[AF-FORUM] 173E 老年人房颤
AF Symposium
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星期一 四月 30 23:05:14 ART 2007
173E 老年人房颤
尊敬的Dr. Francisco Rodriguez Martorell：
不断增长的年龄是房颤发展的主要危险因素之一。80
岁以上的老年人，每年新发房颤约2%。房颤患者的临
床治疗指南中规定房颤的抗凝治疗在60，65和75岁的患
者中存在变化。在丹麦登记的患者（随访15964例突发
脑梗）中。Frost等。（1）通过Cox回归模型评估性别
\年龄在脑卒中的危险，包括年龄分组，由60、75岁或
60-75岁分割年龄段。脑卒中的风险随年龄的增加而逐
渐增加，但并没有明显的高危年龄界值。虽然许多临
床医师都意识到抗栓治疗来预防脑卒中的益处，尤其
是使用华法林，但当前关于抗栓治疗选择的指南依然
含糊且不一致。CHADS2危险分层是一项有用的临床工具
来鉴别患者是否通过华法林获益，将那些患者和低
危、只需阿司匹林就足够的患者中区分开来。CHADS2危
险分层基于以下几点：
心衰史
高血压
年龄>75岁
糖尿病
之前曾有脑卒中或脑血管病史
颅内出血的危险因素包括抗凝强度、高血压和年龄。
在确诊后的第一年，性别、年龄和伴随环境与房颤相
比，和生活治疗更相关。当年老的房颤患者考虑抗凝
时，以下问题需要回答。
是否有明确指征？
是否有出血的高风险或抗凝的强禁忌症？
3）药物的联合使用或疾病状态是否明显增加出血风
险或干扰了抗凝的控制？
4）药物依从性和使用抗凝药物时监测是否成为问题？
5）患者是否常规回顾，尤其是意识到抗凝的风险和
获益？
仔细并且常规评估对于年老房颤患者保证出血风险不
超过抗凝获益是十分必需的。
在FRACTAL研究，在多方面调整后，女性与症状得分高
及生活治疗低强烈相关。年龄>65岁的患者被报道突出
的疾病-特殊损害生活质量较年轻人少。在部分由于
73%患者在第一年中出现了SR，房颤临床进程在此期间
对生活质量的影响很小。在老年患者，亚临床甲状腺
疾病（STD）十分普遍。表现为血清TSH异常，但T4和T3
仍在正常参考范围内。STD对于老年人的房颤及绝经后
骨质疏松症来说也是一危险因素。对于房颤人群筛查
和适当的处理十分重要。
新发房颤是冠脉搭桥（CABG）术后常见的心律失常并
发症。老年患者进行此手术的，其危险评估较普通人
群困难。在2001年9月至2005年12月中，Nisanoglu 等研究了
426例进行CABG的老年患者（年龄≥65岁）。91例出现了
术后房颤（房颤组），其他335例并没有出现房颤（非
房颤组）。多变量分析被用来评估房颤术后的预后。
老年人CABG术后房颤的发生率在这项研究中为21.4%。多
变量分析确定以下为预兆物 ：
1）年龄大于75岁：老年、脑卒中患者合并房颤更容易
失去生活自理能力，需要依靠他人；
2）术前肾功能不全；
3）Euro分数(OR 1.18, P < 0.038)；
4）Cross-clamping时间(OR 1.02, P < 0.012)作为房颤发生的预
测物。
房颤组ICU住院天数明显较长且延长ICU住院天数（≥6
天）的患者比例明显要高。在院死亡率非房颤组为
3.2%,房颤组为2.2%。
对于老年患者，CABG术的死亡率在可以接受的范围
内，但这些患者与其他人比较术后死亡率较高。
参考文献：
1) Frost L, Vukelic Andersen L, Godtfredsen J, et al.Age and risk of
stroke in atrial fibrillation: evidence for guidelines?
Neuroepidemiology. 2007; 28:109-115.
2)Reynolds MR, Lavelle T, Essebag V, et al. Influence of age, sex,
and atrial fibrillation recurrence on quality of life outcomes in a
population of patients with new-onset atrial fibrillation: the
Fibrillation Registry Assessing Costs, Therapies, Adverse events and
Lifestyle (FRACTAL) study. Am Heart J. 2006; 152:1097-1103.
3) Krysiak R, Okopien B, Herman ZS. Subclinical thyroid disorders Pol
Merkur Lekarski. 2006;21:573-578.
4)Nisanoglu V, Erdil N, Aldemir M, et al. Atrial fibrillation after
coronary artery bypass grafting in elderly patients: incidence and
risk factor analysis.Thorac Cardiovasc Surg. 2007; 55:32-380.
5)Basaran M, Selimoglu O, Ozcan H, et al. Being an elderly woman: is
it a risk factor for morbidity after coronary artery bypass surgery?
Eur J Cardiothorac Surg. 2007 Apr 19; [Epub ahead of print]
在此表达我诚挚的祝愿。
Andrs Ricardo Prez Riera MD
电生理组主任，FMABC,FUABC - Santo
Andr So
Paulo - Brazil.
Dr. Sergio Dubner
科委会主席
Dr. Edgardo Schapachnik
组委会主席
潘佳君译
173E AF in elderly patients. Dr. Perez Riera
Dear Dr. Francisco Rodriguez Martorell.
Advancing age is a major risk factor for the development of AF; new
cases of AF are diagnosed in men over age 80 at the rate of 2% per
year. Guidelines for the clinical management of patients with AF
suggest that treatment strategies for prescribing oral anticoagulant
therapy should implicate change at age 60, 65 and 75 years. In the
Danish National Registry of Patients (follow-up 15,964 incident
strokes). Frost et al. (1) examined the risk of stroke by age in men
and women using Cox regression models, which included age categorized
in intervals, linear splines of age with cut points at age 60 and 75
years, or at age 65 and 75 years. The risk of stroke increased
gradually by increasing age, but there are not any threshold
concerning risk of stroke by age.
Although most clinicians are aware of the benefits of antithrombotic
therapy, especially warfarin, for prevention of stroke, current
guidelines for selection of antithrombotic therapy are confusing and
inconsistently applied.
The CHADS2 risk-stratification scheme is a useful clinical tool to
identify patients likely to benefit from warfarin, distinguishing
these patients from patients at lower risk for whom aspirin is
sufficient. The CHADS2 risk-stratification scheme is based on:
1) Clinical history of HF;
2) Hypertension;
3) Age >75;
4) Diabetes;
5) Previous stroke or cerebrovascular disease
Risk factors for intracerebral hemorrhage include anticoagulation
intensity, hypertension and age. Within the first year after
diagnosis, sex, age, and comorbid conditions are more strongly
associated with quality of life outcomes than the clinical course of
AF itself.
When considering anticoagulation in the elderly patient with AF, the
following questions should be made.
1) Is there a definite indication?
2) Is there a high risk of bleeding or strong contraindication
against anticoagulation?
3) Will concurrent medication or disease states significantly
increase bleeding risk or interfere with anticoagulation control?
4) Is drug compliance and attendance at anticoagulant clinic for
monitoring likely to be a problem?
5) Will there be regular review of the patient, especially with
regard to risks and benefits of anticoagulation?
Careful and continuing evaluation of the elderly patient with AF is
necessary to ensure that the risks of bleeding do not outweigh the
benefits from anticoagulation.
In FRACTAL study (2), after multivariable adjustment, female sex was
strongly associated with higher symptom scores and lower quality of
life scores. Age >65 years patients reported less prominent disease-
specific impairment in quality of life than younger patients. In part
because 73% of patients appeared to maintain SR for the first year,
AF clinical course had a comparatively small impact on quality of
life during this timeframe.
In elderly women Subclinical Thyroid Disorders (STD) are especially
prevalent. This term apply to patients who have an abnormal serum TSH
concentration with T4 and T3 levels within their reference ranges.
STD represents a considerable risk factor for AF in the elderly and
for postmenopausal osteoporosis. In this population with AF
screening and adequate management are very important (3).
New-onset AF is the most frequent arrhythmic complication after
Coronary Artery Bypass Grafting (CABG). Elderly patients who undergo
this operation may have a different risk profile from the general
population. Between September 2001 and December 2005, 426 elderly
patients (age >/= 65 years) underwent CABG were studied by Nisanoglu
et al. (4). 91 developed post-CABG AF (AF group), and the other 335
(no-AF group) did not develop this complication. Multivariate
analysis was used to identify independent clinical predictors of
post- CABG AF. The incidence of post-CABG AF in elderly patients
during the study period was 21.4 %. Multivariate analysis identified
as predictors:
1) Age mayor than 75 years: in the elderly, strokes associated with
AF would result in a much greater disability and dependency;
2) Preoperative renal insufficiency;
3) EuroSCORE (OR 1.18, P < 0.038), and
4) Cross-clamping time (OR 1.02, P < 0.012) as predictors of AF
occurrence.
The AF group had a significantly longer mean intensive care unit
(ICU) stay and a significantly higher proportion of patients with
prolonged (>/= 6 days) ICU stays. Hospital mortality was 3.2 % in the
no-AF group and 2.2 % in the AF group.
In elderly women, CABG procedures can be done with acceptable
mortality rates; but these patients are still associated with a
higher prevalence of postoperative morbidity when compared with the
male counterparts (5).
References
1) Frost L, Vukelic Andersen L, Godtfredsen J, et al.Age and risk of
stroke in atrial fibrillation: evidence for guidelines?
Neuroepidemiology. 2007; 28:109-115.
2)Reynolds MR, Lavelle T, Essebag V, et al. Influence of age, sex,
and atrial fibrillation recurrence on quality of life outcomes in a
population of patients with new-onset atrial fibrillation: the
Fibrillation Registry Assessing Costs, Therapies, Adverse events and
Lifestyle (FRACTAL) study. Am Heart J. 2006; 152:1097-1103.
3) Krysiak R, Okopien B, Herman ZS. Subclinical thyroid disorders Pol
Merkur Lekarski. 2006;21:573-578.
4)Nisanoglu V, Erdil N, Aldemir M, et al. Atrial fibrillation after
coronary artery bypass grafting in elderly patients: incidence and
risk factor analysis.Thorac Cardiovasc Surg. 2007; 55:32-380.
5)Basaran M, Selimoglu O, Ozcan H, et al. Being an elderly woman: is
it a risk factor for morbidity after coronary artery bypass surgery?
Eur J Cardiothorac Surg. 2007 Apr 19; [Epub ahead of print]
All the best for all
Andrs Ricardo Prez Riera MD
Chief of Electro-Vectocardiology Sector of the Discipline of
Cardiology,
ABC Faculty of Medicine (FMABC), Foundation of ABC (FUABC) - Santo
Andr So
Paulo - Brazil.
riera在uol.com.br
--
Dr. Sergio Dubner
President of Scientific Committee
Dr. Edgardo Schapachnik
President of Steering Committee
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