房颤患者脑卒中类型及发病机制分析

非瓣膜性房颤患者脑卒中类型及发病机制分析【摘要】目的回顾性分析我院心房颤动脑卒中患者的脑梗死类型及相关发病因素，以探讨非瓣膜性房颤患者发生脑卒中可能存在的发病机制和意义。

方法对2005年9月至2007年9月在我院住院和门诊的房颤并发脑卒中患者进行调查，观察分析瓣膜性和非瓣膜性心房颤动合并脑卒中患者的梗死类型和相关发病因素的区别，筛选非瓣膜性心房颤动发生脑卒中的可能病因和机制。

结果瓣膜性房颤和非瓣膜性房颤脑卒中患者有相同的危险因素：心衰、高纤维蛋白原，也有不同的危险因素：瓣膜性房颤脑卒中与过快的心室率（即：频速型房颤）关系密切，非瓣膜性房颤脑卒中则与高血压、动脉硬化、高脂血症、高血糖的关系密切；非瓣膜性房颤与瓣膜性房颤发生脑卒中的类型不同，瓣膜性房颤发生大动脉栓塞的可能性大，而非瓣膜性房颤发生脑卒中的类型多种多样，包括大动脉栓塞、皮层支梗死、分水岭梗死及腔隙性梗死，特别以分水岭梗死为多。

结论非瓣膜性心房颤动病人可能发生不同类型的脑梗死，发病机制除了心源性栓子脱落造成脑栓塞外，还包括其它不同机制引起的梗死，包括血流动力学改变、动脉粥样硬化斑块形成或脱落、血液流变学改变等，而分水岭梗死的多发则提示血流动力学的改变应为其发生脑梗死的可能病因和重要机制；同时，非瓣膜性房颤脑卒中患者合并高血压、动脉硬化、高脂血症、高血糖的机率大，因而，对卒中的预防除了强调抗凝之外应包括：较好地控制心室率、控制血压、血糖、血脂水平，只有从综合防治的角度出发，改善血流动力学状态，控制血液流变学因素，逆转动脉硬化程度等，才能起到防治中风的目的。

【关键词】非瓣膜性房颤卒中发病机制Stroke categories of non valvular atrial fibrillation andanalyses of their pathogenesis【Abstract 】Objective To probe into the possible pathogenesis and its significance of cerebrovascular disorders of the patients with non-valvular atrial fibrillation (abbreviated to non-VAF) by restropectively analyzing the categories of cerebral infarct and their related pathogenic factors of the non-VAF patients from my hospital. Methods I have screened out the possible etiogenic mechanism of cerbrovascular disorders of the non-VAF patients through investigation into some inpatients and outpatients from my hospital between 2005 and 2007 with auricular fibrillation complicated by cerebrovascular disorders,and by carefully observing and analyzing of the distinctions of the categories of cerebral infarct and their related pathogenesis between stroke patients with valvular auricular fibrillation (abbreviated to VAF) and those with non-VAF.Results Stroke patients with non-VAF and those with VAF share the same hazard factors : heart failure, high fibrinogen; also they have different risk factors:VAF-related cerebrovascular disorders are tightly connected with fast ventricular rhythm, i.e. frequent auricular fibrillation, however, non-VAF-related cerebrovascular disorders are closely connected with hypertension, arteriosclerosis, hyperhipemia and hyperglycemia. Stroke patients with non-VAF and those with VAF fall into different categories. VAF is more likely to occur with aortic embolism, whilenon-VAF may be accompanied by a wide variety of cerebrovascul-ardisorders,including aortic embolism, cortical branch infarct ,watershed infarct and lacunar infarct and so on ,especially of watershed infarct.Conclusion Non-VAF patients may suffer from a variety of cerebral infarction, whose pathogenesis involves not only cerebral thrombosis caused by scaling-off cardiogenic emboli, but also embolism triggered by some other mechanisms, including hemodynamic changes, atherosclerotic plaque formations or scales-off,hemorheologic changes and so on;while frequently-occurring watershed infarct suggests that hemodynamic changes may be the pathogenesis of cerebral infarct.In the meantime,stroke patients with non-VAF have a higher risk of cocurrently developing hypertention, arteriosclerosis, hyperlipemia, and hyperglycemia. Therefore, preventive measures taken besides specially applying anticoagulants should include good control over ventricular rhythm , blood pressure, and levels of blood sugar and blood fat. The intentional precautions against cerebrovascular disorders can only be fulfilled by imposing integrated controls to improve the stateof hemodynamics, to check the hemorheologic factors and to reverse the degree of arteriosclerosis and so on.Key Wordsnon-valvular atrial fibrillation；stroke ；pathogenesis非瓣膜性房颤患者脑卒中类型及发病机制分析心房颤动是临床常见的持续性心律失常, 也是脑卒中的独立危险因素,既往我们对房颤引起脑卒中的认识集中在脑栓塞方面,这与过去瓣膜性房颤（valvular atrial fibrillation，VAF）发病率高有关,随着近年来非瓣膜性房颤（non-valvular atrial fibrillation，NVAF）患者的增多,我们发现临床上许多NVAF患者发生的缺血性脑卒中的类型是多种多样,心源性血栓栓子脱落引起栓塞只是其中的一部分,还有许多的不同脑梗死类型的存在,这是否预示着NVAF患者脑卒中的发生与VAF不同，存在除栓塞以外的不同发病机制？带着这个疑问，笔者对近年来就诊我院房颤并发脑梗死患者的影像学表现及临床资料进行研究和分析,探讨其相关因素和可能存在的发病机制。

1研究对象与方法1．1研究对象选择2005年9月至2007年9月在我院住院和门诊诊断为心房颤动并脑卒中的患者。

年龄>18岁，心电图、动态心电图及相关病史记录证实有心房颤动存在。

1．2房颤及脑卒中的诊断标准房颤指持续时间超过30秒且与可逆性病因无关的房颤发作。

在心电图上表现为P波消失，代之以振幅、形态、间距绝对不规则f波(频率在240～320次／min)及绝对不规律的心室激动。

脑卒中的诊断标准参照Framingham研究[1]，根据患者的临床表现及且必须经影像学证实。

1．3房颤及脑卒中的分型房颤根据病因可分为VAF及NVAF，VAF：主要指风湿性房颤；NVAF：符合房颤的诊断标准，经临床和超声心动图排除风湿性心脏瓣膜疾病者；根据心室率分为，频速型房颤：心室率〉90次/分，非频速型房颤：心室率< 90次/分。

脑卒中的分型方法是按发病机制并结合影像学表现[2]，分为A型（即以大脑动脉主干梗死型为主，包括大面积脑梗死和出血性脑栓塞)、B型（即以分水岭梗死为主），C型（即以腔隙性梗死为主），D型（以皮层支脑梗死为主、包括单发、多发小梗死)，；同时，将B、C、D型梗死定义为非主干梗死型；1．4调查内容采用回顾性病历分析的方法，阅读住院和门诊病历记录，按统一调查表格，填写以下项目：1)一般情况：性别、年龄。