Division of Cardiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Division of Cardiology, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.
Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
JACC Clin Electrophysiol. 2019 Feb;5(2):231-241. doi: 10.1016/j.jacep.2018.08.025. Epub 2018 Nov 1.
In this study the authors investigated effectiveness and safety of an initial treatment strategy with class IC or class III antiarrhythmic drugs (AAD) for newly diagnosed atrial fibrillation (AF) or atrial flutter (AFL).
There is limited evidence to guide optimal AAD selection for rhythm control in newly diagnosed AF/AFL.
Using data from TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF), the authors performed a retrospective cohort study of patients with AF/AFL from 2004 to 2014 and class IC or class III AAD prescription within 90 days following diagnosis. Patients with prior myocardial infarction, heart failure, or end-stage renal disease were excluded. Inverse probability treatment weighted propensity scores were used to evaluate the association of AAD class on hospitalization and cardiovascular events. To evaluate residual confounding, falsification outcomes were evaluated.
A total of 230,762 patients developed newly diagnosed AF/AFL during the study period. Of those, 3,973 patients (1.7%) were prescribed class IC and 6,909 (3.0%) were prescribed class III AAD. Median follow-up was 4.9 years. After inverse probability treatment weighted adjustment, class IC medications were associated with lower risk of hospitalizations for AF/AFL (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.73 to 0.81), cardiovascular disease (HR: 0.78; 95% CI: 0.75 to 0.81), heart failure (HR: 0.70; 95% CI: 0.64 to 0.76), and lower incidence of ischemic stroke (HR: 0.74; 95% CI: 0.65 to 0.85). Similar results were found in CHADS (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke, Transient Ischemic Attack, or Thromboembolism) 0 or 1 and CHADS-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke, Transient Ischemic Attack, or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) 0 or 1 subgroups. Falsification analyses for outcomes of urinary tract infection, pneumonia, and hip fracture were generally nonsignificant.
Prescription of class IC AAD as initial treatment for newly diagnosed AF/AFL, compared with prescription of class III AAD, may be associated with lower risk of hospitalization and cardiovascular events.
本研究旨在调查新诊断心房颤动（AF）或心房扑动（AFL）患者初始采用 Ic 类或 III 类抗心律失常药物（AAD）治疗策略的疗效和安全性。
目前，关于新诊断 AF/AFL 患者节律控制中 AAD 选择的最佳方案，证据有限。
利用 TREAT-AF（房颤的回顾性评估和治疗）研究数据，作者对 2004 年至 2014 年间新诊断为 AF/AFL 且在诊断后 90 天内开具 Ic 类或 III 类 AAD 的患者进行了回顾性队列研究。排除了有既往心肌梗死、心力衰竭或终末期肾病的患者。采用逆概率治疗加权倾向评分评估 AAD 类别与住院和心血管事件的相关性。为了评估残余混杂因素，还评估了验证结果。
在研究期间，共有 230762 例患者新发 AF/AFL。其中，3973 例（1.7%）患者开具了 Ic 类 AAD，6909 例（3.0%）患者开具了 III 类 AAD。中位随访时间为 4.9 年。经逆概率治疗加权调整后，Ic 类药物与 AF/AFL 住院风险降低相关（风险比 [HR]：0.77；95%置信区间 [CI]：0.73 至 0.81）、心血管疾病（HR：0.78；95% CI：0.75 至 0.81）、心力衰竭（HR：0.70；95% CI：0.64 至 0.76）风险降低，以及缺血性脑卒中发生率降低（HR：0.74；95% CI：0.65 至 0.85）。在 CHADS（充血性心力衰竭、高血压、年龄≥75 岁、糖尿病、既往卒中、短暂性脑缺血发作或血栓栓塞、血管疾病、年龄 65 岁至 74 岁、性别）0 或 1 以及 CHADS-VASc（充血性心力衰竭、高血压、年龄≥75 岁、糖尿病、既往卒中、短暂性脑缺血发作或血栓栓塞、血管疾病、年龄 65 岁至 74 岁、性别）0 或 1 亚组中，也观察到了类似的结果。验证结果显示，尿路感染、肺炎和髋部骨折结局的假阳性分析结果通常不显著。
与开具 III 类 AAD 相比，新诊断 AF/AFL 患者初始采用 Ic 类 AAD 治疗可能与降低住院和心血管事件风险相关。
