Department of Medicine, Health + Hospitals/Metropolitan, New York, NY, USA.
New York Medical College, Valhalla, NY, USA.
Am J Cardiovasc Drugs. 2018 Oct;18(5):347-360. doi: 10.1007/s40256-018-0276-1.
Heart failure affects nearly 26 million people worldwide. Patients with heart failure are frequently affected with atrial fibrillation, and the interrelation between these pathologies is complex. Atrial fibrillation shares the same risk factors as heart failure. Moreover, it is associated with a higher-risk baseline clinical status and higher mortality rates in patients with heart failure. The mechanisms by which atrial fibrillation occurs in a failing heart are incompletely understood, but animal studies suggest they differ from those that occur in a healthy heart. Data suggest that heart failure-induced atrial fibrosis and atrial ionic remodeling are the underlying abnormalities that facilitate atrial fibrillation. Therapeutic considerations for atrial fibrillation in patients with heart failure include risk factor modification and guideline-directed medical therapy, anticoagulation, rate control, and rhythm control. As recommended for atrial fibrillation in the non-failing heart, anticoagulation in patients with heart failure should be guided by a careful estimation of the risk of embolic events versus the risk of hemorrhagic episodes. The decision whether to target a rate-control or rhythm-control strategy is an evolving aspect of management. Currently, both approaches are good medical practice, but recent data suggest that rhythm control, particularly when achieved through catheter ablation, is associated with improved outcomes. A promising field of research is the application of neurohormonal modulation to prevent the creation of the "structural substrate" for atrial fibrillation in the failing heart.
心力衰竭影响全球近 2600 万人。心力衰竭患者常伴有心房颤动，这两种病理之间的关系很复杂。心房颤动与心力衰竭有相同的危险因素。此外，它与心力衰竭患者的基线临床状况风险较高和死亡率较高相关。在衰竭的心脏中发生心房颤动的机制尚不完全清楚，但动物研究表明，它们与在健康心脏中发生的机制不同。有数据表明，心力衰竭引起的心房纤维化和心房离子重塑是促进心房颤动的潜在异常。心力衰竭患者心房颤动的治疗考虑因素包括危险因素的修正和指南指导的药物治疗、抗凝、心率控制和节律控制。正如在非衰竭心脏中治疗心房颤动所建议的那样，心力衰竭患者的抗凝治疗应根据栓塞事件风险与出血事件风险的仔细评估来指导。选择以心率控制还是节律控制策略为目标是管理的一个不断发展的方面。目前，这两种方法都是良好的医疗实践，但最近的数据表明，节律控制，特别是通过导管消融实现的节律控制，与改善结果相关。一个有前途的研究领域是应用神经激素调节来防止心力衰竭中心房颤动的“结构底物”的形成。
