Download ACC/AHA/ESC Guidelines for the Management of Patients With

中文題目：心房顫動之治療準則 (內科常見疾病之 Guidelines I)
英文題目：ACC/AHA/ESC Guidelines for the Management of Patients With Atrial
Fibrillation
講座：江晨恩
服務單位：台北榮民總醫院心臟科
ACC/AHA/ESC Guidelines for the Management of Patients With Atrial
Fibrillation
Chern-En Chiang, MD, PhD. Division of Cardiology, Taipei Veterans General Hospital
and National Yang-Ming University, Taipei, Taiwan
Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice.
It frequently causes symptoms such as palpitation, dizziness, shortness of breath, and
fatigue, because of loss of atrial kick and rapid ventricular rate. Patients with AF have a
significantly increased risk of stroke and it doubles the mortality rate for all kinds of
cardiovascular diseases.
Management of patients with AF requires knowledge of its pattern of presentation
(paroxysmal, persistent, or permanent) and decisions about restoration and maintenance
of sinus rhythm, control of the ventricular rate, and anticoagulation.
1. Newly Discovered AF. In patients who have self-limited episodes of AF,
antiarrhythmic drugs to prevent recurrence are usually unnecessary unless AF is
associated with severe symptoms related to hypotension, myocardial ischemia, or HF.
The decision of long-term or even short-term anticoagulation must be individualized
for each patient based on the intrinsic risk of thromboembolism. When AF persists,
one option is to accept progression to permanent AF, with attention to antithrombotic
therapy and control of the ventricular rate. Although it may seem reasonable to make
at least one attempt to restore sinus rhythm, this may not be in the best interest of all
patients. In certain circumstances, the potential toxicity of antiarrhythmic drugs may
outweigh the benefit of restoration of sinus rhythm. If the decision is made to attempt
to restore and maintain sinus rhythm, anticoagulation and rate control are important
before cardioversion. Although long-term antiarrhythmic therapy may not be needed
to prevent recurrent AF after cardioversion, short-term therapy may be beneficial. In
patients with AF of more than 3 months’ duration, early recurrence is common after
cardioversion. Antiarrhythmic medication may be initiated before cardioversion (after
adequate anticoagulation) in such cases to reduce the likelihood of recurrence, and the
duration of drug therapy would be brief.
2. Recurrent Paroxysmal AF. In those who have very mild recurrences of AF, it is
reasonable to avoid antiarrhythmic drugs, but troublesome symptoms generally call
for suppressive antiarrhythmic therapy. Rate control and prevention of
thromboembolism are appropriate in both situations. In any given patient, several
different antiarrhythmic drugs may be effective, and thus the initial selection is based
mainly on safety. For individuals with no or minimal structural heart disease,
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flecainide, propafenone, and sotalol are recommended as initial antiarrhythmic
therapy because they are generally well tolerated and are essentially devoid of
extracardiac organ toxicity. When one or another of these drugs is ineffective or is
associated with side effects, then second or third-line choices include amiodarone,
dofetilide, disopyramide, procainamide, and quinidine, which have greater potential
for adverse reactions.
For patients with CHF, safety data support the selection of amiodarone or
dofetilide to maintain sinus rhythm. Patients with ischemic heart disease often require
beta-blocker medication, and sotalol, a drug with both beta-blocking activity and
primary antiarrhythmic efficacy, is considered first, unless the patient has HF.
Amiodarone and dofetilide are considered secondary agents. In patients with
hypertension without LV hypertrophy, drugs such as flecainide and propafenone,
which do not prolong repolarization and the QT interval, may offer a safety advantage
and are recommended first. If these agents either prove ineffective or produce side
effects, then amiodarone, dofetilide, or sotalol represent appropriate secondary
choices. Disopyramide, procainamide, and quinidine are considered third-line agents
in this situation. Hypertrophied myocardium may be prone to proarrhythmic toxicity
and development of the torsade de pointes type of ventricular tachycardia.
Amiodarone is suggested as first-line therapy in patients with LV hypertrophy (wall
thickness greater than or equal to 1.4 cm) because of its relative safety compared with
several other agents.
3. Recurrent Persistent AF. Patients with minimal or no symptoms referable to AF who
have undergone at least 1 attempt to restore sinus rhythm may remain in AF after its
second occurrence, with therapy for rate control and prevention of thromboembolism
as needed. Alternatively, those with symptoms favoring sinus rhythm should be
treated with an antiarrhythmic agent (in addition to medications for rate control and
anticoagulation) before cardioversion. The selection of an antiarrhythmic drug should
be based on the same algorithm used for patients with recurrent paroxysmal AF.
4. Permanent AF. Permanent AF is the designation given to cases in which sinus rhythm
cannot be sustained after cardioversion of AF or when the patient and physician have
decided to allow AF to continue without further efforts to restore sinus rhythm. It is
important to maintain control of the ventricular rate and to use anti-thrombotic
therapy.
(modified from JACC 2001;38:1266i-lxx)
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