坎地沙坦对阵发性房颤射频消融术后复发及房颤发作持续时间的影响

张芳 夏振伟 冯磊 王小斌

·药物与临床·

坎地沙坦对阵发性房颤射频消融术后复发及房颤发作持续时间的影响

张芳 夏振伟 冯磊 王小斌

目的 探讨坎地沙坦对阵发性心房颤动(房颤)射频消融术后复发及房颤发作持续时间的影响。方法 64例阵发性房颤患者,均给予射频消融术治疗,术后随机分为治疗组和对照组,每组32例。治疗组口服坎地沙坦,对照组未给予药物。观察比较两组的复发次数及房颤持续时间。结果 随访8～12个月,治疗组平均每例房颤复发次数(8.5±1.2)次少于对照组的(10.1±1.5)次,差异具有统计学意义(P＜0.01)。治疗组平均房颤发作持续时间(10.5±2.3)min/次短于对照组的(41.3±3.6)min/次,差异具有统计学意义(P＜0.01)。结论 坎地沙坦可减少阵发性房颤射频消融术后的复发情况,且可缩短房颤发作持续时间。

阵发性心房颤动；射频消融术；坎地沙坦；复发；发作持续时间

房颤是临床最常见的一种心律失常。目前,抗心律失常药物治疗和导管消融治疗是房颤患者转复和维持窦律的主要方法,但是,上述两种方法的成功率不尽如人意。近年来,有研究显示,非抗心律失常药物如血管紧张素转化酶抑制剂、血管紧张素Ⅱ受体拮抗剂及他汀类药物可减少部分患者房颤的初发及复发［1-3］。本文通过探讨坎地沙坦对阵发性房颤射频消融术后复发及房颤发作持续时间的影响,现报告如下。

1 资料与方法

1.1 一般资料 选取2014年3月～2015年6月本院收治的阵发性房颤患者64例,年龄45～70岁,平均年龄(56.2±6.3)岁,所有患者均给予射频消融术治疗术后随机分为对照组与治疗组,每组32例。排除器质性心脏病和甲状腺功能亢进。

1.2 方法 所有患者入组前常规停用抗心律失常药物2周,行超声心动图检查排除瓣膜性心脏病,行肺静脉增强CT明

确有无左房血栓,对发作频繁或发作持续时间较长者需经食管超声除外心房血栓；其他术前准备同普通射频消融术。所有患者在三维标测系统指导下,在肺静脉外口0.5～1.0 cm的左心房完成环状消融。消融终点是消融线两侧双向传导阻滞。对复发的患者进行再次消融时,均再次行电生理检查,术中所用标测及消融设备相同,并由同一术者完成。所有患者均未发生心包填塞。术后华法令抗凝3个月,维持国际标准化比值(INR)1.8～2.5之间。术后对照组未给予药物,治疗组口服坎地沙坦(武田药品工业株式会社)4 mg,1次/d,6个月后,治疗组及对照组均有1例患者失访,余患者均完成研究。患者房颤复发时用电复律或盐酸普罗帕酮复律,未长期口服抗心律失常药物。

1.3 观察指标 记录两组患者随访期间房颤复发次数及房颤发作持续时间,并进行比较。

1.4 统计学方法 采用SPSS17.0统计学软件处理数据。计量资料以均数±标准差(±s)表示,采用t检验。P＜0.05表示差异具有统计学意义。

2 结果

随访8～12个月,治疗组平均每例房颤复发次数(8.5±1.2)次,对照组平均每例房颤复发次数(10.1±1.5)次,治疗组平均每例房颤复发次数明显少于对照组,差异具有统计学意义(P＜0.01)。治疗组平均房颤发作持续时间(10.5±2.3)min/次,对照组平均房颤发作持续时间(41.3±3.6)min/次,治疗组平均房颤发作持续时间明显短于对照组,差异具有统计学意义(P＜0.01)。

3 讨论

房颤增加患者心力衰竭、脑卒中、死亡风险［4］。房颤的发病率随年龄增长而增加［5］。房颤的机制至今未明。目前,多数研究提示心房电重构、心房结构重构和炎症可能参与其中。心房结构重构的早期是心房电重构,晚期是心房纤维化、淀粉沉积、细胞凋亡等组织学改变。近期有研究提示肾素-血管紧张素系统在心房结构重整过程中,起了重要作用［6］。血管紧张素转化酶促进血管紧张素Ⅰ转化成血管紧张素Ⅱ,激活血管紧张素受体-1,血管紧张素受体-1通过G蛋白介导引发磷酸化瀑布链式反应,并作用于细胞外信号激酶和活化转录因子等,刺激成纤维细胞的增值、肥大和凋亡。另有多项研究提示血管紧张素Ⅱ可以导致药物性心律失常［7］。在基础研究和临床试验中也发现心肌纤维化组织中血管紧张素转化酶表达增加、血管紧张素Ⅱ相关的信号通路激活［8-12］。

如果阻断血管紧张素Ⅱ,可延缓心房纤维化,减少房颤复发。本研究发现：坎地沙坦治疗组房颤复发次数少于对照组,房颤发作持续时间短于对照组,差异均具有统计学意义(P＜0.01),进而证实血管紧张素Ⅱ受体拮抗剂可减少房颤射频消融术后的复发情况,并缩短房颤发作持续的时间。结果也提示：现阶段,抗心律失常药物和导管消融在房颤转复和维持窦律的成功率有限,加用非抗心律失常药物(如血管紧张素Ⅱ受体拮抗剂)可进一步提高房颤心律治疗的效果。因本研究严格控制入组条件,所以入选病例数少,且随访时间短、随访方法有限、缺失部分无症状房颤的结果,可能对本研究结果产生影响。因此,后续研究将持续进行。

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Influence of candesartan on recurrence and duration of atrial fibrillation attack after radiofrequency ablation for paroxysmal atrial fibrillation

ZHANG Fang,XIA Zhen-wei,FENG Lei,et al.Department of Cardiology,Liaoning Province Dalian City Central Hospital,Dalian 116033,China

ObjectiveTo explore influence of candesartan on recurrence and duration of atrial fibrillation attack after radiofrequency ablation for paroxysmal atrial fibrillation.MethodsA total of 64 paroxysmal atrial fibrillation patients all treated with radiofrequency ablation were randomly divided into treatment group and control group,with 32 cases in each group.The treatment group received oral candesartan,and the control group received no medicine.Observation and comparison were made on recurrent frequency and duration of the atrial fibrillation attack in two groups.ResultsAfter follow-up review for 8～12 months,the treatment group had less average recurrence of atrial fibrillation as (8.5±1.2) times than (10.1±1.5) times in the control group,and their differences had statistical significance (P＜0.01).The treatment group had shorter average duration of atrial fibrillation attack as (10.5±2.3) min/time than (41.3±3.6) min/time in the control group,and their difference had statistical significance (P＜0.01).ConclusionCandesartan can reduce the recurrence after radiofrequency ablation for paroxysmal atrial fibrillation,and also can shorten the duration of atrial fibrillation attack.

Paroxysmal atrial fibrillation; Radiofrequency ablation; Candesartan; Recurrence; Duration of attack

10.14164/j.cnki.cn11-5581/r.2017.03.039

2016-12-28］

116033 辽宁省大连市中心医院心内科