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1、胡大一 孙艺红北京大学人民医院,中国心房颤动流行病学现实与问题,心房颤动(AF),最常见的心律失常 发病率随年龄增长和器质性心脏病的发展而增加卒中常见的病因之一(占所有卒中10-15%)明显增加心血管死亡和致残即使经过抗心律失常药物治疗，半数患者有复发倾向,AF占心律失常出院诊断1/3,Bialy D.J Am Coll Cardiol.1992;19:41A.,18%Unspecified,Percent of subject died in follow-up,years,AF 死亡率,Benjamin EJ,Circulation 1998;946-952,10%,30%,50%,Wom
2、en,No AF,Men,AF,Women,AF,Men,No AF,Odds Ratio for Death,Dorian P et al.J Am Coll Cardiol.2000;36:1303-1309.,生活质量,Higher scores=better QQL,*,*,*,*,AF,CAD,Controls,*P0.05,patients with AF compared to healthy controls P0.05,patients with AF compared to those with CAD,Framingham 研究:AF危险因素,Benjamin EJ,et
3、 al.JAMA,1994;271:840-844,Ryder KM,et al.Am J Cardiol 1999;84:131R-138R.,AF患病率的地理差异,5.5%,5.4%,50 yrs,USA(CHS),single ECG 65 yrs,UK,single ECG 60 yrs,Netherlands,single ECG&medical record 50 yrs,UK,single ECG 55 yrs,Netherlands,single ECG 35 yrs,USA,medical record 50 yrs,UK,single ECG Review results
4、60 yrs,Australia,triennial survey 40 yrs,Japan,single ECG 60 yrs,Hong Kong,single ECG 35 yrs,Denmark,single ECG25-64 yrs,west German,single ECG 15 yrs,India,single ECG,0.1%,5.1%,3.7%,3.0%,2.8%,2.4%,1.5%,1.3%,1.3%,0.60%,0.28%,Estimate of prevalence of AF vary based on the characteristics of populatio
5、n studied and how AF is ascertained.,%of hospitalization,7.65%,7.90%,8.16%,1999,2000,2001,6.0%,6.5%,7.0%,7.5%,8.0%,9.0%,Qi W,et al.Chinese J Cardiol,2003；31：913-916,AF住院率增加：中国,Average,7.90%,中国AF的流行病学 14个自然人群,13 个省,中国心房颤动的流行病学调查,中国自然人群国际标准化方法 29079 人年龄 35 岁连续采样,Hu D,et al.2004 Chin J Intern Med;in pr
6、ess.,方法,中国AF患病率-年龄/性别分层,Age Group,y,Rate per 100,30-39,40-49,50-59,60-69,Overall,Men(n=13358),Women(n=15521),0.3,0.2,0.5,0.6,1.4,1.1,3.6,2.6,7.5,7.4,70-79,80,0.9,0.7,Data collected from 13 natural populations from 14 different provinces across China,Hu D,et al.2004 Chin J Intern Med;in press.,P0.05,
7、0.77,不同国家患病率比较,FHS:the Framingham study.Wolf PA et al.Sroke 1991;22:983-988Australia:Lake FR,et al.Aust NZ Med 1989;19:321-326UK:Hill JD et al.J R Coll Gen Pract 1987;37:172-173,AF患病率：中国及其他地区,阵发性/持续性AF的趋势,Hu D,et al.2004 Chin J Intern Med;in press.,阵发性AF的转归,64例17.9,住院病人回顾分析 阵发性心房颤动 358例平均5年后 64例（17.
8、96%）变为持续性房颤,2004 中国心脏起搏与心电生理杂志,中国AF卒中的患病率,%,12.95%,24.81%,17.5%,Hu D,2004,Qi W,2003,0,5%,10%,15%,20%,25%,Hu D,2003,Hu D,et al.2004 Chin J Intern Med;in press.Random sample of populationQi W,et al.2003 Chin J Cardiol;31:913-916.Case-control study.Hospitalized patientsHu D,et al.2003 Chin J Intern Med
9、;42:157-161.Case-control study.Hospitalized patients,0,5,10,Ma C,et al.Chin J cardiol 2002;30:165-167,60,6069,7079,80,AF患者卒中发生率：每年5.3%,%,Without risk factor,With risk factor,Age Range(years),1.0,1.6,3.1,5.1,4.0,8.8,7.7,7.9,520 consecutive nonvalvular AF patients without taking warfarin were followed
10、 6.754.03 years.Hypertension,diabetes and ischemic stroke history has a positive correlation with incidence of AF related stroke.,中国AF卒中危险因素:病例对照研究,回顾性研究,18家医院，2年,RVD:rheumatic valvular disease,HU D,et al.Chin J Intern Med,2003;42:157-161,AF住院患者一般情况,Idiopathic AF,RVD,CHF,CAD,Advanced age,58.1%,56.3%
11、,Hypertension,caidiomyopathy,34.8%,33.1%,24.1%,7.4%,5.4%,4.1%,Diabetes,CAD:coronary artery disease;CHF:congestive heart failure;RVD:rheumatic valve disease,HU D,et al.Chin J Intern Med,2003;42:157-161,NVAF患者卒中患病率：年龄分层,years,0,5,10,15,20,25,Prevalence(%),30,40,4049,6069,50-59,7079,80,HU D,et al.Chin
12、J Intern Med,2003;42:157-161,4.9,9.7,15.2,21.0,28.9,32.1,NVAF卒中危险:病例对照研究,HU D,et al.Chin J Intern Med,2003;42:157-161,%,Lone AF,PersistenceAF,Control of heart rate,75.2,2.3,97.7,P0.001,0,25,Paroxymal AF,Conversion,50,75,24.8,51.9,P=0.21,100,None valve AF,P=0.009,18.8,NVAF患者卒中危险因素,AGE 76 yrs,Hyperten
13、sion,Diabetes,LA thrombi,SBP,1.76(1.08-2.89),1.52(1.28-1.80),1.39(1.11-1.76),1.71(1.21-2.28),1,2,3,4,5,2.77(1.25-6.13),HU D,et al.Chin J Intern Med,2003;42:157-161,0,2,4,6,8,AFASAK58%7 81,SPAF67%27 85,BAATAF86%51 96,CAFA42%-68 80,SPINAF79%52 90,TOTAL68%5079,Risk reduction,AF Investigators.Arch Inter
14、n Med 1994;154:1449-1457.Atwood et al.Herz 1993;18:27-38.,Stroke Incidence(%),95%CI,AF Investigators:Meta-analysisWarfarin for Stroke Prevention,p 0.03,p 0.01,p 0.02,p 0.2,p 0.002,p 0.001,老年人心房颤动 年龄是抗凝的禁忌吗?,老年人禁忌症多出血并发症多对华法林敏感严密监测INR，年龄不是危险因素,Fihn SD,et al;Ann Int Med;1996;124:970-979,抗栓治疗明显降低住院AF患者
15、的卒中,Number of Strokes Prevented,Qi W,et al.Chinese J Cardiol,2003；31：913-916,0,5%,10%,15%,20%,25%,No Therapy,Anticoagulation,5.5%,24.2%,P0.001,stroke rate,华法林抗凝 433例（9.64）平均年龄 61.4812.44岁治疗时间中位数为 7个月（1个月3年）平均剂量 2.770.83mg（1-6mg）,Hu D,et al.2004 Chin J Intern Med;,中国住院AF病人华法林抗凝治疗,非瓣膜性心房颤动华法林年龄分层,Hu D
16、,et al.2004 Chin J Intern Med;,华法林抗凝监测INR分布情况,中国住院AF病人INR监测情况,24,Hu D,et al.2004 Chin J Intern Med;,华法林 阿司匹林 非抗栓,P=0.001,抗栓治疗总出血发生率,中国住院AF病人华法林抗凝的安全性,Hu D,et al.2004 Chin J Intern Med;,轻微出血（84%）严重出血（16%）,出血事件 31例 严重出血 5例 脑出血 2例 严重上消化道出血 2例 硬膜下腔出血 1例轻微出血 26例 鼻出血 6例 齿龈出血 6例 血尿 5例 皮肤粘膜瘀斑 5例 黑便 3例 球结膜出血
17、 1例,中国住院AF病人华法林抗凝的安全性,p=0.259,65 62,OR=3.73(p=0.001),华法林抗凝并发出血的危险因素,中国住院AF病人华法林抗凝的安全性,56%Rhythm control,20%Rate control,24%NO therapy,Amiodarone 31.0%,Cedilanid 29.6%,-Blocker 18.3%,Propafenone 14.3%,阵发性AF住院患者 治疗现状,Qi W,et al.Chinese J Cardiol,2003；31：913-916,Rate Control 83%,Rhythm Control 14%,No t
18、reatment3%,持续性AF住院患者 治疗现状,Qi W,et al.Chinese J Cardiol,2003；31：913-916,2%Warfarin,60%None,Aspirin38%,AF患者抗栓治疗现状：人群流调,Hu D,et al.2004 Chin J Intern Med;in press,9.64%Warfarin,90.36%No anticoagulation,Sun Y,Hu D,et al.Chinese J Cardiol,2004；43：258-260,AF住院患者抗凝治疗的现状,N=4511,INR was monitored in 77.2%pat
19、ients treated with warfarin Thirty one(7.11%)confirmed bleeding events CHF and HT increased the risk of bleeding during warfarin treatment INR between 1.5 and 3.0 is safe and effective,结 论,AF的流行病学危险因素与国外的研究基本一致AF发生与年龄密切相关AF并发脑卒中的发生率在中国很高 多数AF患者没有进行抗凝治疗中国人口逐渐在老龄化，具有AF高危险的人群越来越多 未来，AF导致卒中和致残也将越来越多,指南医生教育患者科普教育抗栓门诊,抗栓治疗的服务模式,CHALLENGE,
