Patel Taral K, Passman Rod S
Division of Cardiology, Department of Internal Medicine, Northwestern University, Feinberg School of Medicine, 251 East Huron Street, Feinberg 8-503, Chicago, IL, 60611, USA.
Curr Treat Options Cardiovasc Med. 2013 Jun;15(3):299-312. doi: 10.1007/s11936-013-0234-9.
Atrial fibrillation (AF) remains a major risk factor for stroke. Unfortunately, clinical trials have failed to demonstrate that a strategy of rhythm control--therapy to maintain normal sinus rhythm (NSR)--reduces stroke risk. The apparent lack of benefit of rhythm control likely reflects the difficulty in maintaining NSR using currently available therapies. However, there are signals from several trials that the presence of NSR is indeed beneficial and associated with better outcomes related to stroke and mortality. Most electrophysiologists feel that as rhythm control strategies continue to improve, the crucial link between rhythm control and stroke reduction will finally be demonstrated. Therefore, AF specialists tend to be aggressive in their attempts to maintain NSR, especially in patients who have symptomatic AF. A step-wise approach from antiarrhythmic drugs to catheter ablation to cardiac surgery is generally used. In select patients, catheter ablation or cardiac surgery may supersede antiarrhythmic drugs. The choice depends on the type of AF, concurrent heart disease, drug toxicity profiles, procedural risks, and patient preferences. Regardless of strategy, given the limited effectiveness of currently available rhythm control therapies, oral anticoagulation is still recommended for stroke prophylaxis in AF patients with other stroke risk factors. Major challenges in atrial fibrillation management include selecting patients most likely to benefit from rhythm control, choosing specific antiarrhythmic drugs or procedures to achieve rhythm control, long-term monitoring to gauge the efficacy of rhythm control, and determining which (if any) patients may safely discontinue anticoagulation if long-term NSR is achieved.
心房颤动（AF）仍然是中风的主要危险因素。不幸的是，临床试验未能证明节律控制策略（即维持正常窦性心律（NSR）的治疗）能降低中风风险。节律控制明显缺乏益处可能反映了使用现有疗法维持NSR的困难。然而，几项试验显示，NSR的存在确实有益，且与中风和死亡率方面更好的结果相关。大多数电生理学家认为，随着节律控制策略不断改进，节律控制与降低中风之间的关键联系最终将得到证实。因此，房颤专家往往积极尝试维持NSR，尤其是对有症状房颤的患者。通常采用从抗心律失常药物到导管消融再到心脏手术的逐步方法。在特定患者中，导管消融或心脏手术可能会取代抗心律失常药物。选择取决于房颤的类型、并发的心脏病、药物毒性特征、手术风险和患者偏好。无论采用何种策略，鉴于现有节律控制疗法的有效性有限，对于有其他中风危险因素的房颤患者，仍建议口服抗凝药预防中风。房颤管理中的主要挑战包括选择最可能从节律控制中获益的患者、选择实现节律控制的特定抗心律失常药物或手术、进行长期监测以评估节律控制的疗效，以及确定如果实现长期NSR哪些（如果有的话）患者可以安全停用抗凝药。
