合并心房颤动的急性缺血性卒中168例临床分析

<正>我国目前约有1千万心房颤动(AF)患者,AF是缺血性卒中的独立危险因素,并且增加其5倍的发病率[1]。AF与缺血性卒中的严重程度,并发症的高发病率和不良预后具有明显相关性[2]。抗栓治疗是AF管理的重要措施。对AF患者进行血栓栓塞和出血风险的危险分层,对采用不同的抗栓策略有重要的临床意义。本研究旨在探讨合并AF的急性缺血性卒中患者在采用危险分层后进行口服抗凝药物(OAC)治疗,观察其临床特点,影响因     

心房颤动卒中危险分层状况及抗栓治疗效果观察

目的 分析心房颤动患者卒中(血栓栓塞)危险分层状况及抗血栓治疗的临床效果.方法 选择2013年4月-2014年5月期间收治的300例心房颤动患者,随机分为实验组和对照组,各150例.应用ACC/AHA/ESC心房颤动指南血栓栓塞危险分层标准对300例患者的血栓栓塞的状况进行分析.实验组患者根据血栓栓塞危险分层状况分别服药华法林或阿司匹林进行治疗,对照组患者仅给予阿司匹林进行治疗,比较两组患者的临床治疗效果.结果 经过分析,150例实验组患者中低度危险39例,低—中度危险43例,中度危险25例,高度危险22例,极高度危险21例;150例对照组患者中低度危险38例,低—中度危险44例,中度危险23例,高度危险23例,极高度危险22例.两组患者在血栓危险分层方面无差异性(P＞0.05);经过治疗,实验组患者分别有3例低度危险患者、4例低—中度危险患者发生血栓栓塞事件,与对照组患者比较差异性不大(P＞0.05),实验组有2例中度危险患者、2例高度危险患者以及3例极高度危险患者发生血栓栓塞事件,总血栓栓塞事件发生率为6.7％,均显著低于对照组各个危险层次患者的血栓时间发生率.具有明显差异性(P＜0.05),经过治疗,两组患者发生颅内出血、尿血、牙龈出血、消化道出血等差异无统计学意义(P＞0.05).结论 可通过ACC/AHA/ESC心房颤动指南血栓栓塞危险分层标准对心房颤动患者进行血栓栓塞危险分层,并根据血栓栓塞分层结构进行抗栓治疗.采用华法林治疗中度危险以上的心房颤动患者,能够得到较优的临床疗效,使用阿司匹林对低度危险以及低—中度危险层次的心房颤动患者,效果较佳.     

心房颤动抗凝新药-Ximelagatran的研究进展

心房颤动（atrial fibrillation,AF）是临床上导致栓塞的常见危险因素。非瓣膜性心房颤动（nonvalvularAF,NVAF）和风湿性瓣膜性房颤栓塞的危险分别是健康对照组的5.6倍、17.6倍。     

房颤患者应用华法令的观察和护理

动脉栓塞是心房颤动的严重并发症之一，具有一定的致死性与致残性。有研究表明，心房颤动(AF)患者栓塞事件的危险性是窦性心律的5-17倍，国外临床研究表明口服华法令抗凝治疗可显著降低栓塞的危险。近年来，我科采用小剂量华法令抗凝溶栓治疗AF，在治疗期间严密监护观察护理，取得满意的效果。     

小剂量胺碘酮对心房颤动的治疗价值

心房颤动（AF）是临床上最常见的持续性房性心律失常。AF在一般人群中发生率为0．4邻，在60岁以上的患者中增至2～5％。非风湿性AF患者中，血栓栓塞发生率为每年3～7．4％，几乎为窦性心律患者的6倍；在某些高危险AF亚组病例中，血栓栓塞发生率则高达每年18％以上。AF恢复为窦性心律的患者，如不用抗心律失常药维持治疗，1年后仅有95％病例仍维持窦性心律。如用I类抗心律失常药如查记丁维持治疗，则1年后又有50％病例AF复发。而且，I类抗心律失常药不无危险，可有致心律失常作用，也可引起心衰恶化和非心脏毒性。致心律失常作用对器质…     

心房颤动的抗血栓治疗

心房颤动是临床常见的心律失常,血栓栓塞为其严重并发症.本文主要就房颤并发血栓栓塞的发病机制、危险分层、治疗方法及进展,以及循证医学的证据做详细阐述.     

达比加群酯预防心房颤动患者脑卒中的现状与研究进展

心房颤动（AF）是脑卒中的独立危险因素,多年来华法林作用因治疗窗窄,较高的出血风险,极大地影响患者的依从性。新型抗凝血酶抑制剂达比加群酯因其在减少血栓栓塞及大出血方面的优势,成为近几年研究的热点。现就达比加群酯的药理机制、预防AF相关性脑卒中相关临床研究及临床应用前景进行综述。     

预防非瓣膜性心房颤动患者缺血性脑卒中的抗栓疗法比较

非瓣膜性心房颤动(NVAF)作为缺血性脑卒中的独立危险因素可使栓塞的发生率显著增加,其卒中发生率比正常窦性心律高5.6倍。减少非瓣膜性AF患者缺血性脑卒中的发生的重要措施就是抗栓治疗。本研究回顾性分析了180例非瓣膜性AF患者的抗栓治疗状况,比较抗凝与抗血小板治疗缺血性脑卒中的预防作用,为临床抗栓疗法的选择进一步提供依据。     

急性肺栓塞的早期诊断及治疗

目的探讨急性肺动脉栓塞的临床特点,早期诊断并积极干预治疗,降低临床死亡率和致残率。方法回顾性分析100例急性肺动脉栓塞患者的临床资料,对易患因素、症状、体征、实验室检查、心电图检查和影像学资料、危险分层、治疗和预后进行分析。结果早期急性肺动脉栓塞临床表现中呼吸困难93.0%、肺动脉高压57.0%、晕厥16%最常见;高危患者占20%,中危者占33%,低危占47%;治疗上,低分子肝素和华法林抗凝者90例,占90%;尿激酶溶栓者7例,占7%;介入碎栓2例(2%);手术取栓1例(1%),治疗好转86例86%,死亡14例(14%)。结论呼吸困难、肺动脉高压和晕厥是急性肺动脉栓塞主要表现,结合D二聚体、B超、CT等影像学检查可提高早期诊断率;根据危险分层,采取溶栓或抗凝治疗,是目前治疗肺动脉栓塞的主要措施。     

心房颤动的研究进展

心房颤动(AF)是临床上最常见的心律失常之一，且大多转律后容易反复发作，部分转为永久性AF，它可引起血流动力学恶化，有发生脑血管栓塞的危险，将成为21世纪新生的心血管流行疾病。现将近年来的研究概况综述如下。     

心房颤动合并慢性肾脏病患者口服抗凝药物治疗的研究进展

慢性肾病与心房颤动(房颤)密切相关并常常共存.慢性肾病和房颤均是血栓发生的危险因素,因此房颤合并慢性肾病人群其缺血性卒中及体循环栓塞的风险显著增加.对于普通的房颤人群,口服抗凝药物治疗是预防缺血性卒中和体循环栓塞发生的有效干预手段,并且慢性肾病还会增加出血风险,因此合并慢性肾病的房颤人群进行口服抗凝药物治疗可能并不具有...     

单核细胞计数与高密度脂蛋白比值联合单核细胞/大血小板比率检测对老年慢性阻塞性肺疾病急性加重期肺栓塞危险分层诊断效能

目的 探讨单核细胞计数与高密度脂蛋白比值（MHR）联合单核细胞/大血小板比率（MLPR）检测对老年慢性阻塞性肺疾病急性加重期（AECOPD）肺栓塞危险分层诊断效能。方法 回顾2018年5月至2022年5月长治市人民医院收治的233例老年AECOPD并发肺栓塞病人的临床资料,比较不同危险分层病人MHR、MLPR水平,并分析MHR、MLPR与危险分层的相关性。采用多元有序logistic回归分析明确MHR、MLPR与AECOPD肺栓塞危险分层的关系,并评估其对危险分层的预测价值。结果高危组病人MHR、MLPR分别为0.74(0.70,0.86)、1.83(1.52,2.10),高于非高危组的0.55(0.39,0.62)、0.80(0.59,1.27)(P<0.05);中高危组和中低危组的MHR分别为0.62(0.57,0.71)、0.39(0.31,0.56),MLPR分别为1.32(0.75,1.61)、0.64(0.55,0.90),高危组MHR、MLPR高于中高危组,中高危组高于中低危组（P<0.05）。Spearman分析显示,MHR、MLPR水平与危险分层均呈正相关...     

心房颤动患者华法林假日疗法的临床观察

目的：观察华法林假日疗法对心房颤动患者抗凝治疗的疗效及安全性。方法：将江苏省镇江市中医院2009年1月-2013年9月间收治的38例心房颤动患者随机分为华法林常规治疗组（对照组,n=20）和华法林假日疗法治疗组（观察组,n=18）,观察两组患者为期12个月的不良反应发生情况。结果：观察组患者治疗后的脑血栓等栓塞事件的发生率与对照组患者间无显著差异（5.6%：5%,P＆gt;0.05）。观察组患者治疗后出血发生率低于对照组患者（5.6%：20%,P＜0.05）,对照组由于未监测INR发生1例出血性死亡事件。结论：观察组患者栓塞风险未增加,出血风险发生率较低,价格便宜且不需要频繁监测INR,值得临床进一步观察使用。     

高风险冠心病合并房颤用抗凝和双联抗栓治疗的疗效及安全性观察

目的观察冠心病合并房颤患者抗栓与抗凝治疗的疗效及安全性。方法将67例栓塞风险评分（CHADS2）为3-6分,出血风险评分（HEMORR2HAGES）〉2分的冠心病合并房颤患者随机分为抗凝组与抗栓组,抗凝组使用华法林钠,抗栓组使用阿司匹林和氢氯吡格雷,随访观察4年,比较两组栓塞事件及出血事件的发生情况,并重新使用2010版血栓栓塞风险评估评分法（CHA2DS2-VASC）和出血风险评估法（HAS—BLED）进行回顾性评分。结果抗凝组栓塞事件发生较抗栓组明显减少,两组差异有统计学意义;而出血风险抗凝组较抗栓组有增高趋势．但差异无统计学意义。结论抗凝治疗可以减少高卒中高出血风险冠心病合并房颤患者栓塞风险。     

Role of Emerging Antithrombotic Therapy in the Prevention of Cardioembolic Complications in Patients with Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is an independent risk factor of potentially catastrophic cardioembolic strokes. AF patients are categorized into high-, intermediate-, and low-risk for thromboembolic complications using the CHADS₂ or CHA₂DS₂-VASc scoring system. Oral anticoagulation using warfarin has been the standard therapy for stroke prevention in intermediate- to high-risk AF patients. However, warfarin use has been limited by several factors such as narrow therapeutic windows, drug-drug and drug-food interactions, and hemorrhagic complications. Rigorous research evaluated dual antiplatelet therapy of clopidogrel and aspirin (acetylsalicylic acid) as a potential alternative to warfarin in the ACTIVE W trial. Dual antiplatelet therapy of clopidogrel and aspirin was found to be inferior to warfarin in preventing stroke and systemic embolism with increased bleeding risk. Other extensive research has led to the development of new antithrombotic agents. Recently, dabigatran etexilate 150 mg twice daily, a direct thrombin inhibitor, was approved by the US FDA for stroke prevention in patients with non-valvular AF after it was found to be superior to warfarin in preventing thromboembolic events and associated with less bleeding in the RE-LY trial. It was also cost effective when compared with warfarin. Dabigatran can be considered in high-risk AF patients who are unable or unwilling to comply with the frequent laboratory and clinic visits that are required when receiving treatment with warfarin. Factor Xa inhibitors are another class of new anticoagulants that have been developed. Oral rivaroxaban was non-inferior to warfarin in thromboprophylaxis and with similar bleeding in the ROCKET-AF trial (HR 0.88; p=0.117). Apixaban, another factor Xa inhibitor, was superior to aspirin in reducing stroke and systemic embolism in patients with AF in the AVERROES trial (HR 0.45; p<0.001). The results of the ARISTOTLE trial, which is evaluating apixaban against warfarin in ～18 000 patients with AF, are expected to be available later this year. Edoxaban, another oral factor Xa inhibitor, is currently being evaluated against warfarin in the ENGAGE AF-TIMI 48 trial in ～20 000 patients with AF. With these new developments, there is a necessity for the clinical practitioner to become familiar with these new and upcoming therapies and guidelines. This review provides an overview of the available data regarding the clinical usefulness of these agents.     

Stroke prevention in atrial fibrillation patients

Importance of the field: Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice and is associated with an increased risk of stroke, mortality and significant morbidity. Given the rapidly increasing incidence and prevalence of AF, and the resulting public health burden of the consequences associated with this arrhythmia, stroke prevention is an extremely important topic.

Areas covered in this review: This review covers the epidemiology of AF, the pathophysiology of ischemic stroke in AF and current antithrombotic therapy choices for stroke prevention in this condition. In addition, this article discusses important topics such as the assessment of stroke risk stratification and bleeding risk assessment, which are key issues in deciding upon thromboprophylaxis for AF patients. Finally, the review highlights the advent of new anticoagulant therapies and discusses the future challenges for researchers in this area.

What the reader will gain: This review summarizes all of the major antithrombotic trials conducted in AF patients over the last twenty years and highlights the importance of anticoagulation therapy for the prevention of stroke, after appropriate individual stroke and bleeding risk assessment.

Take home message: Assessment of individual stroke risk and bleeding risk is key in determining appropriate thromboprophylaxis for AF patients, given the associated thromboembolic and hemorrhagic complications. The availability of newer, safer and more convenient drugs will mean that oral anticoagulation is available for a larger proportion of AF patients who may benefit from it.     

Moving troponin testing into the 21st century: will greater sensitivity be met with greater sensibility?

With its superior sensitivity and specificity, cardiac troponin has gradually replaced other cardiac enzymes, and is now the biomarker of choice in making the critical diagnosis of an acute coronary syndrome (ACS). The early stratification of risk from unstable angina to non-ST segment elevation myocardial infarction (NSTEMI), is crucial in the timing and treatment of the ACS. Troponin elevations have also been shown to be powerfully prognostic in a variety of clinical settings and because of this predictive value, may be useful in determining benefit of various clinical interventions. However, inherent in this improved sensitivity and specificity of the measurement tools is the inclusion of non-ACS patients with abnormal troponin measurements. Increased understanding of the alternative diagnoses associated with elevated troponins as well as assays which allow more rapid and accurate diagnosis of ACS, are needed to further improve patient care. Clinical trials of risk stratification controlling for concomitant associated diagnoses including renal insufficiency, pulmonary embolism, atrial fibrillation and congestive heart failure will provide data to optimize this tool.     

血浆脑钠肽、肌钙蛋白I联合D-二聚体检测在急性肺栓塞中的临床意义

目的探讨联合检测急性肺栓塞（APE）患者的血浆脑钠肽（BNP）、肌钙蛋白I（cTnI）及D-二聚体（D-dime）r水平在急性肺栓塞诊治中的意义。方法 2011年12月～2012年11月间经256层螺旋CT肺动脉成像确诊的急性肺栓塞患者48例,分为大面积肺栓塞组和非大面积肺栓塞组,测定2组患者血浆cTnI、BNP及D-dimer水平。比较分析2组间测值水平的差异及2组间右心功能及病死率的差异。结果 48例APE患者中,大面积肺栓塞组21例,非大面积肺栓塞组27例,大面积肺栓塞组血浆cTnI、BNP浓度明显高于非大面积肺栓塞组,2组间差异有统计学意义（P〈0.05）;而D-dimer浓度在2组间差异无统计学意义（P=0.121）;大面积肺栓塞组发生右心功能不全者和病死率均高于非大面积肺栓塞组,差异有统计学意义（P=0.001）。结论联合应用BNP、cTnI及D-dimer浓度水平对APE患者诊断有一定的价值,在APE患者早期危险分层、临床决策及预后判断中具有重要的临床意义。     

心房颤动抗栓药物治疗进展

心房颤动(房颤)是导致卒中和外周栓塞的重要独立预测因素,华法林抗凝治疗可降低卒中率,但目前华法林临床应用不足。正在研究或已经上市的新型抗栓药物包括达比加群酯、利伐沙班和阿派沙班等可能革命性的改变这一现状。