Teng M P, Catherwood L E, Melby D P
Cardiology Division, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
Pharmacoeconomics. 2000 Oct;18(4):317-33. doi: 10.2165/00019053-200018040-00002.
Atrial fibrillation is the most common supraventricular tachyarrhythmia encountered in clinical practice, affecting over 5% of persons over the age of 65 years. A common pathophysiological mechanism for arrhythmia development is atrial distention and fibrosis induced by hypertension, coronary artery disease or ventricular dysfunction. Less frequently, atrial fibrillation is caused by mitral stenosis or other provocative factors such as thyrotoxicosis, pericarditis or alcohol intoxication. Depending on the extent of associated cardiovascular disease, atrial fibrillation may produce haemodynamic compromise, or symptoms such as palpitations, fatigue, chest pain or dyspnoea. Arrhythmia-induced atrial stasis can precipitate clot formation and the potential for subsequent thromboembolism. Comprehensive management of atrial fibrillation requires a multifaceted approach directed at controlling symptoms, protecting the patient from ischaemic stroke or peripheral embolism and possible conversion to or maintenance of sinus rhythm. Numerous randomised trials have demonstrated the efficacy of warfarin--and less so aspirin (acetylsalicylic acid)--in reducing the risk of embolic events. Furthermore, therapeutic strategies exist that can favourably modify symptoms by restoring and maintaining sinus rhythm with cardioversion and antiarrhythmic prophylaxis. However, the risks and benefits of various treatments is highly dependent on patient-specific features, emphasising the need for an individualised approach. This article reviews the findings of cost-effectiveness studies published over the past decade that have evaluated different components of treatment strategies for atrial fibrillation. These studies demonstrate the economic attractiveness of acute management options, long term warfarin prophylaxis, telemetry-guided initiation of antiarrhythmic therapy, approaches to restore and maintain sinus rhythm, and the potential role of transoesophageal echocardiographic screening for atrial thrombus prior to pharmacological or electrical cardioversion. Further, we discuss the merits and limitations of the cost-effectiveness analyses in the context of overall treatment strategies. Finally, we identify areas that will require additional research to achieve the goal of effective and economically efficient management of atrial fibrillation.
心房颤动是临床实践中最常见的室上性快速心律失常，影响超过5%的65岁以上人群。心律失常发生的常见病理生理机制是由高血压、冠状动脉疾病或心室功能障碍引起的心房扩张和纤维化。较少见的情况下，心房颤动由二尖瓣狭窄或其他诱发因素引起，如甲状腺毒症、心包炎或酒精中毒。根据相关心血管疾病的程度，心房颤动可能导致血流动力学损害，或出现心悸、疲劳、胸痛或呼吸困难等症状。心律失常引起的心房淤滞可促使血栓形成，并可能导致随后的血栓栓塞。心房颤动的综合管理需要多方面的方法，旨在控制症状、保护患者免受缺血性卒中或外周栓塞，并可能恢复或维持窦性心律。大量随机试验已证明华法林（阿司匹林[乙酰水杨酸]的效果稍差）在降低栓塞事件风险方面的疗效。此外，存在一些治疗策略，可通过心脏复律和抗心律失常预防来恢复和维持窦性心律，从而有利地改善症状。然而，各种治疗的风险和益处高度依赖于患者的具体特征，这强调了个体化方法的必要性。本文综述了过去十年发表的成本效益研究结果，这些研究评估了心房颤动治疗策略的不同组成部分。这些研究证明了急性管理方案、长期华法林预防、遥测引导的抗心律失常治疗起始、恢复和维持窦性心律的方法以及在药物或电复律前经食管超声心动图筛查心房血栓的潜在作用在经济上具有吸引力。此外，我们在整体治疗策略的背景下讨论了成本效益分析的优点和局限性。最后，我们确定了需要进一步研究的领域，以实现有效且经济高效地管理心房颤动的目标。
