群组和华法林组,随访至2015年5月31日。纳入统计的有达比加群组78例,服用达比加群胶囊每日2次,每次110 mg;华法林组86例,服用华法林,维持监测国际标准化比值（INR）为2.0～3.0。比较2组血栓栓塞事件、出血事件的发生率。结果：华法林组发生血栓栓塞事件11例,达比加群组3例,2组比较差异有统计学意义（P＜0.05）;达比加群组消化道出血5例,颅内出血3例,华法林组消化道出血2例,颅内出血5例,2组比较差异无统计学意义（P＞0.05）;Has-bled评分是华法林严重出血的危险因素（P＜0.05）,不是达比加群的危险因素（P＞0.05）。结论：达比加群可以有效减少非瓣膜性房颤伴卒中患者再发血栓栓塞事件。同时,Has-bled评分不一定适用于评估服用达比加群进行二级预防抗凝的出血风险。     

左心耳封堵术对非瓣膜性房颤患者预防卒中的安全性及有效性事件单组率的Meta分析

目的 对LAAO在非瓣膜性房颤患者预防卒中治疗的有效性和安全性事件进行Meta分析。方法 以“left atrial appendage occlusion”和“atrial fibrillation”为关键词检索PubMed、EMbase、Cochrane数据库,以“左心耳封堵术”和“心房颤动”为关键词检索万方数据库和CNKI数据库筛选出2005年7月20日～2018年5月20日刊出的左心耳封堵术预防卒中的所有随机对照试验(RCTs),并进行筛选和评估,再采用STATA 8.0软件进行Meta分析。结果 共纳入16项研究,共2350例患者。Meta分析结果显示,卒中事件发生率为1.5%(95%CI:0.9～2.1),心源性/神经源性死亡发生率4.8%(95%CI:0.1～9.5),装置表面血栓形成发生率2.6%(95%CI:1.5～3.6),心包填塞发生率1.5%(95%CI:1.0～2.0),空气/设备栓塞发生率0.8%(95%CI:0.3～1.4),大出血发生率2.1%(95%CI:1.1～3.1)。结论 LAAO治疗非瓣膜性房颤预防卒中效果较好、安全性较高、并发症较少,值得临床推广应用。     

A patient decision aid regarding antithrombotic therapy for stroke prevention in atrial fibrillation: a randomized controlled trial.

CONTEXT: Decision aids are tools designed to help patients participate in the clinical decision-making process. OBJECTIVE: To determine whether use of an audiobooklet (AB) decision aid explaining the results of a clinical trial affected the decision-making process of study participants. DESIGN: Randomized controlled trial conducted from May 1997 to April 1998. SETTING: Fourteen centers that participated in the Stroke Prevention in Atrial Fibrillation (SPAF) III trial. PARTICIPANTS: A total of 287 patients from the SPAF III aspirin cohort study, in which patients with atrial fibrillation and a relatively low risk of stroke received 325 mg/d of aspirin and were followed up for a mean of 2 years. INTERVENTION: At the end of SPAF III, participants were randomized to be informed of the study results with usual care plus use of an AB (AB group) vs usual care alone (control group). The AB included pertinent information to help patients decide whether to continue taking aspirin or switch to warfarin. MAIN OUTCOME MEASURES: Patients' ability to make choices regarding antithrombotic therapy, and 6-month adherence to these decisions. Their knowledge, expectations, decisional conflict (the amount of uncertainty about the course of action to take), and satisfaction with the decision-making process were also measured. RESULTS: More patients in the AB group made a choice about antithrombotic therapy than in the control group (99% vs 94%; P = .02). Patients in the AB group were more knowledgeable and had more realistic expectations about the risk of stroke and hemorrhage (in the AB group, 53%-80% correctly estimated different risks; in the control group, 16%-28% gave correct estimates). Decisional conflict and satisfaction were similar for the 2 groups. After 6 months, a similar percentage of patients were still taking their initial choice of antithrombotic therapy (95% vs 93%; P = .44). CONCLUSIONS: For patients with atrial fibrillation who had participated in a major clinical trial, the use of an AB decision aid improved their understanding of the benefits and risks associated with different treatment options and helped them make definitive choices about which therapy to take. Further studies are necessary to evaluate the acceptability and impact of decision aids in other clinical settings.