Aronow W S
Hebrew Hospital Home, Bronx, New York 10475, USA.
J Am Geriatr Soc. 1999 Jun;47(6):740-8. doi: 10.1111/j.1532-5415.1999.tb01602.x.
To review the management of the older person with atrial fibrillation (AF).
A computer-assisted search of the English language literature (MEDLINE) database followed by a manual search of the bibliographies of pertinent articles.
Studies on the management of persons with AF were screened for review. Studies of persons older than age 60 and recent studies were emphasized.
Pertinent data were extracted from the reviewed articles. Emphasis was placed on studies involving older persons. Relevant articles were reviewed in depth.
Available data about the management of persons with paroxysmal or chronic AF were summarized
Management of AF includes treatment of the underlying disease and precipitating factors. Immediate direct-current cardioversion should be performed in persons with AF associated with an acute myocardial infarction, chest pain caused by myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous verapamil, diltiazem, or beta-blockers should be used to slow a very rapid ventricular rate associated with AF immediately. Oral verapamil, diltiazem, or a beta-blocker should be given if a rapid ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected persons with symptomatic life-threatening AF refractory to other drug therapy. Nondrug therapies should be performed in persons with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drug therapy. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in persons with AF who develop cerebral symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds that are not drug-induced. Elective cardioversion of AF should not be performed in asymptomatic older persons with chronic AF. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective direct-current or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer the treatment strategy, especially in older persons, of ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Digoxin should be avoided in persons with sinus rhythm who have a history of paroxysmal AF. Older persons with chronic or paroxysmal AF who are at high risk for stroke or who have a history of hypertension and no contraindications to warfarin should receive long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Older persons with AF who are at low risk for stroke or who have contraindications to warfarin should receive 325 mg of aspirin daily.
回顾老年心房颤动（AF）患者的管理。
通过计算机辅助检索英文文献数据库（MEDLINE），随后人工检索相关文章的参考文献。
筛选有关AF患者管理的研究进行综述。重点关注60岁以上人群的研究及近期研究。
从综述文章中提取相关数据。重点关注涉及老年人的研究。对相关文章进行深入回顾。
总结阵发性或慢性AF患者管理的现有数据。
AF的管理包括治疗基础疾病和诱发因素。对于伴有急性心肌梗死、心肌缺血所致胸痛、低血压、严重心力衰竭或晕厥的AF患者，应立即进行直流电复律。静脉注射维拉帕米、地尔硫䓬或β受体阻滞剂应立即用于减慢与AF相关的极快速心室率。如果尽管使用了地高辛，在静息或运动时仍出现快速心室率，则应给予口服维拉帕米、地尔硫䓬或β受体阻滞剂。对于有症状的危及生命的AF且对其他药物治疗无效的特定患者，可使用胺碘酮。对于有症状的AF患者，如果药物治疗无法减慢快速心室率，则应采用非药物治疗。与心动过速-心动过缓综合征相关的阵发性AF应采用永久性起搏器联合药物治疗。对于AF患者，如果出现与心室停搏大于3秒相关的头晕或晕厥等脑部症状且非药物所致，应植入永久性起搏器。对于无症状的慢性AF老年患者，不应进行选择性AF复律。除非在复律前经食管超声心动图显示左心耳无血栓，否则在选择性AF直流电复律或药物复律前应给予口服华法林3周，并在维持窦性心律后至少持续4周。许多心脏病专家更喜欢心室率控制加华法林的治疗策略，尤其是在老年人中，而不是用抗心律失常药物维持窦性心律。有阵发性AF病史的窦性心律患者应避免使用地高辛。慢性或阵发性AF且有高卒中风险或有高血压病史且无华法林禁忌证的老年患者应接受长期华法林治疗，使国际标准化比值达到2.0至3.0。AF且有低卒中风险或有华法林禁忌证的老年患者应每日服用325mg阿司匹林。
