姚文艷 邵慧珺 劉媛
【摘要】 目的:研究長(zhǎng)時(shí)程連續(xù)心電監(jiān)控房顫對(duì)急性缺血性卒中(發(fā)病<5 d)入住院患者的卒中后復(fù)發(fā)情況。方法:將篩選的103例急性缺血性腦卒中且STAF評(píng)分5分的患者,按是否進(jìn)行10 d長(zhǎng)時(shí)程或者短時(shí)程2個(gè)24 h動(dòng)態(tài)心電監(jiān)測(cè)房顫是否發(fā)生,分成監(jiān)控組51例和常規(guī)組52例,比較兩組患者的房顫?rùn)z出率、腦卒中復(fù)發(fā)卒中復(fù)發(fā)率,并按照美國(guó)國(guó)立衛(wèi)生研究院健康卒中評(píng)分標(biāo)準(zhǔn)計(jì)算NIHSS分值、平均住院天數(shù)。結(jié)果:監(jiān)控組中共檢診斷陣發(fā)性心房顫動(dòng)患者9例(17.6%),常規(guī)組中診斷出陣發(fā)性心房顫動(dòng)患者3例(5.8%),監(jiān)控組陣發(fā)性房顫的檢出率明顯高于常規(guī)組(P<0.05)。監(jiān)控組腦卒中復(fù)發(fā)3例(5.9%)明顯低于常規(guī)組7例(13.5%);監(jiān)控組腦卒中后NIHSS評(píng)分(9.7±4.1)分低于常規(guī)組(18.3±5.4)分;監(jiān)控組腦卒中后平均住院日(15.9±5.1)d低于常規(guī)組(23.1±11.3)d,各指標(biāo)間比較均有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論:長(zhǎng)時(shí)程連續(xù)心電監(jiān)控房顫可以及早發(fā)現(xiàn)并糾正房顫,降低腦卒中復(fù)發(fā)率,降低腦卒中復(fù)發(fā)后的NIHSS評(píng)分,減少平均住院日。
【關(guān)鍵詞】 房顫; 腦卒中; 動(dòng)態(tài)心電圖; 復(fù)發(fā)率
【Abstract】 Objective:To investigate the post-stroke relapse of inpatients with acute ischemic stroke by the long-term continuous electrocardiogram monitoring of recurrent atrial fibrillation (disease time less than 5 days).Method:103 selected stroke patients with STAF score of 5 were divided into monitoring group of 51 cases and common group of 52 cases according to whether or not receive 10-day long-term ECG monitoring or 2 times of 24-hour dynamic ECG monitoring to determine whether atrial fibrillation was occurred.The detection rate of atrial fibrillation and the recurrent rate of recurrent stroke, as well as the NIHSS score and the average duration of hospitalization of patients in the two groups were compared.Result:There were 9 patients(17.6%)diagnosed with paroxysmal atrial fibrillation in the monitoring group,while there were 3 patients(5.8%)diagnosed with paroxysmal atrial fibrillation in the common group,the detection rate of paroxysmal atrial fibrillation in the monitoring group was obviously higher than that in the common group(P<0.05).The recurrent rate of stroke in the monitoring was 5.9% evidently lower than that in the common group 13.5%(P<0.05).The post-stroke NIHSS score of the monitoring group was (9.7±4.1)points lower than that of the common group(18.3±5.4)points(P<0.05).The average duration of hospitalization after stroke of the monitoring group was (15.9±5.1)d less than that of the common group(23.1±11.3)d(P<0.05).Conclusion:Long-term ECG monitoring can early detect and correct atrial fibrillation,decrease the recurrent rate of stroke,lower the post-stroke NIHSS score of brain stroke,and reduce the average hospitalization period.
【Key words】 Atrial fibrillation; Schemic stroke; Electrocardiographic monitoring; Recurrence rate
First-authors address:The Friendship Hospital of Dalian,Dalian 116001,China
doi:10.3969/j.issn.1674-4985.2017.25.033
腦卒中是導(dǎo)致成人致死殘疾的一個(gè)重要的原因,缺血性卒中占其中患者的60%~70%的比例,按照急性腦卒中治療試驗(yàn)(TOAST)的病因分型,其中心源性腦卒中占20%左右[1],心房顫動(dòng)(簡(jiǎn)稱房顫)是臨床中最常見(jiàn)的心律失常[2],是心源性卒中最為常見(jiàn)的原因,占50%左右。有研究表明房顫可使卒中風(fēng)險(xiǎn)增加5倍[3],并且房顫與非房顫相關(guān)因素導(dǎo)致的腦卒中比較,房顫患者卒中導(dǎo)致的死亡率相對(duì)其他原因的死亡率高,復(fù)發(fā)率也較高,并且有更嚴(yán)重的致死致殘率,住院時(shí)間也延長(zhǎng),給患者和社會(huì)帶來(lái)重大的負(fù)擔(dān)。應(yīng)用抗凝治療與抗血小板治療相比,預(yù)防效果更佳,但是目前研究主要集中在持續(xù)性房顫方面,主要集中在對(duì)于持續(xù)性房顫的診治。陣發(fā)性房顫由于其有陣發(fā)性和隱匿性等特點(diǎn),不易發(fā)現(xiàn),常規(guī)的檢查可能無(wú)法篩查到這種危險(xiǎn)因素。故本文對(duì)本院卒中患者選取的103例急性缺血性腦卒中患者進(jìn)行復(fù)發(fā)和預(yù)后進(jìn)行研究和分析,為預(yù)防和診治該類疾病提供證據(jù)。endprint
1 資料與方法
1.1 一般資料 本研究為單中心、前瞻性研究,收集2013年1月-2016年12月期間住院大連市友誼醫(yī)院神經(jīng)內(nèi)科病房住院系統(tǒng)診治的急性缺血性腦卒中患者,并按如下所述條件從中篩選所研究的導(dǎo)致卒中的高危房顫患者。筆者根據(jù)房顫篩查量表(Score for the targeting of atrial fibrillation,STAF)來(lái)初步篩選房顫的高危人群,該量表按年齡、美國(guó)國(guó)立衛(wèi)生研究院卒中量表(National Institute of Health stroke scale,NIHSS)評(píng)分、左心房?jī)?nèi)徑和血管狹窄情況分別評(píng)分,見(jiàn)表1。滿分8分,其中評(píng)分為5分的選入為房顫高?;颊叻秶鶾4],故筆者設(shè)計(jì)方案選取易發(fā)生房顫導(dǎo)致卒中的高危人群實(shí)施有效的心電監(jiān)測(cè)房顫(STAF評(píng)分大于5分),并且也需符合如下納入標(biāo)準(zhǔn):(1)首次發(fā)病住院的患者;(2)發(fā)病在5 d以內(nèi)的患者;(3)符合2014年中國(guó)急性缺血性腦卒中診治指南中的診斷標(biāo)準(zhǔn)[5],且經(jīng)顱腦CT和/或MRI檢查證實(shí)存在此次發(fā)病的責(zé)任病灶。排除標(biāo)準(zhǔn):(1)患者既往2年內(nèi)發(fā)生缺血腦卒中及腦出血病史;(2)卒中患者合并患有冠心病或者風(fēng)濕性心臟病、未控制的甲狀腺功能亢進(jìn)、病態(tài)竇房結(jié)綜合征的患者;(3)伴發(fā)嚴(yán)重肺部的感染及其他部位嚴(yán)重感染、呼吸衰竭、電解質(zhì)紊亂、高熱、飲酒等影響心臟活動(dòng)的疾病。選入研究對(duì)象的患者隨機(jī)分兩組,長(zhǎng)時(shí)程監(jiān)控組51例和常規(guī)組52例,長(zhǎng)時(shí)程監(jiān)控組動(dòng)態(tài)監(jiān)控心電圖10 d,常規(guī)組應(yīng)用2次24 h動(dòng)態(tài)心電圖檢查,記錄房顫發(fā)生情況,并且選入研究的兩組患者性別、年齡、總膽固醇(TC)及低密度脂蛋白膽固醇(LDL-C)分值方面比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表2。并且入選時(shí)監(jiān)測(cè)組與常規(guī)組的GCS評(píng)分[(6.2±3.6)比(8.5±4.2)分]比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。
1.2 方法 完善檢查并選取研究對(duì)象后,長(zhǎng)時(shí)程監(jiān)控組予以連續(xù)監(jiān)測(cè)心電一周,常規(guī)組患者監(jiān)測(cè)2次24 h動(dòng)態(tài)心電圖,并計(jì)算所研究長(zhǎng)時(shí)程監(jiān)控組患這和常規(guī)組患者的房顫?rùn)z出率、腦卒中復(fù)發(fā)率,腦卒中復(fù)發(fā)后NIHSS分值、平均住院日。值班護(hù)士注意監(jiān)測(cè)短陣房顫和陣發(fā)性房顫(監(jiān)護(hù)儀器設(shè)報(bào)警),連續(xù)記錄并將信號(hào)實(shí)時(shí)上傳至監(jiān)護(hù)中心,在受試者與參與研究的人員間建立緊密的聯(lián)系,發(fā)生房顫及時(shí)通知醫(yī)生予以糾正心律失常、抗凝、糾正電解質(zhì)紊亂等病因等綜合治療。
1.3 統(tǒng)計(jì)學(xué)處理 使用SPSS 24.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)處理,計(jì)量資料以(x±s)表示,比較采用t檢驗(yàn),計(jì)數(shù)資料以率(%)表示,采用 字2檢驗(yàn),以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
長(zhǎng)時(shí)程監(jiān)控組患者的房顫?rùn)z出9例(17.6%)與常規(guī)組3例(5.8%)比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。長(zhǎng)時(shí)程監(jiān)控組卒中復(fù)發(fā)3例(5.9%),常規(guī)組復(fù)發(fā)7例(13.5%),兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。長(zhǎng)時(shí)程監(jiān)控組患者的腦卒中復(fù)發(fā)后NIHSS分值、平均住院天數(shù)與常規(guī)組比較,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表3。
3 討論
房顫可以使卒中的發(fā)生風(fēng)險(xiǎn)上升3~5倍,并且與房顫相關(guān)的卒中預(yù)后通常較差,尤其一些隱匿的房顫患者難以及時(shí)發(fā)現(xiàn)并予以控制,房顫的檢出對(duì)于缺血性腦卒中患者的治療決策有著重大影響,因此,及時(shí)發(fā)現(xiàn)房顫對(duì)預(yù)防房顫引起的卒中至關(guān)重要。目前很多研究證據(jù)表明隨心電監(jiān)測(cè)時(shí)間的延長(zhǎng)[6],隱源性卒中患者的房顫?rùn)z出率增加,3 d時(shí)程監(jiān)測(cè)以下為5%左右,1周或更長(zhǎng)的監(jiān)測(cè)檢出率為15%左右,3個(gè)月的時(shí)程監(jiān)測(cè)檢出率30%[7-8]。患者發(fā)生卒中事件發(fā)生后,如果條件允許情況下應(yīng)盡早開(kāi)始監(jiān)測(cè)也可提高檢出率[9],也有研究提出監(jiān)測(cè)時(shí)程對(duì)預(yù)防卒中有益[7]。目前美國(guó)AHA/ASA的指南提出,對(duì)于急性隱源性卒中或短暫腦缺血發(fā)作患者,應(yīng)在患者卒中事件發(fā)生的6個(gè)月內(nèi)需進(jìn)行30 d的延長(zhǎng)心律監(jiān)測(cè),該指南推薦的證據(jù)評(píng)級(jí)并不高,30 d監(jiān)視時(shí)段可能不是最佳的,在一些研究中,有一半以上的房顫事件是在監(jiān)測(cè)的最初一個(gè)月后檢測(cè)到的。如果監(jiān)測(cè)時(shí)間不夠長(zhǎng),很可能錯(cuò)過(guò)抗凝藥物措施的開(kāi)展,然而各方面條件限制,筆者對(duì)所研究患者進(jìn)行長(zhǎng)時(shí)程10 d的動(dòng)態(tài)心電監(jiān)測(cè)。本研究得出的結(jié)論,10 d的監(jiān)測(cè)發(fā)現(xiàn)陣發(fā)性房顫的檢出率高于對(duì)照組。有關(guān)研究也表明房顫是發(fā)生卒中的獨(dú)立危險(xiǎn)因素,相對(duì)于無(wú)房顫患者,房顫患者卒中風(fēng)險(xiǎn)增高5倍,且隨著年齡增加其相關(guān)性明顯增加[10],15%~40%卒中患者與房顫有關(guān)[11-14],且房顫相關(guān)性卒中常以反復(fù)發(fā)生、阻塞較大血管為其發(fā)病特點(diǎn),因此導(dǎo)致梗死面積相對(duì)較大,出現(xiàn)更多神經(jīng)系統(tǒng)功能缺失,從而明顯增加患者的致死、致殘率,梗死后功能恢復(fù)更差[13-15]。很多研究證實(shí),無(wú)論陣發(fā)性房顫還是持續(xù)性房顫,有癥狀性房顫或無(wú)癥狀性房顫在導(dǎo)致卒中風(fēng)險(xiǎn)上并無(wú)顯著差異[16-17]。綜上所述,筆者對(duì)房顫和卒中方面進(jìn)一步研究,本研究表明在所納入研究的急性缺血性腦卒中部分患者中長(zhǎng)時(shí)程監(jiān)控組的房顫?rùn)z出率高于常規(guī)組,并且因?yàn)榧皶r(shí)發(fā)現(xiàn)并予以糾正抗心律失常藥物、抗凝、糾正電解質(zhì)紊亂等病因等綜合治療穩(wěn)定心律,減少了房顫導(dǎo)致卒中的機(jī)會(huì),所以長(zhǎng)時(shí)程監(jiān)控組NIHSS評(píng)分和平均住院天數(shù)也明顯低于常規(guī)組,比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。這項(xiàng)研究也提示,要重視對(duì)老年男性的房顫患者進(jìn)行預(yù)防和早期干預(yù),有積極的重要意義。
2016年的陣發(fā)性房顫與腦卒中研究進(jìn)展建議對(duì)于既往有短暫性腦缺血發(fā)作、缺血性卒中病史的陣發(fā)性房顫患者給予抗凝治療[18]。但同時(shí)新指南強(qiáng)調(diào),臨床醫(yī)師必須在出血風(fēng)險(xiǎn)與預(yù)防卒中獲益之間謹(jǐn)慎地根據(jù)家屬意見(jiàn)做出權(quán)衡利弊的選擇。2016年歐洲心臟病學(xué)會(huì)(ESC)/歐洲心胸外科協(xié)會(huì)房顫管理指南建議,對(duì)房顫進(jìn)行進(jìn)一步細(xì)化分類,包括初發(fā)房顫、陣發(fā)性房顫、持續(xù)性房顫、長(zhǎng)程持續(xù)性房顫和以及永久性房顫5種。初診房顫患者需對(duì)其進(jìn)行全面的心血管系統(tǒng)評(píng)估,評(píng)估內(nèi)容主要集中于血流動(dòng)力學(xué)穩(wěn)定性,感染、離子紊亂及心臟疾病等誘發(fā)因素或基礎(chǔ)疾病、卒中的風(fēng)險(xiǎn)和抗凝指征、室率控制情況來(lái)決策如何應(yīng)用藥物及其它措施來(lái)控制糾正房顫。在醫(yī)療工作中,減少房顫相關(guān)性缺血性卒中的發(fā)病率,關(guān)鍵在于提前預(yù)防,及早發(fā)現(xiàn)早預(yù)防才能有較好的預(yù)后,首先就是要控制好相關(guān)危險(xiǎn)因素(血壓、血糖、血脂、心功能不全等)。及早發(fā)現(xiàn)房顫,根據(jù)抗凝指征予以新型的口服抗凝藥利伐沙班等預(yù)防及抗栓治療,如果藥物及上述措施不理想,可以進(jìn)行復(fù)律治療上有電復(fù)律,還可以選擇手術(shù)治療,如導(dǎo)管消融術(shù)及左心耳封堵術(shù)或切除術(shù)。endprint
房顫相關(guān)性缺血性卒中有較高的患病率、發(fā)病率、致殘率和死亡率,因此需要做好高?;颊叩娘L(fēng)險(xiǎn)管理,控制好相關(guān)危險(xiǎn)因素,積極做好一級(jí)預(yù)防,合理選擇藥物和手術(shù)治療,避免房顫患者血栓形成后導(dǎo)致重癥卒中發(fā)生,不但可以減輕和改善患者生活質(zhì)量,而且減輕了家庭及社會(huì)的巨大負(fù)。Weber-Kruger 等[19]發(fā)現(xiàn)每小時(shí)房性期前收縮>4次的卒中患者更易在長(zhǎng)程心電監(jiān)測(cè)中發(fā)現(xiàn)陣發(fā)性房顫,其機(jī)制可能為心房的異常電活動(dòng)能夠觸發(fā)房顫,因此對(duì)長(zhǎng)時(shí)程心電監(jiān)測(cè)對(duì)房早的發(fā)現(xiàn)也應(yīng)重視,仍具有重要意義,在實(shí)際醫(yī)療診療活動(dòng)中很多工作要去做要去完善,所以長(zhǎng)時(shí)程動(dòng)態(tài)心電監(jiān)測(cè)在臨床工作中具有重要意義[20]。
參考文獻(xiàn)
[1] Wessler B S,Kent D M.Controversies in cardioembolic stroke[J].Curr Treat Options Cardiovasc Med,2015,17(1):358.
[2] Stewart S,Hart C L,Hole D J,et al.Population prevalence,incidence,and predictors of atrial fibrillation in theRenfrew/Paisley study[J].Heart,2001,86(5):516-521.
[3] January C T,Wann L S,Alpert J S,et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Forceon Practice Guidelines and the Heart Rhythm Society[J].J Am Coll Cardiol,2014,64(21):e1-76.
[4] Suissa L,Bertora D,Lachaud S,et al.Score for the targeting of atrial fibrillation (STAF):a new approach to the detection of atrial fibrillation in the secondary prevention of ischemic stroke[J].Stroke,2009,40(8):2866-2868.
[5]中華醫(yī)學(xué)會(huì)神經(jīng)病學(xué)分會(huì).中國(guó)急性缺血性腦卒中診治指南[J].中華神經(jīng)外科雜志.2015,48(4):246-252.
[6] Choe W C,Passman R S,Brachmann J,et al.A Comparison of Atrial Fibrillation Monitoring Strategies After Cryptogenic Stroke(from the Cryptogenic Stroke and Underlying AF Trial)[J].Am J Cardiol,2015,116(6):889-893.
[7] Inoue K,Suna S,Iwakura K,et al.Outcomes for Atrial Fibrillation Patients with Silent Left Atrial Thrombi Detected by Transesophageal Echocardiography[J].Am J Cardiol,2017,pii:S0002-9149(17)31030-5.
[8] Suissa L,Lachaud S,Mahagne M H.Optimal timing and duration of continuous electrocardiographic monitoring fordetecting atrialfibrillation in stroke patients[J].J Stroke Cerebrovasc Dis,2013,22(7):991-995.
[9] Korhonen M,Muuronen A,Arponen O,et al.Let atrialappendage morphology in patients with suspected carliogenicstroke without known atrial fibrillation[J].PLoS One,2015,10(3):e0 118 822.
[10] Abdul-Rahim A H,Lees K R.Paroxysmal atrial fibrillation after ischemic stroke: how should we hunt for it[J].Expert Rev Cardiovasc Ther,2013,11(4):485-494.
[11] Wolf P A,Abbott R D,Kannel W B.Atrial fibrillation as an independentrisk factor for stroke: the Framingham Study[J].Stroke,1991,22(8):983.
[12] Ericson L,Bergfeldt L,Bj?rholt I.Atrial fibrillation: the cost of illness in Sweden[J].Eur J Health Econ,2011,12(5):479-487.endprint
[13] Bjorck S,Palaszewski B,F(xiàn)riberg L,et al.Atrial fibrillation, stroke risk, and warfarin therapy revisited:a population-based study[J].Stroke,2013,44(11):3103-3108.
[14] Gattellari M,Goumas C,Aitken R,et al.Outcomes for patients withischaemic stroke and atrial fibrillation: the PRISM study (A Program ofResearch Informing Stroke Management)[J].Cerebrovasc Dis,2011,32(4):370-382.
[15] Ogilvie I M,Newton N,Welner S A,et al.Underuse of oralanticoagulants in atrial fibrillation: a systematic review[J].Am J Med,2010,123(7):638-645.
[16] Lip G Y.Stroke and bleeding risk assessment in atrial fibrillation:when, how, and why[J].European Heart J,2011,13(5):723.
[17] Healey J S,Connolly S J,Gold M R,et al.ASSERT Investigators.Subclinical atrial fibrillation and the risk of stroke[J].N Engl J Med,2012,366:120-129.
[18]南京,楊水詳.陣發(fā)性心房纖顫與腦卒中研究進(jìn)展[J].中華老年心血管病雜志,2015,17(6):665-667.
[19] Weber-Krüger M,Gr?schel K,Mende M,Seegers J,et al. Excessive supraventricular ectopic activity is indicative of paroxysmal atrialfibrillation in patients with cerebral ischemia[J].PLoS One,2013,8(6):e67 602.
[20] Sirimarco G,Hirt L,Sztajzel R,et al.Stroke prevention in patients with atrial fibrillation[J].Rev Med Suisse,2017,13(560):911-915.
(收稿日期:2017-08-10) (本文編輯:周亞杰)endprint
中國(guó)醫(yī)學(xué)創(chuàng)新2017年25期