Khand A U, Rankin A C, Kaye G C, Cleland J G
Department of Cardiology, Glasgow Royal Infirmary, Glasgow, UK.
Eur Heart J. 2000 Apr;21(8):614-32. doi: 10.1053/euhj.1999.1767.
To systematically review the management of atrial fibrillation (AF) in patients with heart failure.
Studies investigating the management of AF in patients with heart failure published between 1967 to 1998 were identified using MEDLINE, the Cochrane register and Embase databases. Reference lists from relevant papers and reviews were hand searched for further papers.
Eight studies pertaining to acute and twenty-four pertaining to chronic AF were identified. For patients with acute AF ventricular rate control, anticoagulation and treatment of heart failure should be pursued simultaneously before cardioversion is attempted. Digoxin is relatively ineffective at controlling ventricular response and for cardioversion. Intravenous diltiazem is rapidly effective in controlling ventricular rate and limited evidence suggests it is safe. Amiodarone controls ventricular rate rapidly and increases the rate of cardioversion. There are insufficient data to conclude that immediate anti-coagulation, trans-oesophageal echocardiography to exclude atrial thrombi followed by immediate cardioversion is an appropriate strategy. Patients with chronic AF should be anti-coagulated unless contra-indications exist. It is not clear whether the preferred strategy should be cardioversion and maintenance of sinus rhythm with amiodarone or ventricular rate control of AF combined with anticoagulation to improve outcome including symptoms, morbidity and survival. Electrical cardioversion has a high initial success rate but there is also a high risk of early relapse. Amiodarone currently appears the most effective and safest therapy for maintaining sinus rhythm post-cardioversion. Digoxin is fairly ineffective at controlling ventricular rate during exercise. Addition of a beta-blocker reduces ventricular rate and improves symptoms. Whether digoxin is required in addition to beta-blockade for the control of AF in this setting is currently under investigation. If pharmacological therapy is ineffective or not tolerated then atrio-ventricular node ablation and permanent pacemaker implantation should be considered.
There is a paucity of controlled clinical trial data for the management of AF among patients with heart failure. The interaction between AF and heart failure means that neither can be treated optimally without treating both. Presently treatment should be on a case by case basis.
系统评价心力衰竭患者心房颤动（AF）的管理。
利用MEDLINE、Cochrane注册库和Embase数据库，检索1967年至1998年间发表的关于心力衰竭患者AF管理的研究。手工检索相关论文和综述的参考文献列表以获取更多论文。
确定了8项关于急性AF的研究和24项关于慢性AF的研究。对于急性AF患者，在尝试复律前应同时进行心室率控制、抗凝和心力衰竭治疗。地高辛在控制心室反应和复律方面相对无效。静脉注射地尔硫䓬能迅速有效控制心室率，且有限的证据表明其安全。胺碘酮能迅速控制心室率并提高复律率。尚无足够数据得出立即抗凝、经食管超声心动图排除心房血栓后立即复律是合适策略的结论。慢性AF患者应进行抗凝，除非存在禁忌证。尚不清楚首选策略是使用胺碘酮复律并维持窦性心律，还是控制AF的心室率并联合抗凝以改善包括症状、发病率和生存率在内的结局。电复律初始成功率高，但早期复发风险也高。胺碘酮目前似乎是复律后维持窦性心律最有效和最安全的疗法。地高辛在运动期间控制心室率效果相当不佳。加用β受体阻滞剂可降低心室率并改善症状。在这种情况下，除β受体阻滞剂外是否还需要地高辛来控制AF目前正在研究中。如果药物治疗无效或无法耐受，则应考虑房室结消融和永久性起搏器植入。
心力衰竭患者AF管理的对照临床试验数据匮乏。AF与心力衰竭之间的相互作用意味着不治疗两者就无法对任何一方进行最佳治疗。目前应根据具体情况进行治疗。
