房颤心室率控制 加拿大指南

uid So nd MD, D, Com a University of Calgary/Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada b Southlake Regional Health Centre, Newmarket, Ontario, Canada c Montreal Heart Institute, Université de Montréal and McGill University, Montreal, Québec, Canada y of Toro s AC. C g Conse AB The age life ma The ma and AF Be init his not Digoxin and dronedarone may be used in combination with other agents to optimize rate control. The first-choice antiarrhythmic drug for mainte- nan any wit RÉ Les du d’a ass con tra et/ sym fré per Les les triculaire de la FA et du flutter auriculaire chez la plupart des patients sans antécédent d’infarctus du myocarde ou dysfonction ventriculaire gauche. La digoxine n’est pas recommandée enmonothérapie pour le contrôle de At ate tio Rec Sci Tel CC lite con diology 082 doi ce of sinus rhythm in patients with non structural heart disease can be one of dronedarone, flecainide, propafenone, or sotalol. In patients h abnormal ventricular function but left ventricular ejection fraction la fréquence ventriculaire chez les patients actifs. L’ajout de digoxine ou de dronédarone en combinaison avec d’autres agents peut être considéré pour optimiser le traitement. Chez les patients dont la fonction ventriculaire rial fibrillation (AF) and atrial flutter (AFL) are often associ- d with rapid and irregular ventricular rates causing palpita- ns, dyspnea, fatigue, reduced exercise tolerance, other symp- toms, and in some cases, left ventricular dysfunction and congestive heart failure. The approach to the management of AF and AFL includes, in parallel, identification and treatment eived for publication November 4, 2010. Accepted December 3, 2010. Corresponding author: Dr Anne M. Gillis, University of Calgary, Cardiac ences, 3280 Hospital Drive N.W., Calgary, Alberta, Canada T2N 4Z6. : �1-403-220-6841, fax: �1-403-270-0313. E-mail: amgillis@ucalgary.ca The disclosure information of the authors and reviewers is available from the with amandate to formulate disease-specific recommendations. These recommen- dations are aimed to provide a reasonable and practical approach to care for spe- cialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in man- d St Michael’s Hospital and Universit e For a complete listing of committee members, see Gillis AM, Skane 2010: Implementing GRADE and Achievin STRACT goals of atrial fibrillation (AF) and atrial flutter (AFL) arrhythmia man- ment are to alleviate patient symptoms, improve patient quality of , and minimize the morbidity associated with AF and AFL. Arrhythmia nagement usually commences with drugs to slow the ventricular rate. addition of class I or class III antiarrhythmic drugs for restoration or intenance of sinus rhythm is largely determined by patient symptoms preferences. For rate control, treatment of persistent or permanent and AFL should aim for a resting heart rate of�100 beats perminute. ta-blockers or nondihydropyridine calcium channel blockers are the ial therapy for rate control of AF and AFL in most patients without a tory of myocardial infarction or left ventricular dysfunction. Digoxin is recommended as monotherapy for rate control in active patients. S on the followingWeb sites: www.ccs.ca and www.ccsguidelineprograms.ca. This statement was developed following a thorough consideration of medical rature and the best available evidence and clinical experience. It represents the sensus of aCanadian panel comprised ofmultidisciplinary experts on this topic agin the abl sari 8-282X/$ – see front matter © 2011 Canadian Cardiovascular Society. Published by :10.1016/j.cjca.2010.11.001 nto, Toronto, Ontario, Canada anadian Cardiovascular Society Atrial Fibrillation Guidelines nsus. Can J Cardiol 2011;27:27-30. SUMÉ principaux objectifs du traitement de la fibrillation auriculaire (FA) et flutter auriculaire sont d’atténuer les symptômes des patients, méliorer leur qualité de vie et de réduire au minimum la morbidité ociée à la FA et au flutter auriculaire. Le traitement de l’arythmie siste d’abord à ralentir la fréquence ventriculaire. La décision d’un itement avec antiarythmiques de classe I ou III pour la conversion ou le maintien du rythme sinusal repose sur la présence de ptômes et les préférences du patient. L’objectif du contrôle de la quence ventriculaire pour la FA ou le flutter auriculaire persistant ou manent est une fréquence cardiaque inférieure à 100/min au repos. béta-bloquants ou les inhibiteurs calciques (non-dihydropyridine) sont médicaments de premier choix pour le contrôle de la fréquence ven- Society G Canadian Cardiovascular Guidelines 2010: Rate a Anne M. Gillis, MD, FRCPC,a Atul Verma, Stanley Nattel, MD, FRCPC,c Paul Dorian, M Guidelines Canadian Journal of Car elines ciety Atrial Fibrillation Rhythm Management FRCPC,b Mario Talajic, MD, FRCPC,c FRCPC,d and the CCS Atrial Fibrillation mitteee 27 (2011) 47–59 g clinical care in consultation with the patient, with appropriate regard to all individual circumstances of the patient, diagnostic and treatment options avail- e and available resources. Adherence to these recommendations will not neces- ly produce successful outcomes in every case. Elsevier Inc. All rights reserved. of fac an sin tom 1). to an rhy en on rhy na ep no Th Alt ma tim arr 1). acc infl sum an ap Go are R s w R s c e Q �35%, dronedarone, sotalol, or amiodarone is recommended. In pa- tie on the tie alt ma qu con est normale, les anti-arythmiques de premier choix pour le maintien du ryth le ma rec tien %, occ au atiq fré dér ant sin Fig con req Fig mo an 11 48 Canadian Journal of Cardiology Volume 27 2011 precipitating causes, antithrombotic therapy based on risk tors for stroke, drug therapy to control ventricular rates, and tiarrhythmic therapy as required to restore and/or maintain us rhythm with the major goal of alleviating patient symp- s and minimizing the morbidity associated with AF (Fig. 1,2 Arrhythmia management usually commences with drugs slow the ventricular rate. The addition of class I or class III tiarrhythmic drugs for restoration or maintenance of sinus thm is largely determined by patient symptoms and prefer- ces as, to date, none of the large randomized trials has dem- strated that pharmacologic therapy to maintain sinus thm has improved survival or reduced the risk of stroke.3-7 AFmay be classified as newly detected, paroxysmal (self-termi- ting episodes lasting�7 days), persistent (non–self-terminating isodes lasting�7 days), or permanent (no further attempts or initial attempt to restore sinus rhythm to be undertaken).8-9 e nature of AF is recurrent and frequently progressive (Fig. 2). hough a treatment strategy of rate control or rhythm control y be selected initially, the treatment strategy may change over e if the selected treatment strategy has been unsuccessful, as the hythmia progresses, or as the patient’s condition changes (Fig. 10 Thus, treatment strategies and their effectiveness, safety, and eptability must be constantly reevaluated. Factors that might uence a decision for rate control versus rhythm control are marized in Table 1. AFLmay also occur in the patient with AF ormay present as isolated arrhythmia. The goals of therapy and management proaches for AFL are similar to those for AF. nts with left ventricular ejection fraction �35%, amiodarone is the ly drug usually recommended. Intermittent antiarrhythmic drug rapy (“pill in the pocket”) may be considered in symptomatic pa- nts with infrequent, longer-lasting episodes of AF or AFL as an ernative to daily antiarrhythmic therapy. Referral for ablation of AF y be considered for patients who remain symptomatic after ade- ate trials of antiarrhythmic drug therapy and in whom a rhythm trol strategy remains desired. Overview of AF Management Detec�on and AF Detected Treatment of Precipita�ng Causes M t fA t f Management of Arrhythmia Assessment of Thromboembolic Risk (CHADS ) Rate RhythmOAC Rate Control Rhythm Control OAC Aspirin No an�thrombo�c may be appropriate in selected young pa�ents with no stroke risk factors 2 ure 1. Overview of AF management. If a strategy of rate or rhythm trol is not successful, crossover to the alternate strategy may be uired. AF, atrial fibrillation; OAC, oral anticoagulation. als of AF Arrhythmia Management The major goals of AF and AFL arrhythmia management to ● Identify and treat underlying structural heart disease and other predisposing conditions ● Relieve symptoms ● Improve functional capacity and quality of life (QOL) ● Reduce morbidity and mortality associated with AF and AFL, that is, ● Prevent tachycardia-induced cardiomyopathy ● Reduce or prevent emergency room visits or hospital- izations secondary to AF and AFL ● Prevent stroke or systemic thromboembolism ECOMMENDATION We recommend that the goals of ventricular rate control hould be to improve symptoms and clinical outcomes hich are attributable to excessive ventricular rates (Strong ecommendation, Low-Quality Evidence). We recommend that the goals of rhythm control therapy hould be to improve patient symptoms and clinical out- omes and that these goals do not necessarily imply the limination of all AF (Strong Recommendation, Moderate- uality Evidence). me sinusal incluent la dronédarone, la flécaïnide, la propafénone ou sotalol. Chez les patients dont la fonction ventriculaire est anormale is avec fraction d’éjection ventriculaire gauche supérieure à 35 %, on ommande la dronédarone, le sotalol ou l’amiodarone. Chez les pa- ts dont la fraction d’éjection ventriculaire gauche est inférieure à 35 seule l’amiodarone est recommandée. Un traitement anti-arythmique asionnel (“pill-in-the-pocket”) peut-être considéré comme alternative traitement antiarythmique quotidien chez les patients symptom- ues qui présentent des épisodes de FA ou de flutter auriculaire in- quents mais de longue durée. L’ablation par cathéter doit être consi- ée chez les patients symptomatiques après échec du traitement iarythmique et pour lesquels une stratégie de maintien du rythme usal demeure indiquée. P l P iParoxysmal Persistent Permanent Patterns of AF Newly Diagnosed AF ure 2. Interrelationships among categories of AF. Arrows indicate st common forms of progression. AF, atrial fibrillation. Adapted d reprinted with permission from Fuster V, et al.8 Circulation 2006; 4(7):e257-e354. ©2006 American Heart Association, Inc. V a r c o r Re ere car or tie an tac tac ab ref hig the tro an Ra tie im fun du sh av th tri ch som rat or co H de stu bp rat 15 (co str fou pro tio tar ha of 12 an de qu gro �1 saf he all pa ma exc exe of sta tes ach str tha sho an AF R a ( s a t t r i V h s e H blo dr Th Fig th Al co Table 1. Factors favouring rate versus rhythm control Fav Per Les Ag Hy No h Pre d Pat Gillis et al. Rate and Rhythm Management 49 alues and preferences. These recommendations place high value on the decision of individual patients to balance elief of symptoms and improvement in QOL and other linical outcomes with the potentially greater adverse effects f class I or class III antiarrhythmic drugs compared with ate-control therapy. ferral for Specialty Care Most patients with a history of AF or AFL should be consid- d for referral to a cardiologist or an internist with an interest in diovascular disease for an expert opiniononmanagement ofAF AFL, as well as any underlying cardiovascular conditions. Pa- nts aged�35 years with symptomatic AF should be referred to arrhythmia specialist to rule out other forms of supraventricular hycardia that may trigger AF (so-called “tachycardia-induced hycardia”) and that would be best treated by radiofrequency lation. Patients with isolated AFL may also be considered for erral for curative ablation therapy.11 Patients who remain hly symptomatic despitemultiple trials of antiarrhythmic drug rapy or who remain unresponsive to or intolerant of rate-con- lling therapies should be referred to an arrhythmia specialist for expert opinion on management alternatives. te Control of AF and AFL Rate control is an important part of therapy for all pa- nts with AF or AFL. The primary goal of rate control is to prove symptoms and prevent deterioration of cardiac ction associated with excessively rapid ventricular rates ring AF or AFL. In addition, therapy for rate control ould aim to improve exercise tolerance, QOL, and to oid hospitalization. Tachycardia-induced cardiomyopa- y refers to a condition characterized by reversible left ven- cular systolic dysfunction occurring in patients with ronic rapid heart rates. This complication can occur in e patients with AF or AFL and very rapid ventricular es (eg,�120/min for most or all of the time) and is totally partially reversible and preventable with adequate rate ntrol.12 eart rate targets In the past, adequate heart rate control had been empirically fined as�80 beats per minute (bpm) at rest.3-6,8,13,14 A recent dy randomized patients to strict (�80 bpm at rest and�110 m during moderate exercise) or lenient (�110 bpm at rest) ours rate control Favours rhythm control sistent AF Paroxysmal AF Newly detected AF s symptomatic More symptomatic ed �65 years Aged �65 years pertension No hypertension history of congestive eart failure Congestive heart failure clearly exacerbated by AF vious antiarrhythmic rug failure No previous antiarrhythmic drug failure ient preference Patient preference AF, atrial fibrillation. e-control strategies. No difference in the primary outcome mposite of cardiovascular death, heart failure hospitalization, oke, systemic embolism, bleeding, and arrhythmic events) was nd, and the lenient strategy rate goal was achieved in a larger portion of patients, with lower drug doses and fewer combina- ns of drugs, resulting in far fewer visits to achieve the intended get.15 Relatively fewpatients randomized to lenient rate control d restingheart rates�100 to110bpm.Furthermore, at the end the first year, average resting heart rates were 86� 15 and 75� bpm in the lenient and strict rate-control arms, respectively, d the difference of 10 to 11 bpm remained through the remain- r of the trial. Thus, although the definition of lenient seems ite liberal, in the trial itself the difference in heart rates in the 2 ups was quite small. Since few patients had resting heart rates 00 bpm and previous studies cannot conclusively show the ety of resting heart rates �100 bpm, we recommend that a art rate target of�100 bpm at rest be used formost patients. In cases, the heart rate target may need modification based on tient symptoms and preferences. Patients with persistent or per- nentAF orAFLwhohave exertional symptoms possibly due to essive heart rates should have an assessment of rate response to rcise. Activity heart rate assessment can be achieved in a variety ways, including recording heart rate after brisk hall walking or ir climbing, 24-hour ambulatorymonitoring, or formal exercise ting. Correlation of symptoms and heart rate may also be ieved by patient-activated electrocardiogram (ECG) rhythm ips (“event recorders”). In all patients, it is reasonable to verify t symptoms are caused by rapid ventricular rates. Finally, it uld be noted that rate control in paroxysmal AF is empirical, d heart rate targets are impractical for these briefer episodes of . ECOMMENDATION We recommend that ventricular rate be assessed at rest in ll patients with persistent and permanent AF or AFL Strong Recommendation, Moderate-Quality Evidence). We recommend that heart rate during exercise be as- essed in patients with persistent or permanent AF or AFL nd associated exertional symptoms (Strong Recommenda- ion, Moderate-Quality Evidence). We recommend that treatment for rate control of persis- ent or permanent AF or AFL should aim for a resting heart ate of �100 bpm (Strong Recommendation, High-Qual- ty Evidence). alues and preferences. These recommendations place a igh value on the randomized clinical trials and other clinical tudies demonstrating that ventricular rate control of AF is an ffective treatment approach for many patients with AF. eart rate control agents Beta-blockers, nondihydropyridine calcium channel ckers (diltiazem, verapamil), and digitalis are the primary ugs used for ventricular rate control during AF or AFL. e approach to selection of rate-control agents is shown in ure 3. The doses, adverse effects, and practical tips about e different rate-control agents are summarized in Table 2. l these drugs act by slowing atrioventricular (AV) nodal nduction and prolonging AV nodal refractoriness. Many sm no In tor no ch ex pa dig blo em va th be du ag ro co tio ag am wh ha an tie wi co R c o m ( a w f i b h d t r b e r f L V o i u p Ra tie tiv avo wi tio pa or blo fec Fig pre bid art Ta Cla Bet A B M N P Ca V D D pro 50 Canadian Journal of Cardiology Volume 27 2011 all comparative drug trials have been performed but have t shown major advantages of one agent over another.13-19 small, mostly blinded randomized trials, beta-adrenocep- blockers led to lower heart rates at rest and exercise but change or a decrease in exercise capacity.14 Calcium annel blockers were less effective at heart rate lowering on ercise but led to an increase or no change in exercise ca- city. In one study, beta-adrenoceptor blockers added to oxin did not result in improved QOL, whereas calcium ckers resulted in small improvements in physical and otional function.20 Digitalis prolongs AV nodal refractoriness by enhancing gal tone. During exercise, vagal tone is withdrawn, and erefore digitalis controls the heart rate less effectively than Rate-control Drug Choices No Heart Disease Hypertension CAD Heart Failure β-blocker β bl kDil�azem Verapamil Combina�on Rx Di it li † β β-blocker* Dil�azem Verapamil -blocker ± digitalis Digitalis† *β-blockers preferred in CAD †Digitalis may be considered as monotherapy in sedentary individuals Dronedarone ure 3. Selection of rate-control drug therapy is based on the sence or absence of underlying heart disease and other comor- ities. Combination therapy (Rx) may be required. CAD, coronary ery disease. ble 2. Drugs for heart rate control ss Dose Adverse effects a-blockers tenolol 50-150 mg orally daily Bradycardia, hypotension, fatigue, depression isoprolol 2.5-10 mg orally daily As per atenolol etoprolol 25-200 mg orally twice a day As per atenolol adolol 20-160 mg orally daily to twice a day As per atenolol ropranolol* 80-240 mg orally 3 times a day As per atenolol lcium channel blockers erapamil* 120 mg orally daily to 240 mg orally twice a day Bradycardia, hypotension, constipation iltiazem* 120-480 mg orally daily Bradycardia, hypotension, ankle swelling igoxin 0.125-0.25 mg orally daily Bradycardia, nausea, vomiting, visual disturbances *Sustained release preparations are available and generally preferred to long the dose interval and improve patient convenience or compliance. ta-adrenoceptor blockers or calcium channel blockers ring exercise. Digitalis should thus be avoided as the sole ent in active patients.21,22 On its own, digoxin does not utinely control the heart rate and frequently has to be mbined with another rate-slowing drug. Drug combina- ns are frequently effective when treatment with a single ent fails. Dronedarone is a newly released analogue of iodarone with significant rate-controlling properties23 ich may also be useful in selected patients. Amiodarone s significant rate-controlling properties in addition to its tiarrhythmic actions and may be used in refractory pa- nts. However, because of the risk