[AF-FORUM] 104E 动脉粥样硬化和AF - Dr. Perez Riera

星期二十月 20 14:10:13 ART 2009

尊敬的Mykola Iabluchansky医生以及全体同仁：
急性心肌梗死后心房颤动
房颤是急性心梗的常见并发症（约10%到15%），常与卒中或死亡所致发病率及死亡 
率的增加有关。观察发现，非高加索人群的AF发生率较低，亚洲人群在罹患急性缺 
血性疾病时AF的发生率显著低于白种人。我们需要进行更多有关其机制和潜在的遗 
传基础的研究（1）。已发现炎症标志物升高与AMI患者心脏事件高危风险相关。C 
反应蛋白（CRP）被认为可能参与AF的始动过程。CRP可能是急性前壁心梗患者发生 
AF的危险因素（2）。一个大规模试验（120566 例心梗患者）证实AF在ST段抬高型 
心梗中比在非ST段抬高型心梗中更多见。已证实在ST段抬高型心梗中和非ST段抬高 
型心梗中AF与其近期与远期死亡率的关系（3）。在非ST段抬高型心梗中，伴有心 
电图变化（P波持续时间延长≥110ms）以及超声心动图左房大小异常（左房扩大） 
的患者比不伴有上述变化的患者AF的复发率更高（4）。
    发生AF的患者因AMI住院期间的急性中风及死亡风险均增高。高龄、女性、既 
往心梗史，及住院期间发生AF都是脑卒中的高危因素（5）。AF患者的出院后生存 
率明显降低。（6）。急性心梗伴有房颤或房扑的患者因心源性猝死（SD）发生率 
高二长期预后差。应用ACEI及洋地黄治疗可能对SD具有远期有利效应。（7）
    ESTEEM研究分析1883例MI患者联合应用希美加群阿司匹林与单用阿司匹林相 
比，治疗6个月后预防缺血事件的效果，入选患者心梗后14天随机分组。发生心梗 
后，9%的患者住院期间发生AF。希美加群相对于安慰剂的多因素危险比在AF患者中 
进行计算。在101例应用希美加群治疗的AF患者中6.9%的患者发生死亡、心梗或卒 
中，而在73例应用安慰剂的AF患者中其发生率为20.6%，希美加群能降低死亡、心 
梗或卒中的风险达70%。对于单独的终点事件，其他作者也得出相似的但无显著性 
差别的趋势（8）。
    一项入选8659例患者的随机对照研究发现大剂量他汀治疗并不显著降低急性冠 
脉综合患者的AF短期发生率。（9）
    雷诺嗪，晚期Na通道阻滞剂，ACS患者住院后第一周持续心电监护发现其具有 
抗心律失常作用。试验特殊设计以证实雷诺嗪潜在的抗心律失常作用。在心肌缺血 
兔子中，其作用主要是通过影响钠依赖性钙离子通道从而改变细胞内Na离子水平。 
因此，大鼠中，雷诺嗪间接抑制有致心肌缺血作用的钙超载。已知雷诺嗪可以增加 
心电图上QT间期。QTc间期平均增加约6毫秒，约5％的人可能有QTc间期延长15毫秒 
或更长。因此，与其他延长QT的药物联用时，雷诺嗪应慎用。此外，由于肝功能异 
常患者中QT延长作用明显，在轻、中或重度肝病患者中禁用。
在鱼肝油ω-3延缓AF复发的临床试验（FORomegaARD）中研究药源性补充1克ω- 3 - 
苯甲酸乙酯是否可减少既往可恢复窦性心律AF的复发率（11）。
    房颤患者常规使用药物洗脱支架似乎并不合理，与裸支架相比期严重出血的风 
险增高，因此药物涂层支架更倾向于仅限于病变或再狭窄的高危患者。（12）

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致
Andrés Ricardo Pérez Riera MD
In Charge of electro-vectorcardiogram sector. Cardiology Discipline. ABC
Medical Faculty.  ABC Foundation. Santo André - São Paulo. Brazil
Sebastião Afonso, 885     CEP: 04417-000
Jardim Miriam – São Paulo - Brazil
Phone: (11) 5621-2390
riera在uol.com.br