美国新版《抗栓治疗和血栓预防指南》心房颤动和瓣膜病的更新解读

Update and explanation of suggestions on anticoagulant therapy of atrial fibrillation and valvular heart disease in the 2012-edition guideline from The American College of Chest Physicians

2012年美国胸科医师学院(ACCP)第9版《抗栓治疗和血栓预防指南》在心房颤动(AF)抗栓治疗中强调基于CHADS2评分的危险分层抗栓策略,CHADS2评分≥1分患者均应给予口服抗凝药物,包括华法林(国际标准化比值目标2.0～3.0)和新型口服抗凝药物达比加群。不推荐应用抗血小板治疗。此外,还对特殊情况如合并冠心病以及复律时的抗凝治疗给予建议。多数风湿性瓣膜病和机械瓣膜置换术后需要口服华法林。发生感染性心内膜炎的患者不建议抗凝治疗,如患者长期抗凝也要暂时停用直至病情稳定。机械瓣膜置换术后长期华法林抗凝,人工瓣膜血栓的处理策略需要根据血栓大小和位置来决定溶栓还是外科手术治疗。

The ninth edition of ACCP （The American College of Chest Physicians） guideline emphasizes the antithrombotic therapy based on CHADS2 stratification in patients with atrial fibrillation （AF）. For patients with nonrheumatic AF （NVAF） ,including those with paroxysmal AF, who are at intermediate to high risk of stroke （e. g. , CHADS 2 score ≥1 ） , we recommend oral anticoagulation, which include warfarin and a new oral anticoagulant （darbigatran）. Antiplatelet treat- ment is not universally recommended for NVAF. The guideline also states how to choose the antithrombotic strategies in pa- tients with acute coronary syndrome （ACS） or stent and in those undergo cardioversion. For patients with rheumatic vavular disease and prosthetic valve implantation, dose-adjusted wafarin is strongly recommended. The guideline suggests stopping VKA （ vitamin K antagonist） therapy until the patient is stabilized without neurologic complications for infective endocardi- tis of a prosthetic valve. In patients with thrombosed prosthetic valve, fibrinolysis is recommended for right-sided valves and left-sided valves with thrombus area 0. 8 cm2 （ Grade 2C ）. For patients with left-sided prosthetic valve thrombosis and thrombus area 0. 8 cm2 ,we recommend early surgery.