--Topol?????

1
????????????

• ?????????????????????
• --???

2
?????????????

• ????????,?????,????,???????,????,?????????????
• ?????????,????,??????????,?????,????
• ??????????????
• ????????,??,??
• ???????????????, ?????????
• --Topol?????

3
?????????????

• ?????????????????????,?????,??????
• ??????????????,??????????EF??????,???????????????
  ??
• ????????????PR ?QRS ?QT????,??????????,?ß????????
  ???,?????????????????
• ????????????????????,??????,??????,???????
• --Topol?????

4
?????????

• ??????????,??????????????
• ???????????????,??????????
• ???????????,?????
• ????,???????,??????????????
• ???????????????????

5
????

• ???????????????????????????????????????????
  ?????

6
????

• ???????????(???????????)????(??????)?????(?????
  ??????)????????(??????????)????

7
????

• ???????
• ?????????,???????,????????????????????????????
  ?????????????????????????????????????????????
  ?????

8
???????
9
?????

• ?????????????,???????????????????, ß-????CCB
• ???????,??????????????????????????????????ß-?????
  ?

10
???????

• ???????????(AVNRT)??????,????????????????????????
  ??????,??????????????????-????
• ?????????(AVRT)?????????????,????????????????-???
  ??

11
???????

• ????????
• ???????????,????
• ??????CCB?ß-blcok?
• ????ATP10-15mg iv????0.4mg?????????150mg?????????
  ????????70mg???????????????????
• TEAP????????
• ???

12
???????

• ??????????????????????CCB,ß-block??????????????
  ,????Ic????????(????)????????????

13
???????

• ??????
• ????????????????????,???????????????????????
• ? ???????,??????,??????????????ß-block?CCB?????
  ???????????????????????????????

14
? ?

• ????????????????????????,????????????

15

• ???????
• ??????????
• ?????????????????????
• ?????????????????????????
• ???????????????????????????

16
???????????

• ??????????
• ???????
• ????????
• ??
• ????
• ??????????
• ???????????

17
???????

• 1???????? ??
• 2??????????
• 3?lt60?,????????????
• 4?????????,AAD???????
• 5?????????

18
??7?????????
?? ???? ??? ????
???????
???? ?? ? A
??? ?? ? A
???? ?? ? A
???? ????? ? A
??? ????? ?a A
???????
????? ?? ?b C
????? ?? ?b B
??? ?? ?b B
???????
??? ????? ? A
???? ????? ? A
19
??7????????
?? ???? ??? ????
???????
???? ?? ? A
??? ????? ?a A
???? ?? ?a A
???????
????? ?? ?b B
??? ?? ?b B
????? ?? ?b C
???? ????? ?b B
??? ?? ?b B
???????
???? ????? ? A
??? ????? ? C
20
????

• ?????????????150-200J?????????????????(?????1-7
  )?????

21
????

• ????????
• ?????12???
• ???????????????
• ???gt60???????55mm?
• ???????
• ???????lt60?/??
• ???????????
• ???????????????????
• ? ???????????????????????

22
??????????

• ????,??AF??????????1-5???3???4?????(INR
  2.0-3.0)?????????1???
• ?????(TEE)????LAA?????????????TEE????????????????
  ????,???????
• ??AF??????48????????,??????????AF????????????????
  ???????????????????,??????????????????????

23
????---???

• ?????
• ????????????
• ?????
• ?????
• AA???????? ??gt3?AA
• ?????????3?

24
????

• ??
• ????6080?/?
• ?????90115?/?
• ??
• ????????????????????????????????????
• ???????????????
  ??????????????

25

• ????????????????????
• ß-block?????????,?????
• CCB??????,??????????
• ?????????????????????ß?????/????????
• ???a?????????b?????????????????????????

26
AFFIRM trial

• ?gt65???????,???????????????,????????????????????
• ?????,???????????????

27
??????

• ???????????(??65?,??????????)????????????,?INR?1.
  5-2.5?????????????100-300mg/d?

28
???????????
???? ?????
?????TIA???? 2.5
??? 1.7
??? 1.6
???? 1.4
??(??,???) 1.4
29
ACC/AHA/ESC????(2006) -???
????? ?????,?ASA ASA 81325mg
?? 1??????gt1?????????ASA ASA 81 325mg ?? ?
???(INR23) 1????gt1????????
???(INR23,???gt2.5) ?? ASA ?? ???
,???????(???)
???? ????TIA???,?????,??? ???? 75?????????LV
EF35?FSlt25???? ????(less well-validated risk
factor) ???6574?????.
30
Approach to the Older Patient with Atrial
Fibrillation (AF)

• AF is frequent in the elderly and confers a risk
  of stroke.Routine examinations or ECG evaluations
  should be targeted toward detection of AF.Thyroid
  disease and medical conditions should be
  controlled.  
• Anticoagulation is the chief weapon against
  stroke.   Both greater potential benefit and risk
  for fatal intracranial bleeding are present at
  ages older than 75 yr, especially in women.
    Careful attention to anticoagulation monitoring
  is necessary.   Aspirin does not usually provide
  stroke risk reduction in older patients but has
  similar overall bleeding complication rates as
  warfarin.
• Rate control produces equivalent benefits with
  lower costs and morbidity than attempts at rhythm
  control.   
• Useful agents in the elderly include digoxin
  (rest control), beta blockers, nondihydropyridine
  calcium channel blockers, and amiodarone with
  dose adjustments for age, weight, and diseases.

--Braunwald's Heart Disease A Textbook of
Cardiovascular Medicine, 8th ed
31
??????

• ??????????????????????????90??

32
??????????????
33
?????????????

• ?????
• ????75?
• ??????45MM
• ?2????????????????????
• ??????
• ??????????

34
CURRENT CONTROVERSIES IN THE ELDERLY

•      Optimal rate control  
•      Estimating bleeding risk  
•      Indications for rhythm control in older
  patients

35
????

• ?????
• ??????????????????????
• ??????????????????????????????????ß?????????????
  ????????(?A??C)???????????,?????????????
  ???(?A??C)?????????????????????????????,??????????
  ???????
• ??????????????????????????,?IA?IC??????

36

• ???????????????????-????ß-block?CCB?
• ???????? ???????85??,???10???

37
??????

• B?????????,??????????SCD ?????,???,??????????????
• ?????B???????????????ICD???
• ??????????????????????SCD.
• ICD??SCD?????????????????????
• ????????????

38
?????????

• ????????????,gt60???????7080?
• ???????????????????? I A
• ???????????????????????????? I C
• ????????????????????,????ICD??? ? C

39
?????????????

• ??????PVC????????????,??????????gt30?????,PVC?NSV
  T????????
• ??PVC???PVC?????
• ??????????PVC????????????????NSVT

40

• ??????
• ???????????????????????????????

41
?????VT

• ?QRS??????,???VT???I C
• ????????????????????? I C
• ???????????AAD??????,??????????? ?a C
• ??????????????????????? ?b C
• ????????????????CCB?????? ? C

42
?????

• ??????????????? ? B
• ??-??B???,???LQTS????????,??????????? ? C
• ?????????? ? C
• ???????????????? ?b C

43
?????????

• ?????????????????,?????????????????????

44

• ? ?
• ??????????,?300-400J???????????,?????????1mg,?????
  ??50-100mg/???150-300mg???????
• ?????????????(?????? gt10min,????,???????????,????
  ?)?
• ???????,??????
• ???????????,????,?????????ICD?

45
???????Bradyarrhythmias
46
????????(SSS)

• ????
• SSS????,??????????????????,????ECG????????????,
  ??lt40/min?????????????(gt3s)???????????(?)?????????
  ????????,??????????????2??????
• DCG?TAP???????EPS??????????

47
????????(SSS)

• ??
• ??????
• ?????????,????????????????
• ????,?????????????????????
• ????????

48
?????????
???? ?? ????
?????????????,??????????????????????-?????????????????? ???????????EPS?? ??????????????? ????????????? ? C
?????????????????????,???-??????,????lt40bpm ??????,??EPS????(CSNRTgt800ms) ?a C
??????????,?????????lt40bpm,??????????? ?b C
???????? ECG?????????,??????????????? ????????????????????? ? C
49
??????

• ?????????????????????????????????
• ?????????
• I ??II??III??????

50
??????

• I ???????????????
• II???????II?I???????????????????,?????P-P??,?????
  ?,????????P-P?????II?II?????????P????????????????
  
• III??????????????P?,???????????,?????????????

51
??????

• ??????????AMI?????????????SA????????????,??????,
  ?????????????????????????????????

52
??????

• ????I?AVB??610,
• ???II?AVB?III?AVB??II?AVB 0.40.8III?AVB
  0.2

53
??????

• ?????????
• ????????????
• ??????????????,??????????????
  ??????????Levs??Lenegres?
• ???????????
• ????????????
• ?????????,??????????????????(????)?????(????????
  ????)????????????

54

• ????
• II?AVB??????II?AVB?????(??)?????????????(????
  ?????????????????)III?AVB??????????????,????????
  ?

55

• ????
• 1)????????,????????????????????
• 2)??????I?AVB?II ? I???????II?II??III?AVB????????
  ??????

56
???AVB??????
???? ?? ????
1.??????????AVB ? C
2.???????AVB??????? ? B
3.?????AVB?????????????????????? ? C
1.?????????AVB 2.????PR???????AVB ?a C
1.????AVB??????? ?b B
1.??????AVB 2.?????His????????????AVB 3.???????AVB ? C
57
??????????????
Kusumoto F, et al Pacing therapy in the elderly.
Am J Geriatr cardiol 2002 11 305-316.
58
???????

• 1)???????
• 2)???????
• 3)??????
• 4)??????
• 5)??????

59
???????

• ? ?
• ???????????, ??????????????????????????????,
  ????????????????,??????????

60
?????????????????
???? ?? ????
1.?????AVB 2.????AVB 3.??????? 4.???,EPS??HV 100ms???His????? ? C
1.???????AVB??,????????VT??? ?a B
2.????????????????? ?a C
3.???,?EPS??HV 100ms???His????? ?a C
1.??????AVB,???? 2.???????AVB,??? ? B
61
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