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

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。     

住院患者中心房颤动脑卒中753例的回顾性分析

目的统计住院患者心房颤动(AF)缺血性脑卒中的发生率和病因、年龄构成;掌握住院患者AF的抗凝治疗现状。方法以AF缺血性脑卒中住院患者为研究对象,记录年龄,病因,超声心动图检查结果,栓塞并发症及抗凝治疗情况。结果①AF住院患者中缺血性脑卒中的患病率为20.2%,明显高于住院患者中的患病率;65岁以上的患病率高于65岁以下;非风湿性心脏病AF脑卒中患病率明显高于风湿性心脏病AF。②33.2?患者接受华法林治疗,平均剂量(3.0±1.0)mg/d;45%接受阿司匹林及同类药物治疗,平均剂量(75.0±37.0)mg/d。③443例有超声心动图资料的AF患者中,109例检出心腔内血栓。结论①年龄和AF的病因是AF发生脑卒中的危险因素。②与目前观点比较,AF患者的有效抗凝治疗范围偏小;阿司匹林剂量不足。③超声心动图技术对于检出AF和AF脑卒中的危险因素,判断栓子类型和来源,指导制定有效抗凝方案,具有重要意义。     

治疗心房纤颤的新方法

同步直流电复律心房纤颤(AF)患者使用电复律不仅可降低发病的危险,而且还可增加其心输出量及运动耐力,并且不需用抗凝剂。同步直流电复律既安全可靠又经济有效,有效率达85％。如果开始电复律无效,可用负荷剂量的抗心律失常药物治疗,并重复多次。另一种方法是当血药浓度达到治疗水平时,先用抗心律失常药物维持治疗,数天后再进行外部直流电复律。用这些方法,90％的患者可复律。对于AF持续3天以上或心律失常时间不确定的患者,复律前应口服抗凝剂3周,使INR达2.O～3.0,以防止发生栓塞。复律后,应继续使用华法林3～4周,因此时心房虽已恢复电应激性,但仍不能正常收缩。即使AF持续时间短并且超声心动图上未见有血栓形成,但未行抗凝治疗的患者在复律后病情仍可复发。     

冠状动脉旁路移植术后心房颤动的原因及防治

目的讨论冠状动脉旁路移植术(CABG)后心房颤动(AF)的发生原因及防治方法.方法对1998-2003年102例CABG术后患者(其中21例发生AF)进行回顾性研究分析.分析患者的临床资料,包括:年龄、性别、射血分数(EF)、左心房大小、心电图、心肌梗死情况、高血压病史、糖尿病史、搭桥支数、体外循环时间、升主动脉阻断时间、术前术后用药情况、AF患者的药物复律及电复律情况.结果CABG术后AF发生率20.6%.应用胺碘酮后转复窦性心律10例,直流电复律3例,应用β受体阻滞剂后自动转复窦性心律3例,持续心房颤动3例,术后早期死于低心排血量2例.结论CABG术后AF的发生与多因素相关.围术期应用β受体阻滞剂、胺碘酮以及术中良好的心肌保护可降低术后心室率,减少AF的发生.术后应积极控制心室率,应用胺碘酮转律对CABG术后AF患者是较好的安全的手段.     

埋藏式心房复律除颤器的研究进展

心房颤动(AF)是临床最常见的心律失常之一,70岁以下的人群发病率为0.4%,而70岁以上者则达到2%～4%[1]。AF影响患者的心功能、增加脑卒中的发生率和住院次数。故AF的治疗已成为众多学者研究的热点。但目前无论是药物还是非药物治疗,包括手术、消融、起搏、体外复律等均未取得理想的效果。随着埋藏式心脏复律除颤器成功地应用于恶性室性心律失常的治疗,1993年Levy等[2]提出了埋藏式心房复律除颤器(AtICD)的设想。晚近,已对AtICD进行了动物实验和临床应用。本文就其研究进展作一综述。1　At-ICD的基本功能　　AtICD基本功能为正确感…     

心房颤动经静脉低能量电复律的应用现状

心房颤动 (AF)是临床常见的慢性或反复发作性快速心率失常之一。近年来 ,AF的药物与非药物治疗均取得较大进展 ,尤其是在 AF的电学治疗方面。本文主要介绍 AF经静脉低能量电复律的应用现状。1　AF复律治疗的指征与方法选择AF不是一种“良性”心律失常 ,需要临床积极处理。复律治疗是 AF的最佳处理措施 ,它可产生一系列临床效益[1,2 ] 。但在决定给 AF病人施行复律治疗前 ,应估计复律成功的可能性、复律治疗的症状改善程度和远期效果。复律后 AF的复发率与复律前 AF的持续时间密切相关。复律前 AF持续时间 >2年者 ,复律后 6～ 1 2个…     

心律处理心房纤颤随访研究（AFFIRM）试验窦性心律、治疗与生存间的关系

心律处理心房纤颤随访研究 (AFFIRM )试验对卒中或者死亡高危患者的心房纤颤 (Af)两种长期治疗策略进行了对比研究。该试验将患者随机分为心律控制组 ,即转复心律并以控制心律失常药物 (AADs)维持窦性心律 (SR) ,和控制心室律组 ,即AF持续 ,控制心室对AF的反应。两组均使用抗凝     

从2006版指南看心房颤动治疗策略

心房颤动(AF)的治疗主要围绕三个方面:控制心室率或转复窦律;抗凝时机、抗凝药物和抗凝强度的选择;外科手术或射频消融治疗的选择.根据最新的AF治疗指南,结合中国实际情况,针对不同的患者选用有针对性的治疗手段,会使患者得到最大的收益.     

1例左心耳封堵术后应用胺碘酮致间质性肺炎分析

心房颤动(Atrial Fibrillation, AF)患者发生血栓栓塞的风险较高,主要治疗方法包括抗凝、复律、控制心室率等。近年来,左心耳封堵术(left atrial appendage closure, LAAC)的开展大大减小了房颤患者发生血栓栓塞的风险,且术后无须长期服用抗凝药物,但目前对于左心耳封堵术后的患者是否应继续服用抗心律失常药物尚无统一定论。胺碘酮是房颤患者最常用的抗心律失常药物之一,但因其较多的不良反应限制了在临床中的应用。本文报道1例左心耳封堵术后应用胺碘酮所致的间质性肺炎,分享临床诊断及治疗的经验,并结合病例复习相关文献,旨在为此类患者服用胺碘酮后出现不良反应的预防、早期诊断及治疗提供参考。     

心房颤动引发缺血性卒中的防治

心房颤动 (AF)是老年人常见的心律失常之一 ,AF时卒中发生率高 ,病情严重 ,临床治疗棘手。作者对AF卒中心脏复律、抗凝治疗的研究进展进行了综述。     

A Novel Echocardiographic Predictor of Atrial Fibrillation Recurrence: L‐Wave

Diastolic dysfunction leads to atrial fibrillation (AF) by increasing left atrial pressure and also increases recurrence rate after cardioversion. So, L‐wave, which is associated with severe diastolic dysfunction, could predict recurrent AF after cardioversion. The aim of this study was to investigate predictive value of L‐wave for AF recurrence at first month after electrical cardioversion. A total of 127 patients with persistent AF were evaluated for this study and finally 73 patients were included according to the study criteria. Echocardiographic examinations were performed for all patients before and at 24th hour after electrical cardioversion. Heart rates and rhythms were followed with electrocardiography monitor and 12‐lead ECG at first week and first month. Seventy patients achieved sinus rhythm (SR) after cardioversion and 3 patients who did not go into SR excluded from the study. Patients were divided into 2 groups according to having (group 1) or not having (group 2) L‐wave on echocardiography. Twenty‐two patients (6 men, 16 women) had L‐wave and 48 patients (19 men, 29 women) did not have L‐wave. Duration of AF was longer in group 1 as compared to group 2 (P = 0.03). Mean heart rate was lower in group 1 than in group 2 (P < 0.001). Duration of AF and presence of L‐wave were significant parameters for AF recurrence in univariate analysis, however, presence of L‐wave was the only significant parameter for AF recurrence in multivariate analysis. Ten patients in group 1 (45.5%) and 7 patients (14.6%) in group 2 (P = 0.005) had AF recurrence at the end of first month after cardioversion. L‐wave did predict AF recurrence with 59% sensitivity, 77% specificity, 45% positive predictive value, and 85% negative predictive value at 1 month. Echocardiographic L‐wave could predict the AF recurrence.     

Use of bepridil in combination with Ic antiarrhythmic agent in converting persistent atrial fibrillation to sinus rhythm.

BACKGROUND: It has been reported that bepridil is as good as amiodarone in converting persistent atrial fibrillation (AF) to sinus rhythm (SR). The conversion effect of bepridil alone is not always satisfactory, however. The efficacy of pharmacological cardioversion by the combination of bepridil and a class Ic antiarrhythmic drug for persistent AF is studied. METHODS AND RESULTS: The participants comprised 37 consecutive patients in whom pharmacological cardioversion was conducted to treat persistent AF (duration 22.5+/-29.6 months). Each patient first received a class Ia or Ic antiarrhythmic drug, then bepridil alone, then a combined therapy of bepridil at 200 mg/day with a class Ic antiarrhythmic drug at a routine dose. Unaccompanied use of any of the antiarrhythmic drugs achieved pharmacological cardioversion in 14 (38%) of the 37 patients (single therapy group), whereas SR was restored by combination of bepridil and a class Ic antiarrhythmic drug in 22 (combined therapy group) of the remaining 23 patients. The duration of AF was significantly longer in the combined therapy group than in the single therapy group (28.3+/-31.0 vs 7.3+/-4.1 months). CONCLUSION: Combined therapy of bepridil and a class Ic antiarrhythmic drug is efficient for pharmacological cardioversion of refractory long-lasting persistent AF.     

Correlation of Spontaneous and Induced Premature Atrial Complexes Initiating Atrial Fibrillation in Humans: Electrophysiologic Parameters for Guiding Therapy

INTRODUCTION: The low frequency of spontaneous premature atrial contractions (PACs) may be an impediment to mapping and ablation of atrial fibrillation (AF). It has been shown that PACs following external or internal cardioversion of AF can initiate AF. If this method could reproducibly induce PACs from the same location as spontaneous PACs, it would be clinically significant. High-resolution noncontact mapping can map a single beat, should help identify the sites of spontaneously occurring PACs and PACs induced following cardioversion of spontaneous or induced AF, and could help correlate the trigger sites for AF induction. METHODS AND RESULTS: Twelve patients (8 men and 4 women; mean age 49+/-10 years) with spontaneous PACs were included in the study. In all patients, AF was induced and subsequently cardioverted to assess and map isolated PACs or PACs that induced AF. Using the EnSite 3000 noncontact mapping system, mapping was performed of spontaneously occurring isolated PACs and PACs that induced AF and PACs (both with and without AF) that occurred on at least two different occasions following cardioversion. The locations of the spontaneous and the induced PACs were similar; 97% of induced PACs came from the same locations as those of spontaneous PACs (P = 0.5). Radiofrequency lesions guided by this mapping technique were delivered at 14 pulmonary vein sites. Following a single ablation attempt during a mean follow-up of 19+/-4 weeks, 42% of the patients were in sinus rhythm and drug-free, whereas an additional 24% of patients could be maintained in sinus rhythm on drugs that had failed before. CONCLUSION: There is a high degree of correlation between spontaneous and induced PACs as the trigger sites for AF initiation. Cardioversion of spontaneous or induced AF could be used as an electrophysiologic parameter for guiding therapy.     

Comparison of recurrence rates after direct-current cardioversion for new-onset atrial fibrillation in patients receiving versus those not receiving rhythm-control drug therapy

The AFFIRM investigators have recommended rate control as the preferred strategy for recurrent atrial fibrillation (AF), but the appropriate strategy for new-onset persistent AF is uncertain. Our study evaluated the AF recurrence rate and the impact of rhythm-control drugs (class 1A, 1C, and 3 antiarrhythmic drugs) on patients with new-onset persistent AF after successful direct-current (DC) cardioversion. Consecutive patients who underwent DC cardioversion of AF from January 1, 1996 to December 31, 1999 were screened for new-onset persistent AF, and 150 patients met the inclusion criteria. After the first DC cardioversion, 50 patients received rhythm-control drugs (rhythm-control group) and the other 100 did not (rate-control group). The 2 groups had similar clinical characteristics except for a lower ejection fraction (44 +/- 14% vs 49 +/- 14%, p <0.01) and a higher proportion of idiopathic dilated cardiomyopathy (20% vs 1%, p = 0.03) in the rhythm-control group versus the rate-control group. During the follow-up period there was a trend toward a lower rate of early AF recurrence at 24 hours after DC cardioversion in the rhythm-control group versus the rate-control group (6% vs 16%, p = 0.11), but there was a high recurrence rate of AF in both groups at 1 month (30% for the rhythm-control group vs 41% for the rate-control group, p = 0.25). At the end of the follow-up period, rhythm-control therapy was abandoned in 78% of the rhythm-control group patients after the failure of 1 to 3 rhythm-control drugs. In the rate-control group, rhythm-control therapy was attempted after AF recurrence in 62 patients but was later abandoned in 48 patients (77%) because of treatment failure. Therefore, the high incidence of treatment failure with rhythm-control therapy suggests that rate control with anticoagulation should be preferred in patients with new-onset persistent AF if AF recurs after DC cardioversion.     

Persistent atrial fibrillation: a population based study of patients with their first cardioversion

BACKGROUND: Electrical cardioversion is effective in terminating even long standing atrial fibrillation (AF), but the relapse risk of AF is high. Data on long-term success of cardioversion in real life clinical practice are scant. METHODS: Restoration and maintenance of sinus rhythm as well as acceptance of permanent AF was studied in a population based cohort (catchment area with a population of 440,000) of patients with persistent AF after first elective cardioversion. RESULTS: Of the 183 patients having their first electrical cardioversion during the 1-year study period, sinus rhythm was restored in 153 patients (84%). Only 39 of these (25%) maintained sinus rhythm for 1 year, even though 108 (71%) patients had anti-arrhythmic medication. Age, hypertension, coronary artery disease, heart failure and valvular disease, or absence of these known risk factors for AF were not associated with the outcome. The outcome was better if the cardioversion was performed earlier than the median delay (78 days) from the diagnosis of AF to cardioversion compared to longer delay (P=0.022 in multivariate modelling). The decision of acceptance of permanent AF was made in 74 cases (40%) during 1 year of follow-up. CONCLUSIONS: Patients with persistent AF had a high tendency to remain in or relapse into AF, even though most patients had anti-arrhythmic medication after first cardioversion. Short history of arrhythmia was associated with better outcome. Acceptance of permanent AF was made in almost half of the cases during 1 year of follow-up.     

Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen Observational Cardioversion Study

OBJECTIVES: The primary objective was to evaluate the usefulness of transesophageal echocardiography (TEE)-guided cardioversion to prevent thromboembolic complications in patients with atrial fibrillation (AF) and effective anticoagulation (International Normalized Ratio of 2 or 3) at least three weeks before cardioversion. BACKGROUND: Transesophageal echocardiography has been proposed as a method of screening patients for left atrial thrombi before direct-current cardioversion of AF. The usefulness of TEE as a screening tool has always been evaluated in patients without long-term anticoagulation before cardioversion. METHODS: This prospective, single-center, observational study, performed on an intention-to-cardiovert basis, comprised 1,076 consecutive, unselected patients with AF. The initial two years were designed to be the control phase, during which the conventional approach was used. After that, cardioversion guided by TEE was performed in consecutive patients. RESULTS: The prevalence of left atrial thrombi was 7.7% in patients with persistent AF and effective anticoagulation. During the first four weeks after electrical cardioversion, six thromboembolic complications were observed in patients in whom the TEE-guided approach was employed (6 [0.8%] of 719 patients), compared with three thromboembolic complications in patients in whom the conventional approach was used (3 [0.8%] of 357 patients). None of the patients in whom electrical cardioversion was not performed experienced an embolic event. CONCLUSIONS: There were no differences in the rate of embolic events between the two treatment groups. In patients with AF and effective anticoagulation, TEE-guided electrical cardioversion does not reduce the embolic risk. However, TEE revealed left atrial thrombi in 7.7% of patients with AF and effective anticoagulation, before direct-current cardioversion.     

Rate of conversion and recurrence after sotalol treatment in patients with direct current-refractory atrial fibrillation

BACKGROUND: A number of patients with persistent atrial fibrillation (AF) will not have sinus rhythm (SR) restored by direct current (DC) cardioversion. HYPOTHESIS: In patients with DC-refractory AF, oral pretreatment with sotalol increases the success rate at DC cardioversion. METHODS: Consecutive patients with persistent AF, refractory at a first DC cardioversion, were prospectively included. A comparative group of patients with AF not refractory at DC cardioversion was studied. Oral sotalol treatment was started after unsuccessful DC cardioversion and given at least 7 days before renewed cardioversion. Four weeks after cardioversion, an electrocardiogram was performed. RESULTS: In all, 53 patients were enrolled in the study. Forty-three (81%) in the sotalol group regained sinus rhythm (SR): 10 (19%) of these converted pharmacologically and 33 (62%) after a second DC cardioversion; SR was never restored in 10 patients (19%). After 4 weeks, SR was maintained in 29 patients (67%). The comparative group included 132 patients and differed significantly from the DC-refractory patients only with regard to weight. After 4 weeks, SR was maintained by 50 patients (37%) in this group. CONCLUSIONS: In patients with persistent AF refractory to DC cardioversion, oral pretreatment with sotalol results in a high rate of SR restoration, either pharmacologically or by DC cardioversion. Maintenance of SR at 4 weeks is of sufficient clinical relevance to consider this treatment option in patients with AF refractory to DC cardioversion.     

Predictors of atrial fibrillation recurrence in patients with long-lasting atrial fibrillation

BACKGROUND:

Limited data are available on the predictors of atrial fibrillation (AF) recurrence in patients with chronic AF.

OBJECTIVES:

To evaluate potential clinical, echocardiographic and electrophysiological predictors of AF recurrence after internal cardioversion for long-lasting AF.

METHODS:

A total of 99 consecutive patients (63 men and 36 women, mean age 63.33±9.27 years) with long-standing AF (52.42±72.02 months) underwent internal cardioversion with a catheter that consisted of two defibrillating coils. Shocks were delivered according to a step-up protocol. Clinical follow-up and electrocardiographic recordings were performed on a monthly basis for a 12-month period or whenever patients experienced symptoms suggestive of recurrent AF.

RESULTS:

Ninety-three patients (93.94%) underwent a successful uncomplicated cardioversion, with a mean atrial defibrillation threshold of 10.69±6.76 J. Immediate reinitiation of AF was observed in 15 patients (15.78%) of whom a repeated cardioversion restored sinus rhythm in 13 cases. Early recurrence of AF (within one week) was observed in 12 of 93 patients (12.90%). At the end of the 12-month follow-up period, during which seven patients were lost, 42 of the 86 remaining patients (48.84%) were still in sinus rhythm. Multivariate regression analysis showed that left atrial diameter (OR 1.126, 95% CI 1.015 to 1.249; P=0.025) and mitral A wave velocity (OR 0.972, 95% CI 0.945 to 0.999; P=0.044) were significant and independent predictors of AF recurrence, whereas age, left ventricular ejection fraction and AF cycle length were not predictive of arrhythmia recurrence.

CONCLUSION:

The present study showed that the left atrial diameter and mitral A wave velocity are the only variables associated with AF recurrence after successful cardioversion.     

Use of enalapril to facilitate sinus rhythm maintenance after external cardioversion of long-standing persistent atrial fibrillation. Results of a prospective and controlled study.

AIMS: This study aimed to assess whether enalapril could improve cardioversion outcome and facilitate sinus rhythm maintenance after conversion of chronic atrial fibrillation (AF). METHODS AND RESULTS: Patients with chronic AF for more than 3 months were assigned to receive either amiodarone (200mg orally 3 times a day; group I: n=75) or the same dosage of amiodarone plus enalapril (10mg twice a day; group II: n=70) 4 weeks before scheduled external cardioversion. The end-point was the time to first recurrence of AF. In 125 patients (86.2%), AF was converted to sinus rhythm. Group II had a trend to a trend to a lower rate of immediate recurrence of AF than group I did (4.3% vs 14.7%, P=0.067). Kaplan-Meier analysis demonstrated a higher probability of group II remaining in sinus rhythm at 4 weeks (84.3% vs 61.3%, P=0.002) and at the median follow-up period of 270 days (74.3% vs 57.3%, P=0.021) than in group II. CONCLUSIONS: The addition of enalapril to amiodarone decreased the rate of immediate and subacute arrhythmia recurrences and facilitated subsequent long-term maintenance of sinus rhythm after cardioversion of persistent AF.     

Relationship between C-reactive protein level and early recurrence of atrial fibrillation after electrical cardioversion

INTRODUCTION AND OBJECTIVES: Atrial remodeling is responsible for the early recurrence of atrial fibrillation (AF) after cardioversion. Recently, it has been shown that the C-reactive protein (CRP) level is elevated in patients with AF, indicating that inflammation may play a role in the pathogenesis of this arrhythmia. We postulated that a high CRP level would predict early recurrence of AF after electrical cardioversion. PATIENTS AND METHOD: Forty-two patients with persistent AF, but without known heart disease, who underwent elective electrical cardioversion were investigated. The CRP level was measured immediately before cardioversion. The study population comprised the 37 patients in whom sinus rhythm was restored. RESULTS: After a follow-up period of 30 days, 16 patients (43%) had recurrence of AF; the other 21 (57%) remained in sinus rhythm. The mean CRP level was significantly higher in patients with AF recurrence (6.3 [3.3] mg/L vs 2.4 [2.1] mg/L, P=.0001). On dividing patients according to whether their CRP level was < or =3 mg/L or >3 mg/L, it was observed that only 33% of those in sinus rhythm had a level >3 mg/L compared with 81% of those with AF recurrence (P=.004). Patients with a CRP level >3 mg/L had a significant increase in the 1-month risk of AF recurrence (RR=3.7; 95% CI, 1.3-10.8). There was no association between CRP level and left atrial diameter (P =.50) or AF duration (P=.458). CONCLUSIONS: A high CRP level is associated with early recurrence of AF after electrical cardioversion, suggesting that inflammation could play a role in atrial remodeling.