房颤栓塞和出血风险评估的策略成都市第五人民医院成都中医药大学附属第五人民医院郎明健ChengduFifthPeople’sHosp ital精医重德和谐包容房颤的发病率及分布?ESC预计欧洲成年人房颤患病率为2-4%?ESC中国数据全人群发病率0.6% ,低于同期房颤中心汇报结果(全人群0.8%,60-75岁发病率1.4%-5%,75岁以上10%)?1/3的正常人一生中有发生房 颤的风险房颤的临床后果死亡:房颤患者死亡风险是正常人群的1.5-3.5倍,患者多数死于心衰、中风等中风:约有20%-30%的缺 血性脑卒中源于房颤,10%的不明原因脑卒中也与房颤相关心衰:20-30%的房颤患者会出现心衰,这与过快的心室率以及不规则的心室收 缩相关认知功能下降:风险增高1.4-1.6倍,以及老年痴呆发病年龄提前抑郁:房颤患者有16-20%的比例出现抑郁生活质量下降 :超过60%的房颤患者存在生活质量下降住院:每年10-40%的住院率CCTOABCC:ConfirmConfirmAFA 12-leadECGorrhythmstripshowingAFpatternfor≥30sC:Charact erizeA:Anticoagulation/AvoidstrokeCharacterizeAF(the4S-AFsch eme)B:BettersymptomcontrolC:Comorbiditiescardiovascular-risk factormanagement心房颤动的管理:CCToABC(ESC2020)EurHeartJ.2021F eb1;42(5):373-498.ChengduFifthPeople’sHospitalChengduFifth People’sHospital精医重德和谐包容精医重德和谐包容房颤患者管理的ABC流程(ESC2020)抗凝治疗适应证方 面的推荐与2016年指南保持一致重点识别卒中低风险患者NOAC作为首选抗凝药物栓塞风险与出血风险需要动态评估,及时调整抗凝策略Eu rHeartJ.2021Feb1;42(5):373-498.ChengduFifthPeople’sHospi talChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容既往房颤卒中危险分层:CH ADS2评分CHADS2评分系统评分充血性心力衰竭(C)1高血压(H)1年龄?75岁(A)1糖尿病(D)1卒中/TIA(s) 2最高累计分6LipGY.HalperinJL.AmJMed.2010;123(6):484-488ChengduFi fthPeople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德 和谐包容房颤卒中危险因素风险比Multivariatehazardratios(95%CI)Multivariateha zardratios(95%CI)Age(years)Hypertension1.17(1.11-1.22)<6565-7 4≥751.0(Reference)Heartfailure(history)0.98(0.93-1.03)2.97(2.54 -3.48)Diabetemellitus1.19(1.13-1.26)5.28(4.57-6.09)Thyroiddisea se1.00(0.92-1.09)Femalesex1.17(1.11-1.22)Thyrotoxicosi1.03(0.83- 1.28)Previousischaemicstroke2.81(2.68-2.95)Riskfactorsforisc haemicstroke/TIA/systemicembolisminpatientswithAF:theSwed ishCohortAtrialFibrillationstudyIntracranialbleeding1.49(1.3 3-1.67)Vasculardisease(any)1.14(1.06-1.23)MyocardialinfarctionP reviousCABGPeripheralarterydisease1.09(1.03-.15)1.19(1.06-1.33 )1.22(1.12-1.32)CammAJ,etal.EurHeartJ.2012.ChengduFifthP eople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容 两种评分系统评估房颤卒中风险比较CHA2DS2-VASc调整后卒中率(%/年)(95%可信区间)0011.322.233.244 .066.769.879.686.7915.22010Guidelinesforthemanagementofatri alfibrillationCHADS2调整后卒中率(%/年)(95%可信区间)01.912.824.035.948.5612 .5618.2RavieleA,etal.GItalCardiol(Rome).2011ChengduFifth People’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐 包容两种评分系统评估房颤卒中风险比较丹麦国家队列研究(1997-2008),共计22945例CHADS2=1分的NVAF患者,使用 CHA2DS2-VASc评估风险ThrombHaemost,107(6):1172-9.ChengduFifthPeopl e’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容两种评分 系统评估房颤卒中风险比较卒中危险分层(CHADS2)评分:低危(0分)、中危(1-2分)、高危(>2分)低危患者:不抗凝治疗CHA DS2评分局限性?低危?CHADS2=0分的AF患者,卒中率>1.5%/年CHA2DS2-VASc评分系统可以准确识别真正的卒 中低危患者:<65岁且为孤立AF(包括女性患者)CHA2DS2-VASc=0分的AF患者,卒中率>0.84%/年Chengdu FifthPeople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医 重德和谐包容两种评分系统的差别-背景与理念两种评分系统的出台背景——CHADS2产生于非瓣膜病抗凝理念初期,多数患者没有接受抗凝 治疗——CHA2DS2-VASc产生于抗凝治疗高度普及和标准化的欧洲两种评分系统的理念——CHADS2:进行危险分层,找出高危患者 ,给高危患者抗凝——CHA2DS2-VASc:淡化危险分层,找出真正低危患者不抗凝,其他均应抗凝ChengduFifthPeo ple’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容推荐 使用CHA2DS2-VASc评分系统CHA2DS2-VASc评分优于CHADS2评分CHADS2评分低估低危患者,低危患者可能不低 危CHADS2评分为0或者1分时,可使用CHA2DS2-VASc再次评估风险对于抗血小板指针强烈的病人,也可使用CHADS2评分判 断是否抗凝,年龄<65岁且CHADS2为0分的病人,建议单独抗血小板没有使用过CHADS2评分,可以只了解和使用CHA2DS2-V ASc评分ChengduFifthPeople’sHospitalChengduFifthPeople’sHospit al精医重德和谐包容精医重德和谐包容CHA2DS2-VASc评分:房颤患者管理第一步CHA2DS2-VASc评分系统评分充血 性心力衰竭/左心室收缩功能障碍(C)(心力衰竭的症状/体征或有左心室射血分数下降的证据)1高血压(H)至少两次静息血压>140/ 90mmHg1年龄?75岁(A)2糖尿病(D)空腹血糖>125mg/dI(7mmol/L)或需要口服降糖药和/或胰岛素治疗1 卒中/TIA/血栓栓塞史(s)2血管疾病(V)(既往心肌梗死,外周动脉疾病或主动脉斑块)1年龄介于65–74岁(A)1性别因素 (女性)(Sc)1最高累计分9KirchhofP,etal.EurHeartJ.2016ChengduFifth People’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐 包容包括HFrFF、HFmrEF、HFpEF包括稳定的和不稳定的心衰,即包括充血性心力衰竭和无充血(体循环/肺循环淤血)表现的心衰 包括左心衰、右心衰和全心衰只要存在确切的心衰表现(症状/体征)左心室射血分数下降的客观证据与EF降低的程度没有关系CHA2DS2- VASc评分标准解读CHA2DS2-VASc评分系统评分充血性心力衰竭/左心室收缩功能障碍(C)(心力衰竭的症状/体征或有左心 室射血分数下降的证据)1KirchhofP,etal.EurHeartJ.2016ChengduFifthPeo ple’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容≥2 次发现血压升高>140/90mmHg目前正在接受降压药物治疗不论当前血压是否控制正常不论既往诊断高血压还是新诊断高血压不论原发性高 血压还是继发性高血压不论靶器官有无损害不论轻中重度高血压不论是否降压达标不论是否在用降压药物CHA2DS2-VASc评分标准解读 CHA2DS2-VASc评分系统评分高血压(H)至少两次静息血压>140/90mmHg1KirchhofP,etal.Eu rHeartJ.2016ChengduFifthPeople’sHospitalChengduFifthPeopl e’sHospital精医重德和谐包容精医重德和谐包容CHA2DS2-VASc评分标准解读CHA2DS2-VASc评分系统 评分年龄?75岁(A)2糖尿病(D)空腹血糖>125mg/dI(7mmol/L)或需要口服降糖药和/或胰岛素治疗1卒中/TI A/血栓栓塞史(s)2诊断糖尿病明确,即空腹血糖>7mmol/L,或正在接受降糖药物/胰岛素治疗。不符合以上标准不计分既往缺 血性卒中、TIA或其他地方血栓栓塞(体循环)并不一定是心源性血栓脱落所致KirchhofP,etal.EurHeart J.2016ChengduFifthPeople’sHospitalChengduFifthPeople’sHosp ital精医重德和谐包容精医重德和谐包容CHA2DS2-VASc评分标准解读CHA2DS2-VASc评分系统评分血管疾病(V )(既往心肌梗死,外周动脉疾病或主动脉斑块)1年龄介于65–74岁(A)1既往心肌梗死病史记1分,仅诊断冠心病不计分合并多个血管 疾病因素,不重复计分Eurheartj.2018Mar.1;39(9):763-816ChengduFifthPeopl e’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容CHA2 DS2-VASc评分标准解读《2017ESC外周动脉疾病(PAD)诊治指南》对PAD有明确定义:除冠状动脉和主动脉以外的动脉疾病 ,包括颈动脉、椎动脉、肠系膜动脉、肾动脉以及上下肢动脉粥样硬化性疾病Eurheartj.2018Mar.1;39(9):76 3-816ChengduFifthPeople’sHospitalChengduFifthPeople’sHospit al精医重德和谐包容精医重德和谐包容颈动脉疾病颈动脉狭窄:颅外颈内动脉(ICA)50%以上的狭窄,狭窄程度用北美症状性颈动脉内 膜切除试验(NASCET)方法估计。在大部分研究中,颈动脉狭窄定义为:有症状:症状出现在6个月内无症状:无法识别的症状或症状出现在 6个月之前CHA2DS2-VASc评分标准解读下肢动脉疾病Eurheartj.2018Mar.1;39(9):763-816 ChengduFifthPeople’sHospitalChengduFifthPeople’sHospital精医重 德和谐包容精医重德和谐包容CHA2DS2-VASc评分标准解读CHA2DS2-VASc评分系统评分性别因素(女性)(Sc) 1纳入4670例AVERROES、ACTIVE-W、ACTIVE-A研究中阿司匹林单药或阿司匹林联合氯吡格雷且CHADS2评分=1 的患者,其中74%的患者再用CHA2DS2-VASc评分>1这部分CHADS2=1(CHA2DS2-VASc评分1-4分)的患者, 发现“女性”是增加卒中和非CNS全身性栓塞风险的额外风险因素KirchhofP,etal.EurHeartJ.201 6ChengduFifthPeople’sHospitalChengduFifthPeople’sHospital精医 重德和谐包容精医重德和谐包容CHA2DS2-VASc评分:更新2020ESC房颤管理指南CHA2DS2-VASc评分CCo ngestiveheartfailureClinicalHF,orobjectiveevidenceofmoder atetosevereLVdysfunction,orHCM1HHypertensionoronantihyper tensivetherapy1AAge75yearsorolder2DDiabetesmellitusTreatme ntwithoralhypoglyceamicdrugsand/orinsulinorfastingblood glucose>125mg/dL(7mmol/L)1SStrokepreviousstroke,TIA,orthromboe mbolism2VVasculardiseaseAngiographicallysignificantCAD,previo usmyocardialinfarction,PAD,oraorticplaque1AAge65-74years1S CSexcategory(female),(astrokeriskmodifierratherThanarisk factor)1EurHeartJ.2021Feb1;42(5):373-498.ChengduFifthPeo ple’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容其它 房颤卒中高危因素2020ESC房颤管理指南卒中高危因素常用临床危险因素其它临床危险因素影响指标血尿化验指标Stroke/TIA/ systemicembolismImpairedrenalfunction/CKDEchocardiographyCardia ctroponinTandIHypertensionOSALAdilatationNatriureticpeptide sAgeing(perdecade)HCMSpontaneouscontrastorthrombusinLALOWL AAvelocitiesCystatinCstructuralheartdiseaseAmyloidosisindeg enerativecerebralandheartdiseasesComplexaorticplaqueProtein uriaDiabetesmellitusHyperlipidaemiacerebralimagingCrcl/eGFRIL- 6VasculardiseaseSmokingSmall-vesseldiseaseGDF-15CHF/LVdyfuncti onMetabolicsyndromevonWillebrandfactorSexcategory(female)Mal ignancyD-dimerEurHeartJ.2021Feb1;42(5):373-498.ChengduFif thPeople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德 和谐包容心房颤动的抗栓治疗策略:栓塞风险CHA2DS2-VASC评分:男=0分,女=1分CHA2DS2-VASC评分:男≥1分 ,女≥2分CHA2DS2-VASC评分:男≥2分,女≥3分1抗栓有害,不建议抗栓(III类建议,B级证据)积极考虑抗栓,个体 化决策(II类建议,B级证据)必须抗栓,除非禁忌(I类建议,A级证据)23CHA2DS2-VASC评分:0分不抗凝;1分可抗凝 ;≥2分要抗凝ChengduFifthPeople’sHospitalChengduFifthPeople’sHos pital精医重德和谐包容精医重德和谐包容HAS-BLED评分:出血风险评估Riskfactorsanddefiniti onsPointsHUncontrolledhypertensionSBP>160mmHg1AAbnormalrenal and/orhepaticfunctionDialysis,transplant,serumcreatinine>200 umol/L,cirrhosis,bilirubin>x2upperlimitofnormal,AST/ALT/ALP>3 xupperlimitofnormal1/2SStrokePreviousischaemicorhaemorrh agicastrok1BBleedinghistoryorpredispositionPreviousmajorhe amorrhageoranaemia1LLabileINRTTR<60%inpatientreceivingVK A1EElderlyAged>65yearsorextremefrailty1DDrugsorexcessive alcoholdrinkingConcomitantuseofantiplateletorNSAID;and/o rexcessivecalcoholperweek1/2Maximumscore9EurHeartJ.2021 Feb1;42(5):373-498.ChengduFifthPeople’sHospitalChengduFifth People’sHospital精医重德和谐包容精医重德和谐包容HAS-BLED评分标准解读HAS-BLED评分系统评分 H高血压1A肝、肾功能异常(各1分)1/2高血压和卒中风险评估不一样,计分标准强调目前收缩压>160mmHg收缩压已降至160mm Hg以下,不计分肝功能异常:慢性肝病(如肝纤维化)或胆红素>2倍正常上限,谷丙转氨酶>3倍正常上限肾功能异常:慢性透析或肾移植或血 肌酐≥200umol/LChengduFifthPeople’sHospitalChengduFifthPeople’s Hospital精医重德和谐包容精医重德和谐包容药物同时联合抗血小板和非甾体抗炎药,计1分既往出血史和/或出血倾向INR(治 疗时间窗)<60%被定义为“INR值波动”出血史INR值波动HAS-BLED评分标准解读HAS-BLED评分系统评分S卒中史1B 出血史1LINR值波动1E老年(如年龄>65岁)1D药物或嗜酒(各1分)1/2嗜酒指≥8个饮酒量/周备注:1个饮酒量指1个标准杯 的酒量,约等于:360ml普通啤酒(5%)、160ml葡萄酒(12%)、50ml白酒(45%)ChengduFifthPeop le’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容房颤 出血高危因素2020ESC房颤管理指南出血高危因素不可纠正的危险因素潜在可纠正的危险因素可以纠正的危险指标生物标志物Age>65 yearsExtremefrailty±exceseriskoffallsHypertension/elevatedS BPGDF-15PrevusmajorbleedingAnaemiaConcomitantantiplatelet/NSAI DCystatinC/CKD-EPISevererenalimpairment(ondialysisorrenalt ransplant)ReducedplateletExcessivealcoholintakecTnT-hsSevereh epaticdysfunction(cirrhosis)countorfunctionNon-adherencetoOA CHazardoushobbies/occupationsvonWillebrandfactor(+othercoagu lationmarkers)MalignancyRenalimpairmentwithCrCl<60ml/minBridg ingtherapywithhepaarinGeneticfactors(e.gcyp2C9polymorphism s)VKAmanagementstrategeINRcontrol(target2.0-3.0)Previousstro ke,small-vesseldisease,etctargetTTR>70%DiabetesmellitusAppropr iatechoiceofOACandcorrectdosingCognitiveimpairment/dementi aChengduFifthPeople’sHospitalChengduFifthPeople’sHospital精医 重德和谐包容精医重德和谐包容与非抗凝治疗(抗血小板治疗或无抗栓治疗)相比,无论HAS-BLED评分0-2分、或HAS-BLED ≥3分,口服抗凝治疗(OAC)均显著改善临床获益,延长无事件生存(无死亡、缺血性卒中或者颅内出血事件)HAS-BLED评分高危治 疗策略AndreottiFetal.EurHeartJ.(2015)ChengduFifthPeople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容评分为0-2分者属于低风险患者,评分≥3分时提示患者出血风险增高1不应将HAS-BLED评分增高视为抗凝治疗禁忌症2当评分增高时,应谨慎地进行获益风险的评估,制定适应的抗栓措施3积极改善可纠正的危险因素,如酒精戒断、未控制的高血压、INR不稳定或停用抗血小板药物4心房颤动的抗栓治疗策略:出血风险ChengduFifthPeople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容心房颤动风险评估总结正确风险评估是房颤规范化及个体化治疗的前提心房颤动建议常规抗凝治疗,抗凝优选NOAC,除非卒中风险低或有确切抗凝禁忌是否抗凝取决于CHA2DS2-VASc评分,不取决于房颤类型、病因、负荷、病程、症状、出血风险等需要动态评估CHA2DS2-VASc评分,特别是低危暂不抗凝患者动态评估出血风险,纠正可以纠正的出血高危因素,优选出血风险较低的抗凝方案ChengduFifthPeople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容谢谢ChengduFifthPeople’sHospitalChengduFifthPeople’sHospital精医重德和谐包容精医重德和谐包容 |
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