Department of Clinical Medicine and Surgery, Federico II University Hospital, Via S. Pansini, 5, 80131, Naples, Italy.
Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy.
Intern Emerg Med. 2020 Sep;15(6):935-943. doi: 10.1007/s11739-020-02303-5. Epub 2020 Mar 2.
Atrial fibrillation is the most common arrhythmia and its prevalence is expected to further increase. Patients with atrial fibrillation have an increased risk of stroke (fivefold increased risk), heart failure, and death. In patients with non-valvular atrial fibrillation, the most recent guidelines recommend the use of the CHADS-VASc (congestive heart failure, arterial hypertension, age > 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) scoring system to identify those who may benefit from oral anticoagulant treatment. Guidelines recommend initiation of oral anticoagulation with vitamin K antagonists or direct oral anticoagulants in men with a score ≥ 2 and in women with a score ≥ 3, while oral anticoagulation in individuals with a score of 0 is not recommended. Accordingly, men with CHADSVASc score = 1 (and women with CHADSVASc = 2) represent a grey zone where guidelines do not provide a definite oral anticoagulant indication. Implementation of risk stratification with transthoracic echocardiography could be extremely useful. Both prospective and observational studies using transthoracic echocardiography prediction of events and studies utilizing transesophageal echocardiographic parameters as surrogate markers of thromboembolic events make sustainable the hypothesis that echocardiography could improve thromboembolism prediction in non-valvular atrial fibrillation. However, because of some controversial results of different studies, determination of the best echocardiographic parameter predicting thromboembolic events in atrial fibrillation remains uncertain. The combination of left atrial enlargement with left atrial function (in particular assessing left atrial strain) appears to be very valuable, but needs to be confirmed in large-scale multi-center trials.
心房颤动是最常见的心律失常，其患病率预计将进一步增加。心房颤动患者发生中风（风险增加五倍）、心力衰竭和死亡的风险增加。在非瓣膜性心房颤动患者中，最新指南建议使用 CHADS-VASc（充血性心力衰竭、动脉高血压、年龄>75 岁、糖尿病、中风/短暂性脑缺血发作、血管疾病、年龄 65-74 岁、性别）评分系统来识别可能受益于口服抗凝治疗的患者。指南建议 CHADS-VASc 评分≥2 的男性和 CHADS-VASc 评分≥3 的女性开始口服抗凝治疗，而评分 0 的患者不建议进行抗凝治疗。因此，CHADS-VASc 评分=1（女性为 CHADS-VASc=2）的男性属于灰色地带，指南对此类人群没有明确的抗凝适应证。使用经胸超声心动图进行风险分层可能非常有用。使用经胸超声心动图预测事件的前瞻性和观察性研究以及使用经食管超声心动图参数作为血栓栓塞事件替代标志物的研究使超声心动图可以改善非瓣膜性心房颤动的血栓栓塞预测的假说具有可持续性。然而，由于不同研究的一些结果存在争议，确定预测心房颤动血栓栓塞事件的最佳超声心动图参数仍不确定。左心房扩大与左心房功能（特别是评估左心房应变）相结合似乎非常有价值，但需要在大规模多中心试验中得到证实。
