瓣膜性房颤患者的临床特点、卒中一级预防现状及随访调查

Clinical characteristics, primary prevention of stroke and followup survey of patients with valvular atrial fibrillation

摘要:

目的 了解2014 ～ 2015 年成都地区瓣膜性心脏病（VHD）伴心房纤颤（AF）患者的一般资料、卒中相关危险因素及卒中一级预防的现状及预后，为进行有效的卒中一级预防提供理论依据和支持。方法 选取2013年12 月-2015 年4 月四川省人民医院收治的VHD 伴颤且未发生脑卒中的233 例住院患者的完整临床资料，按照病因分为风湿性心脏瓣膜病伴AF 组（n =126）、退行性心脏瓣膜病伴AF 组（n =82）以及其他瓣膜性心脏病AF 组（n =25），对3 组中影响脑卒中的危险因素以及一级预防方法和现状进行分析并随访2 年，观察患者的干预方法是否对脑卒中有预防作用。结果 3 组在年龄分布、性别以及房颤类型等方面差异有统计学意义（P <0.05）。房颤类型以持续性房颤为主；89.3% 的患者有左心房增大；瓣膜性房颤患者的卒中一级预防的干预措施中风湿性VHD 组以抗凝为主，其中（74.8%）使用华法林长期抗凝治疗，退行性VHD 组以抗血小板（57.3%）为主；采用CHA2DS2-VASc 评分来评估房颤患者的卒中风险，高风险人群共173 例（74.3%）；风湿性VHD 组高风险人群以抗凝99% 为主，退行性VHD 高风险人群则以抗血小板为主58.9%。在预防干预后随访2 年，未坚持卒中一级预防的患者中11.1% 出现脑梗死，坚持卒中一级预防的患者中发生脑梗死比例为0.5%。结论 退行性VHD 合并房颤患者比例较前增加。VHD 合并房颤的患者大部分属于高卒中风险人群，使用华法林药物抗凝仍是脑卒中一级预防的主要方法。药物抗凝、手术方式抗凝均能够有效的预防VHD 合并房颤患者的2 年内脑卒中的发生。

关键词:瓣膜性心脏病;房颤;脑卒中;一级预防方法

Abstract:

Objective To collect general data, investigate the risk factors, the current status of primary prevention and prognosis of stroke of valvular heart disease (VHD) patients with atrial fibrillation (AF) (or valvular atrial fibrillation), and provide theory gist for the primary prevention of stroke. Methods The complete clinical data of 233 cases of hospitalized patients with valvular atrial fibrillation and without stroke in Sichuan Provincial People's Hospital from December 2013 to April 2015 were studied. According to the cause of disease, patients with valvular atrial fibrillation were divided into rheumatic VHD group (n = 126), degenerative VHD group (n = 82) and other VHD group (n = 25). The effect of intervention methods on stroke were analyzed based on 2 years’ followup survey where related risk factors, clinical characteristics and primary prevention were observed. Results The age distribution, gender and type of AF were significantly different among the three groups (P < 0.05). Persistent AF is the main type of AF, 89.3% of whom had left atrial growth. Anticoagulant therapy was the major treatment in the rheumatic VHD group, and 74.8% of the patients used warfarin; antiplatelet (57.3%) was widely used in the degenerative VHD group. A total of 173 cases (74.3%) were at high risk according to CHA2DS2-VASc score (male, ≥ 2 points; female ≥ 3 points). Anticoagulant was used in 99% of the patients at high risk in the rheumatic VHD group; antiplatelet was used in 59.0% of the patients at high risk in the degenerative VHD group. According to 2 years’ followed-up, the incidence of cerebral infarction was 11.1% in the patients who did not insist on the primary prevention of stroke while 0.5% of the patients insisted on stroke primary prevention. Conclusions The proportion of patients of degenerative VHD with AF is significantly increased compared with previous data. Most of the VHD patients complicated with AF are at higher risk of stroke. Warfarin is still the main method of the primary prevention of stroke in VHD patients with AF. Anticoagulation and surgery are efficient for stroke prevention in patients with AF within 2 years.

Key words:valvular heart disease; atrial fibrillation; stroke; primary prevention