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1、非抗心律失常藥物對(duì)房顫的 預(yù)防作用南京醫(yī)科大學(xué)第一附屬醫(yī)院心內(nèi)科單其俊AF Grandfatherofarrhythmia; Grandfather’sarrhythmia心房顫動(dòng)危害（1）癥狀，如心悸、胸悶甚至?xí)炟剩?）引起或加重心功能不全；（3）血栓栓塞，如中風(fēng)、體循栓塞等。ClassificationofatrialfibrillationWGA-ESC&NASPEJUNE13,2000TerminologyClinicalFeaturesArrhythmiaPatternTherapeuticImpl
2、icationInitialevent(firstdetectedepisode)SymptomaticAsymptomatic(firstdetected)Onsetunknown(firstdetected)MayormaynotrecurAntiarrhythmictherapyforpreventionisnotneededexceptifsymptomsaresevereParoxysmalSpontaneoustermination<7daysandmostoften<48hoursRecurre
3、ntPreventionofrecurrencesRatecontrolandanticoagrlationifneededpersistentNotself-termimatingLasting>7daysorpriorcardioversionRecurrentRatecontrolandanticoagrlationifneededor/andcardioversionandprophylacticantiarrhythmictherapyPermanent(accepted)Notterminated
4、TerminatedbutrelapsedNocardioversionattemptestablishedRatecontrolandanticoagrlationasneeded房顫臨床表現(xiàn)的多樣性房顫觀察的時(shí)間窗SR10~15年AFAPC;AT;PSVT;AFL?ElectricalremodelingTachyinducedtachySinusbegetssinusAFbegetsAFStructuralremodeling致心律失常基質(zhì)？HT，CHF，CHD，DM….遺傳學(xué)家族性房顫BrugadaS
5、hortQT影響現(xiàn)代心臟病臨床實(shí)踐最重要因素介入心臟病學(xué)循證醫(yī)學(xué)現(xiàn)代房顫治療的基礎(chǔ)(一)房顫常常與年齡有關(guān).在美國(guó)大約50％房顫病人為75歲以上的老人無心臟瓣膜的房顫病人，體循栓塞和中風(fēng)的發(fā)生率較常人高5倍華法林治療維持INR2－3倍能非常有效在降低栓塞和中風(fēng)的發(fā)生率房顫心室率控制不當(dāng)可引起擴(kuò)張型心肌病藥物不能有效地控制心室率，消融房室結(jié)或希氏束加永久起搏目前尚無一種藥物能效地抑制房顫現(xiàn)代房顫治療的基礎(chǔ)(二)盡管用抗心律失常藥物治療仍有半數(shù)的房顫病人會(huì)復(fù)發(fā)抗心律常藥物治療可能引起致心律失常作用，包括致命性的動(dòng)
6、物模型研究表明房顫的機(jī)制可能有幾種心房的電重構(gòu)與結(jié)構(gòu)重構(gòu)節(jié)律控制和心率控制(>65歲)同樣有效射頻導(dǎo)管消融可根治部分房顫針對(duì)結(jié)構(gòu)重構(gòu)的非抗心律失常藥物？現(xiàn)代房顫的機(jī)制AtrialElectrical&Structuralremodeling左房驅(qū)動(dòng)（觸發(fā)+折返基質(zhì)）（肺靜脈有P細(xì)胞，肺靜脈內(nèi)折返，左房與肺靜脈交界處motherrotors、二尖峽部、mashalllig.等）多小波折返右房被動(dòng)（三尖瓣和下腔靜脈峽部）Electricalremodelingincludedecreasedatrialeffec
7、tiverefractoryperiod(ERP)andreducedERPrate-adaptation.Conductionvelocityalsodecreases,butmoreslowly.AFbegetsAFSinusbegetssinusTachyinducedtachyPulmonaryveinsmusclesleeveFigure1.APD90sadaptationtorateinPAFandControlgroups.TheyellowsquarerepresentsControlgrou
8、pandtheredrepresentsPAFgroup.*meansp<0.05******StructuralremodelingAFisassociatedwithatrialdilation,lostofatrialcontraction,andmitralinsufficiency-socalled“atrialstructuralremodeling”Atrialcardiomyopat
