Garnier L F, Rouesnel Ph, Espitalier F
Service de cardiologie, Centre hospitalier, Vendôme.
Arch Mal Coeur Vaiss. 2004 Oct;97(10):1001-5.
Atrial fibrillation (AF) increases the risk of ischemic stroke due to the formation of a thrombus within left atrium. Thus, adjusted-dose (optimal INR: 2-3) anticoagulant therapy such as warfarin dramaticaly decreases this risk of embolic events both in primary and secondary prevention but slightly increases the risk of bleeding, particularly in the elderly. This explains that, although the benefit has been clearly demonstrated, the anticoagulant therapy remains underused. The efficacy of low doses of aspirin is less clear but it may be appropriate in younger patients with lone AF because of a low risk of embolic events. The combination of low doses of warfarin and aspirin should not be given. In case of contraindication to warfarin and aspirin, some others drugs such as indobufen or dipyridamole may be given but the most promising drug is ximelagatran, a direct thrombin inhibitor, which appears to be as effective than warfarin with a lower incidence of bleedings. For patients in AF who require urgent cardioversion, intravenous unfractionated heparin remains the anticoagulant of choice but an approach combining low-molecular-weight heparin and transesophageal echocardiography has been proposed. For each patient the decision of treatment must be tightly correlated to the benefit-risk ratio.
心房颤动（AF）由于左心房内血栓形成会增加缺血性卒中的风险。因此，调整剂量（最佳国际标准化比值：2 - 3）的抗凝治疗，如华法林，在一级和二级预防中均能显著降低栓塞事件的风险，但会轻微增加出血风险，尤其是在老年人中。这就解释了为什么尽管抗凝治疗的益处已得到明确证实，但仍未得到充分应用。低剂量阿司匹林的疗效尚不太明确，但对于孤立性房颤的年轻患者可能适用，因为其栓塞事件风险较低。不应给予低剂量华法林和阿司匹林的联合用药。在对华法林和阿司匹林存在禁忌的情况下，可给予其他一些药物，如吲哚布芬或双嘧达莫，但最有前景的药物是希美加群，一种直接凝血酶抑制剂，其疗效似乎与华法林相当，但出血发生率较低。对于需要紧急心脏复律的房颤患者，静脉注射普通肝素仍然是抗凝治疗的首选，但有人提出了一种将低分子量肝素与经食管超声心动图相结合的方法。对于每位患者，治疗决策必须与效益风险比紧密相关。
