Comparison of the prognosis between rhythm control and rate control in atrial fibrillation patients with Meta analysis

目的 评价房颤患者节律控制与室率控制两种治疗方法预后有无差异.方法 计算机检索Pubmed(2000～2010)、Cochrane Database of Systematic Reviews(2000～2010)、EMbase (2000～2010)中关于房颤患者节律控制与室率控制预后进行比较的随机对照研究(RCTs),同时筛检纳入文献的参考文献,对纳入研究的方法学进行评价.研究者对文献质量进行严格评价和资料提取,对符合质量标准的RCTs用Revman 5.0软件进行Meta分析.结果 6个RCTs共6615例患者纳入研究,其中节律控制组(节律组)3312例,室率控制组(室率组)3303例.Meta分析结果表明房颤患者节律组再次住院人数高于室率组.对于房颤患者节律组与室率组在全因总死亡率、发生缺血性脑卒中、发生非中枢神经系统性出血方面相关的RCTs结果显示无显著差异.结论 与控制房颤的节律相比,控制心室率可以降低患者住院次数但不增加发生其他不良结局的危险性.控制心室率、联合使用抗凝药可以作为房颤患者的治疗方案.     

地尔硫(卓)在心房颤动心室率控制的应用现状

心房颤动(房颤)是临床常见的慢性或反复发作性快速心律失常之一.目前房颤治疗主要存在2种策略:即节律控制和室率控制.大规模临床试验,如AFFIRM和RACE研究并没有证实节律控制在病死率、住院率和脑卒中等方面优于室率控制[1].目前长期维持窦性心律的手段仍然有限,故心室率控制仍然是目前房颤治疗的最主要策略之一.尤其是RACE Ⅱ (rate control efficacy in permanent atrial fibrillation)试验结果的发表,使心室率控制得到关注[2].     

心房颤动合并心力衰竭患者长期心室率控制的实践与认识

心房颤动(简称房颤)合并心力衰竭(简称心衰)愈加受到重视.心室率控制仍是此类患者的重要治疗方案.在节律控制与心室率控制的选择上,心室率控制仍不可替代.目前认为,在房颤患者中,射血分数减低心衰与射血分数保留心衰患者可能面临着不同的心室率控制策略.作为常见的心室率控制药物,β受体阻滞剂、钙通道阻滞剂、洋地黄类药物、胺碘酮各...     

心房颤动中的室率控制和节律控制策略

目的 室率控制和节律控制是临床治疗心房颤动(房颤)的两种基本策略.为了进一步比较两种治疗策略在不同人群中的获益,该研究入选了10个前瞻性随机临床研究进行荟萃分析.方法 以房颤、室率控制、节律控制、随机对照试验为检索词,对MEDLINE、The Cochrane Library、The Clinical Trials 和中国维普期刊数据库进行系统检索,检索截止时间为2010年5月31日.结果 该研究总入选人群7876例,3932例分布在室率控制组,3944例分布在节律控制组.结果显示,在总体年龄中,室率控制组的住院率明显低于节律控制组(17.56％与22.98％,OR:0.37,95％ CI:0.19～0.71);而在平均年龄＜65岁的亚组人群中,室率控制组的总病死率(3.6％与1.9％,OR:1.89,95％CI:1.01～3.53)和进行性加重的心力衰竭事件(2.3％与0.3％,OR:5.6,95％ CI:1.44～21.69)明显高于节律控制组.而对于血栓栓塞事件和出血事件,在总体人群和亚组人群中,两组之间差异无统计学意义.结论研究结果提示,对于相对年轻的房颤患者,节律控制策略可能优于室率控制策略.     

心房颤动合并射血分数减低心力衰竭患者心室率控制的研究进展

心房颤动(房颤)和心力衰竭(心衰)是当前心血管领域的两大堡垒性疾病,两者常相互共存,且互为因果、相互促进。房颤和心衰并存的患者,远期预后差。目前房颤消融是否作为心衰患者的一线治疗仍值得探讨,心室率控制仍为大部分房颤合并心衰患者最主要的治疗方法。本文就房颤合并射血分数减低心衰(HFrEF)患者心室率控制目标、药物以及器械治疗策略的现状及研究进展作一综述。     

控制房颤心室率方法的研究进展

心房颤动(房颤)是临床上最常见的持续性心律失常。尽管房颤本身并不直接危及生命,但房颤时快速、不规则的心室率可引起血流动力学恶化,产生明显症状,尤其使患者有发生脑血管栓塞的危险。目前的房颤治疗策略主要是节律控制、室率控制和预防栓塞性事件。所谓室率控制即允许房颤存在的同时减慢心室率。房颤的最佳心室率值尚未明确,静息时60～80/min,运动时90～115/min,可大致认为心室率已得到较好的控制。以下简要综述控制室率的方法。1药物治疗最常用的室率控制方法是药物治疗,包括几类作用机制不同的药物:地高辛、钙离子拮抗剂、β-受体阻滞…     

节律及频率控制治疗对风心病伴房颤患者预后的影响

目的观察控制心室率(频率控制)与恢复并维持窦性心律(节律控制)对风心病伴房颤(AF)患者预后的影响。方法频率控制组使用阿替洛尔和地高辛控制心室率;节律控制组用胺碘酮或直流电转复,并用胺碘酮维持窦性心律。比较3年后两组的病死率、致残率、生活质量及住院率。结果两组病死率、生活质量无显著性差异(P>0.05),频率控制组的致残率、住院率低于节律控制组(P<0.05)。结论应将控制心室率作为AF的一线干预措施。     

心力衰竭合并心房颤动的治疗策略选择

心力衰竭（简称心衰）和心房颤动（简称房颤）是21世纪最难攻克的两大心血管疾病,二者常互为因果,形成恶 性循环,并发心衰和房颤的患者临床表现更为严重,预后更差。中国心衰注册研究显示,住院心衰患者中房颤发生率 高达24.4%,房颤的发生率与纽约心功能分级（NYHA）相关,分级加重时房颤患病率上升。心衰合并房颤患者的治疗 一直是学术界研究的热点之一,目前的基本治疗策略是心室率控制、节律控制及血栓预防治疗。文章对心衰合并房 颤治疗策略的最新进展作一简要评述。     

心房颤动:控制心室率与转复并维持窦性心律?

心房颤动 (房颤 )是临床上最常见的持续性快速心律失常 ,虽然其本身并不具有致命性特点 ,但房颤患者可以有各种临床症状 ,生活质量下降 ,若产生心房附壁血栓可引起缺血性脑卒中 ,从而增加患者病死率。此外对针对房颤的抗心律失常药产生的副作用 ,也增加对房颤患者的危害。目前公认的房颤治疗策略包括①针对房颤发生的病因或诱因进行治疗 ;②恢复并维持窦性心律 (窦律 ,节律控制 ) ;③控制房颤时心室率 (心室率控制 ) ;④抗凝治疗预防动脉血栓栓塞事件。其中针对心律不整齐的节律控制和心室率控制究竟哪一个更优 ?作为首选多年来一直存有争议…     

ACEI联用ARB治疗慢性心力衰竭的疗效和安全性Meta分析

目的通过对慢性心力衰竭患者在接受相关治疗后的总体死亡率、住院情况、副反应进行比较,对血管紧张素转换酶抑制剂(ACEI)联用血管紧张素受体拮抗剂(ARB)治疗慢性心力衰竭的疗效和安全性进行评价。方法检索MEDLINE(1966-2008)、Cochrane图书馆(1980-2008)、中国生物医学文献数据库(1980-2008),万方数据库(1980-2008),纳入比较ACEI单用与ACEI和ARB合用治疗慢性心力衰竭的随机对照试验,对纳入研究的方法学进行评价,并应用RevMan5.0软件进行统计分析。结果共有7个随机对照研究入选,病例数总计5 853例,其中治疗组2 945例,对照组2 908例。Meta分析结果显示联合治疗组在全因死亡率和全因住院率方面与对照组相比无统计学意义。而在减少全因死亡与全因住院的联合终点事件、降低心衰住院事件、增加副反应方面有统计学意义,合并效应量分别为(RR:0.94;95%CI:0.90～0.98)、(RR:0.86;95%CI:0.79～0.93)、(RR:1.40;95%CI:1.24～1.58)。结论 ACEI基础上加用ARB与单用ACEI相比,可以使慢性心衰患者受益,但同时副反应的发生率有所增加。因此对于慢性心衰在ACEI基础上加用ARB应采取审慎的策略。合用则需要严密监测,防止副反应发生。     

Who, when and how to rate control for atrial fibrillation

PURPOSE OF REVIEW: The aim of this review is to provide a perspective on rate control in atrial fibrillation, in the era after the large randomized trials comparing rate and rhythm control. This review emphasizes the indications for rate control, the optimal heart rate and the different treatment modalities. RECENT FINDINGS: Large studies have shown that rate control is not inferior to rhythm control with regard to cardiovascular morbidity and mortality. Rate control may now be instituted earlier during the course of the disease, even as first-choice therapy in some patients, particularly those with hypertension and underlying heart diseases, and those who are not (severely) symptomatic. The goals of rate-control therapy are to reduce symptoms, improve quality of life, minimize the development of heart failure, and prevent thromboembolic complications. An important negative aspect of rate-control therapy is the side effects of drugs. The optimal heart rate during atrial fibrillation has not yet been carefully investigated. Several approaches to control rate during atrial fibrillation are available, including pharmacological rate control and atrioventricular nodal ablation with pacemaker implantation. SUMMARY: Understanding the indications for rate control, treatment goals and options will gain the largest benefit for the individual patient with atrial fibrillation.     

Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis

BACKGROUND: The 2 fundamental approaches to the management of atrial fibrillation (AF) are reestablishing and maintaining sinus rhythm (rhythm control) and controlling ventricular rate with atrioventricular node blocking agents (rate control). We performed a meta-analysis of randomized controlled trials comparing these strategies in patients with AF to add precision to the relative merits of both strategies on the risk of all-cause mortality and to evaluate the consistency of the results between trials. METHODS: We performed a literature search in MEDLINE (1966 to May 2003), the Cochrane Controlled Trial Registry (first quarter of 2003), and International Pharmaceutical Abstracts (1970 to May 2003). Eligible trials were randomized controlled trials comparing pharmacologic rhythm and rate control strategies as first-line therapy in patients with AF. RESULTS: Five trials were identified that included a total of 5,239 patients with persistent AF or AF that was considered likely to be recurrent. No significant difference was observed between the rate and the rhythm control groups regarding all-cause mortality, although a strong trend in favor of a rate control approach was observed (13.0% vs 14.6%; odds ratio, 0.87; 95% confidence interval, 0.74-1.02; P=.09). No heterogeneity was apparent between the trials (Q value=2.97; P=.56). CONCLUSIONS: In patients with persistent AF or with AF that is likely to be recurrent, a strategy of ventricular rate control, in combination with anticoagulation in appropriate patients, appears to be at least equivalent to a strategy of maintaining sinus rhythm by using currently available antiarrhythmic drugs in preventing clinical outcomes.     

Role of Beta-Blocker Therapy in Heart Failure and Atrial Fibrillation

Heart failure is a serious disorder associated with substantial morbidity and mortality. Approximately 15-30% patients with systolic heart failure are in atrial fibrillation and the proportion increases with severity of heart failure. Patients with heart failure and atrial fibrillation have worse outcome than those in sinus rhythm. Beta-blockers, together with angiotensin-converting enzymes inhibitors, are the standard therapy in patients with chronic heart failure. Retrospective studies have suggested that despite the improvement in left ventricular systolic function after treatment with beta-blockers, the exercise capacity and symptoms in those heart failure patients with atrial fibrillation was not improved as much as those in sinus rhythm. Moreover, the use of bisoprolol in the Cardiac Insufficiency Bisoprolol Study II, unlike those in sinus rhythm, failed to produce any survival benefit in patients with poor systolic function and atrial fibrillation. It seems that those patients with heart failure and atrial fibrillation may have different response to beta-blocker therapy. Prospective trials to clarify the impact of beta-blocker therapy and the optimal therapeutic strategy in this high-risk group of patients are warranted.     

Atrial fibrillation and heart failure comorbidity

Atrial fibrillation and heart failure have in common that they mainly occur in older patients and the patients have similar underlying heart diseases. The prevalence of atrial fibrillation in heart failure patients varies from 10% to 30%. There are conflicting data whether the presence of atrial fibrillation is an independent predictor for an increased mortality in heart failure. Optimal medical heart failure therapy can improve outcome and may influence the relationship between atrial fibrillation and survival. Keystones for the management of atrial fibrillation in heart failure patients are the optimal treatment of heart failure, the use of oral anticoagulation, the case-adjusted decision of rhythm or rate control, and the primary prevention of sudden cardiac death. Heart failure patients with atrial fibrillation should receive long-term oral anticoagulation. The two options to treat atrial fibrillation are rhythm control and rate control. Given the findings of randomised trials, rhythm control of atrial fibrillation with the aim to improve survival is not justified in heart failure patients because of uncertainty about the role of atrial fibrillation as a predictor of worse outcomes and the safety of antiarrhythmic drugs. Rhythm control can be attempted, if rate control is chosen and symptoms persist. The indications for rhythm control are to control symptoms, including a deterioration of heart failure related to a loss of atrial contraction. Amiodarone seems to be the drug of choice to maintain sinus rhythm in patients with paroxysmal atrial fibrillation as well as in patients who returned to sinus rhythm after cardioversion. New non pharmacologic approaches for rhythm control such as catheter-based techniques seem to be highly effective. Rate control to prevent rapid atrial fibrillation is an acceptable approach in otherwise asymptomatic heart failure patients. Slowing of the ventricular rate often leads to a moderate improvement in left ventricular function in many patients. Standard therapy for rate control in heart failure patients consists of partial atrioventricular (AV) node blockade with digoxin and a beta-blocker. Amiodarone is also highly effective to reduce ventricular rate in patients with atrial fibrillation. When rate control remains refractory to medical therapy, rate control is achieved with AV node ablation and subsequent pacemaker implantation. Non pharmacological treatments for the primary prevention of sudden cardiac death are the implantation of a defibrillator.     

Beta-Blocker Efficacy According to Heart Rate and Rhythm in Patients with Heart Failure. Commentary on the Cardiac Insufficiency Bisoprolol Study II Analysis

Large randomized trials have demonstrated that beta-blocker treatment reduces morbidity and mortality in patients in chronic heart failure. Questions remain about the influence of individual characteristics on the magnitude of the benefit of beta-blockers in patients with heart failure including the influence of heart rate and cardiac rhythm. In the Cardiac Insufficiency Bisoprolol Study II, baseline heart rate and heart rate change over time had prognostic value but treatment with bisoprolol was associated with a benefit at all levels of baseline heart rate and additional benefit related to heart rate slowing was observed. In the subgroup of patients with atrial fibrillation, morbidity and mortality rates were similar in placebo and bisoprolol treated patients. It is possible that patients with atrial fibrillation had a higher level of sympathetic stimulation that would have required higher doses of bisoprolol to achieve a similar level of beta-blockade. Alternatively, the failure to observe improved outcome in the subgroup with atrial fibrillation may have been due to chance. However, because this finding was not observed in other large trials, and because there was no clear explanation, it should not be concluded that patients with chronic heart failure and atrial fibrillation do not benefit from beta-blockade.     

The RACE Study in Perspective of Randomized Studies on Management of Persistent Atrial Fibrillation

Atrial fibrillation is the most common sustained cardiac arrhythmia. Treatment strategies are focused on reducing symptoms and minimizing the risks of atrial fibrillation like stroke and heart failure. First choice therapy is the rhythm control strategy, with restoration of sinus rhythm. Drawback of this approach is the low success rate for maintenance of sinus rhythm. Outcome will improve with the use of antiarrhythmic drugs after electrical cardioversion, unfortunately exposing the patient to the risks of life threatening pro-arrhythmia. The second alternative, a rate control strategy, is easy to achieve but it is unknown whether this treatment strategy results in higher morbidity and mortality rates. RACE (RAte Control versus Electrical cardioversion for persistent atrial fibrillation) was a prospective randomized trial comparing both strategies. The primary end point was a composite of death from cardiovascular causes, heart failure, thromboembolic complications, bleeding, pacemaker implants and severe adverse effects of drugs. After a mean follow-up of 2.3 years, the primary end point occurred in 44 of the 256 rate control patients (17.2%) and 60 of the 266 rhythm control patients (22.6%). Other trials as the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management), PIAF (Pharmacological Intervention in Atrial Fibrillation) and STAF (Strategies of Treatment of Atrial Fibrillation) also found that rate control was not inferior to rhythm control in terms of morbidity, mortality and quality of life. These four randomized trials demonstrated that a rate control strategy is an acceptable alternative to rhythm control in patients with recurrent atrial fibrillation. For those with severely symptomatic atrial fibrillation, continued rhythm control is unavoidable. For these patients, safer and more effective methods of maintaining sinus rhythm are needed to reduce morbidity related to palpitations and atrial fibrillation-induced heart failure.Furthermore, the randomized studies showed that rhythm control therapy does not prevent stroke. It was observed from RACE that 21 of the 35 thromboembolic complications occurred under rhythm control, the majority while receiving inadequate anticoagulation therapy. Also in AFFIRM, with patients with one or more stroke risk factors, more strokes were present under rhythm control. Therefore, one of the main lesson learned from the randomized studies is that anticoagulation must be continued if stroke risk factors are present even if patients maintain sinus rhythm.     

Atrial fibrillation in patients with heart failure: pharmacologic options

Atrial fibrillation is a common arrhythmia in patients with heart failure. The presence of atrial fibrillation deteriorates cardiac function and increases the risk of thromboembolic events. The management of patients with atrial fibrillation in association with heart failure should consist of ventricular rate control, prevention of thromboembolic events, and conversion to normal sinus rhythm. Traditionally, digoxin has been widely used in patients with heart failure and atrial fibrillation; however, it does very little to restore sinus rhythm and requires the addition of another rate-limiting agent to control ventricular rate. The likelihood of successful cardioversion is dependent on the duration of heart failure and the degree of neurohormonal activation. The initiation of antiarrhythmic drug therapy in patients with heart failure should be guided by safety issues as well as consideration of potential benefits vs. risks associated with therapy. Amiodarone has been evaluated in numerous clinical trials and appears to be safe and effective when used in low dosage. Treatment with dofetilide is another option. Comparative studies with oral dofetilide vs. amiodarone are needed to evaluate their efficacy in restoration and maintenance of sinus rhythm in patients with heart failure. Such trials will clearly define the role of dofetilide in the treatment of atrial fibrillation. Routine prophylactic use of antiarrhythmic drug therapy for chronic atrial fibrillation in the setting of heart failure is not recommended due to a low efficacy rate and high proarrhythmic risk. Anticoagulation with warfarin and rate control remain the standard therapy. (c)2001 by CHF, Inc.     

Randomized Trials of Rate vs. Rhythm Control for Atrial Fibrillation

Recent randomized trials have not demonstrated mortality or stroke risk reduction benefits from a rhythm-control compared to rate-control strategy in the treatment of atrial fibrillation. These studies reinforce the need for continued anticoagulation in both strategies for patients with atrial fibrillation and risk factors for stroke. Although rate control can be rationalized as a first line approach, rhythm control strategies may be justified for patients who are younger, who remain symptomatic or functionally impaired, or who have a first episode of atrial fibrillation.     

Digoxin—A redundant drug in congestive cardiac failure

Summary Controversy continues concerning the use of digoxin as a positive inotropic agent in the treatment of heart failure in patients in sinus rhythm. Digoxin is properly used to control the heart rate in patients in atrial fibrillation. The findings from 14 uncontrolled and 6 controlled clinical trials have been examined. Digoxin does exert a small chronic positive inotropic effect. Although some individual patients, particularly those with fluid overlond, appear to benefit from digoxin, controlled clinical trials in patients, most of whom have been treated with diuretics, have failed to demonstrate an Increase of exercise capacity. No mortality trial has been attempted. Digoxin has the potential to be harmful in patients with ischemic heart disease. Alternative and safer therapies have been shown to be equal or superior to digoxin.     

Is Rhythm‐Control Superior to Rate‐Control in Patients with Atrial Fibrillation and Diastolic Heart Failure?

Background: Although no clinical trial data exist on the optimal management of atrial fibrillation (AF) in patients with diastolic heart failure, it has been hypothesized that rhythm‐control is more advantageous than rate‐control due to the dependence of these patients’ left ventricular filling on atrial contraction. We aimed to determine whether patients with AF and heart failure with preserved ejection fraction (EF) survive longer with rhythm versus rate‐control strategy. Methods: The Duke Cardiovascular Disease Database was queried to identify patients with EF > 50%, heart failure symptoms and AF between January 1,1995 and June 30, 2005. We compared baseline characteristics and survival of patients managed with rate‐ versus rhythm‐control strategies. Using a 60‐day landmark view, Kaplan‐Meier curves were generated and results were adjusted for baseline differences using Cox proportional hazards modeling. Results: Three hundred eighty‐two patients met the inclusion criteria (285 treated with rate‐control and 97 treated with rhythm‐control). The 1‐, 3‐, and 5‐year survival rates were 93.2%, 69.3%, and 56.8%, respectively in rate‐controlled patients and 94.8%, 78.0%, and 59.9%, respectively in rhythm‐controlled patients (P > 0.10). After adjustments for baseline differences, no significant difference in mortality was detected (hazard ratio for rhythm‐control vs rate‐control = 0.696, 95% CI 0.453–1.07, P = 0.098). Conclusions: Based on our observational data, rhythm‐control seems to offer no survival advantage over rate‐control in patients with heart failure and preserved EF. Randomized clinical trials are needed to verify these findings and examine the effect of each strategy on stroke risk, heart failure decompensation, and quality of life. Ann Noninvasive Electrocardiol 2010;15(3):209–217