Kalus James S
Department of Pharmacy Services, Henry Ford Hospital, 2045 W. Grand Blvd., Detroit, MI 48202, USA.
J Manag Care Pharm. 2009 Aug;15(6 Suppl B):S10-8.
In patients with atrial fibrillation (AF), antiarrhythmic drug therapy currently plays a greater role in maintaining sinus rhythm after cardioversion than it does in converting AF to sinus rhythm. Amiodarone is the most effective antiarrhythmic agent for maintaining sinus rhythm after cardioversion in patients with AF. However, its pharmacokinetics is complex; the drug interacts with many commonly used medications; and long-term use can cause thyroid dysfunction, hepatotoxicity, and other severe extracardiac adverse effects. The use of antiarrhythmic strategies in patients with AF has decreased because of evidence of greater safety and lower costs for hospitalization obtained from the use of rate-control strategies instead. Nevertheless, some patients require a rhythm-control strategy. Warfarin is used to prevent embolic stroke in many patients with AF, but its use is also complex and requires monitoring. Therefore, efforts have been made to develop antiarrhythmic agents with improved tolerability and anticoagulants that are easy to use.
To describe the 3 primary goals of pharmacotherapy in patients with AF, compare and contrast the efficacy and safety of established and investigational pharmacotherapies for AF, and recommend a drug regimen for an individual with AF based on patient-specific factors.
Currently available antiarrhythmic agents differ in their efficacy for maintaining sinus rhythm after cardioversion in AF patients with tolerability problems, comorbidities (particularly heart failure and renal impairment), and potential drug interactions. Hence, when selecting drug therapy to maintain sinus rhythm after cardioversion, it is important to take into consideration patient characteristics, including age, disease states, renal function, and concurrent drug therapies. Outpatient self-administration of single loading doses of flecainide or propafenone with what is referred to as the pill-in-the-pocket approach may be considered for carefully selected patients with recurrent episodes of symptomatic AF. The recently approved antiarrhythmic agent dronedarone has electrophysiologic properties similar to those of amiodarone, but its lack of iodine may improve upon the pharmacokinetic and tolerability issues associated with amiodarone. Vernakalant is another investigational antiarrhythmic agent that may prove useful for cardioversion and maintenance of sinus rhythm after cardioversion in patients with AF. New oral anticoagulants that do not require close laboratory monitoring and are simpler to use than warfarin have been used investigationally for prevention of venous thromboembolism and are in clinical trials for prevention of embolic stroke in patients with AF.
Pharmacotherapy for patients with AF should be individualized based on patient-specific factors. New therapeutic options may become available to facilitate treatment of these patients.
在心房颤动（AF）患者中，目前抗心律失常药物治疗在心脏复律后维持窦性心律方面比将房颤转为窦性心律发挥着更大的作用。胺碘酮是AF患者心脏复律后维持窦性心律最有效的抗心律失常药物。然而，其药代动力学复杂；该药物与许多常用药物相互作用；长期使用可导致甲状腺功能障碍、肝毒性及其他严重的心外不良反应。由于采用心率控制策略具有更高的安全性和更低的住院费用，AF患者中抗心律失常策略的使用有所减少。尽管如此，一些患者仍需要节律控制策略。华法林用于预防许多AF患者的栓塞性卒中，但其使用也很复杂且需要监测。因此，人们一直在努力开发耐受性更好的抗心律失常药物和易于使用的抗凝剂。
描述AF患者药物治疗的3个主要目标，比较和对比已确立的和正在研究的AF药物治疗的疗效和安全性，并根据患者的具体因素为AF患者推荐药物治疗方案。
目前可用的抗心律失常药物在AF患者心脏复律后维持窦性心律的疗效方面存在差异，这些患者存在耐受性问题、合并症（尤其是心力衰竭和肾功能损害）以及潜在的药物相互作用。因此，在选择心脏复律后维持窦性心律的药物治疗时，考虑患者特征很重要，包括年龄、疾病状态、肾功能和同时进行的药物治疗。对于精心挑选的有症状AF复发的患者，可考虑采用门诊自行单次负荷剂量服用氟卡尼或普罗帕酮的所谓“口袋丸”方法。最近批准的抗心律失常药物决奈达隆具有与胺碘酮相似的电生理特性，但它不含碘，可能会改善与胺碘酮相关的药代动力学和耐受性问题。维纳卡兰是另一种正在研究的抗心律失常药物，可能对AF患者心脏复律及复律后维持窦性心律有用。新型口服抗凝剂不需要密切的实验室监测，且比华法林使用更简单，已用于静脉血栓栓塞预防的研究，并且正在进行预防AF患者栓塞性卒中的临床试验。
AF患者的药物治疗应根据患者的具体因素个体化。可能会有新的治疗选择来促进这些患者的治疗。
