Madrid Antonio H, Escobar Carlos, Rebollo José María G, Marín Irene, Bernal Enrique, Nannini Sebastián, Limón Lilianna, Peng Jian, Moro Concepción
Arrhythmia Unit, Ramón y Cajal Hospital, Department of Medicine, Alcalá University, Madrid, Spain.
Card Electrophysiol Rev. 2003 Sep;7(3):243-6. doi: 10.1023/B:CEPR.0000012391.95928.d2.
Atrial fibrillation (AF) is a common arrhythmia associated with increased risk of stroke and mortality. The early appearance of electrical remodeling is followed by structural remodeling of the atrial tissue. Direct current cardioversion of persistent AF is the most effective treatment for the restoration of sinus rhythm, but it is hampered by a high percentage of recurrences. Recurrences may be the consequence of both electrical and structural remodeling. A study on the use of irbesartan to maintain sinus rhythm in patients with long-lasting persistent AF showed that this angiotensin II receptor blocker combined with amiodarone prolonged sinus rhythm after cardioversion. Irbesartan may have antifibrotic effects due not only to the ability to diminish the synthesis of collagen type I molecules but also to its capacity to stimulate the degradation of collagen type I fibers, as has been demonstrated with losartan, another angiotensin II receptor blocker. This suggests that efforts to reduce the structural changes that occur during AF may be more useful in preventing recurrences than efforts designed to minimize the electrical changes alone. The AFFIRM trial compared two approaches to the treatment of AF: cardioversion with antiarrhythmic drugs to maintain sinus rhythm and the use of rate-controlling drugs. The results show that management of AF with the rhythm-control strategy offers no survival advantage over the rate-control strategy. However, non-antiarrhythmic drugs to prevent recurrences, like irbesartan, were not controlled and amiodarone was used in a low percentage of the patients. The treatment strategies proposed in both AFFIRM and RACE, in our opinion, may not be the optimal. The modern clinical approach to AF involves an early intervention to restore sinus rhythm, therefore preventing atrial remodeling. The pretreatment of patients with AF who undergo electrical cardioversion is very important and will be the subject for continuous improvement.
心房颤动（AF）是一种常见的心律失常，与中风和死亡风险增加相关。电重构的早期出现之后是心房组织的结构重构。持续性AF的直流电复律是恢复窦性心律最有效的治疗方法，但它受到高复发率的阻碍。复发可能是电重构和结构重构共同作用的结果。一项关于使用厄贝沙坦维持长期持续性AF患者窦性心律的研究表明，这种血管紧张素II受体阻滞剂与胺碘酮联合使用可延长复律后的窦性心律。厄贝沙坦可能具有抗纤维化作用，这不仅归因于其减少I型胶原分子合成的能力，还归因于其刺激I型胶原纤维降解的能力，正如另一种血管紧张素II受体阻滞剂氯沙坦所证实的那样。这表明，努力减少AF期间发生的结构变化可能比仅旨在最小化电变化的努力在预防复发方面更有用。AFFIRM试验比较了两种治疗AF的方法：使用抗心律失常药物进行复律以维持窦性心律和使用控制心率的药物。结果表明，节律控制策略治疗AF与心率控制策略相比没有生存优势。然而，像厄贝沙坦这样的预防复发的非抗心律失常药物未得到控制，并且只有低比例的患者使用了胺碘酮。我们认为，AFFIRM和RACE中提出的治疗策略可能不是最佳的。现代AF临床方法涉及早期干预以恢复窦性心律，从而预防心房重构。接受电复律的AF患者的预处理非常重要，并且将是持续改进的主题。
