Coventry Cardiology Associates, Easton Hospital, Easton, PA, USA.
Easton Hospital, Easton, PA, USA.
Europace. 2016 Jun;18(6):799-806. doi: 10.1093/europace/euv350. Epub 2015 Nov 26.
We aimed to ascertain whether an insertable cardiac monitor (ICM)-guided rhythm-control strategy and assessment of atrial fibrillation (AF) burden may allow safe withdrawal and obviate long-term use of oral anticoagulants (OACs) in AF patients at high bleeding risk.
We implanted ICMs in 70 patients with AF with high risk of stroke (CHADS2 ≥2, CHA2DS2-VASc score ≥2) and bleeding (HAS-BLED score ≥3) after restoration of normal sinus rhythm (NSR) for continuous rhythm monitoring and optimization of antiarrhythmic drugs (AADs) when necessary. Patients were categorized into: (i) Group A (NSR/low AF burden, <1%), (ii) Group B (moderate/variable AF burden), and (iii) Group C (high AF burden, always AF). At patients' insistence, OACs were discontinued after proper counselling only if they maintained NSR/low AF burden for ≥3 consecutive months. All patients (age 73.3 ± 11.7 years; 53% male) were followed clinically and with ICM monitoring for 23.5 ± 10.5 months for outcomes including stroke, bleeding, death, device malfunction or infection, and AADs' adverse effects. Patients in Group A (n = 43), Group B (n = 20), and Group C (n = 7) had similar CHADS2 (2.09 ± 0.65, 2.05 ± 0.51, and 2.14 ± 0.38, respectively), CHA2DS2-VASc (3.05 ± 1.05, 2.85 ± 0.99, and 2.42 ± 0.53, respectively), and HAS-BLED (3.02 ± 1.01, 3.40 ± 0.68, and 3.00 ± 0.58, respectively) scores (P > 0.05). In 53 (76%) patients (Group A = 41 and Group B = 12) who maintained NSR/low AF burden, OACs were discontinued without adverse events. Severe bleeding occurred in 4 of 17 (24%) patients who remained on OACs.
In AF patients with high bleeding risk, ICM-guided rhythm control with AADs and assessment of AF burden may allow safe discontinuation of OACs.
我们旨在确定可植入式心脏监测仪（ICM）指导的节律控制策略以及对心房颤动（AF）负荷的评估是否可以使高出血风险的 AF 患者安全停药并避免长期使用口服抗凝剂（OAC）。
我们在恢复窦性心律（NSR）后，为 70 例具有高卒中风险（CHADS2≥2，CHA2DS2-VASc 评分≥2）和出血风险（HAS-BLED 评分≥3）的 AF 患者植入了 ICM，以便进行连续节律监测和优化抗心律失常药物（AAD）治疗。如果需要的话。患者分为：（i）A 组（NSR/低 AF 负荷，<1%），（ii）B 组（中/可变 AF 负荷）和（iii）C 组（高 AF 负荷，始终为 AF）。在患者坚持的情况下，仅在他们连续 3 个月保持 NSR/低 AF 负荷的情况下，经过适当的咨询后，方可停止 OAC。所有患者（年龄 73.3±11.7 岁；53%为男性）接受临床随访和 ICM 监测 23.5±10.5 个月，以评估包括卒中、出血、死亡、器械故障或感染以及 AAD 的不良反应在内的结局。A 组（n=43）、B 组（n=20）和 C 组（n=7）患者的 CHADS2 评分分别为（2.09±0.65、2.05±0.51 和 2.14±0.38）、CHA2DS2-VASc 评分分别为（3.05±1.05、2.85±0.99 和 2.42±0.53）和 HAS-BLED 评分分别为（3.02±1.01、3.40±0.68 和 3.00±0.58），差异均无统计学意义（P>0.05）。在 53 例（76%）保持 NSR/低 AF 负荷的患者（A 组=41 例，B 组=12 例）中，OAC 停药后未发生不良事件。仍服用 OAC 的 17 例患者中有 4 例（24%）发生严重出血。
在具有高出血风险的 AF 患者中，ICM 指导的节律控制联合 AAD 治疗和对 AF 负荷的评估可安全停用 OAC。
