Sammut Mark Anthony, Condliffe Robin, Elliot Charlie, Hameed Abdul, Lewis Robert, Kiely David G, Kyriacou Andreas, Middleton Jennifer T, Raithatha Ajay, Rothman Alex, Thompson A A Roger, Turner Richard, Charalampopoulos Athanasios
Department of Cardiology, Northern General Hospital, Sheffield, UK.
Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
Int J Cardiol. 2023 Jan 15;371:363-370. doi: 10.1016/j.ijcard.2022.09.031. Epub 2022 Sep 18.
The development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity and mortality. Rate and rhythm control strategies have not been directly compared.
Eighty-four patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) with new-onset AFL/AF were identified in the ASPIRE registry. First, baseline characteristics and rates of sinus rhythm (SR) restoration of 3 arrhythmia management strategies (rate control, medical rhythm control and DC cardioversion, DCCV) in an early (2009-13) and later (2014-19) cohort were compared. Longer-term outcomes in patients who achieved SR versus those who did not were then explored.
Sixty (71%) patients had AFL and 24 (29%) AF. Eighteen (22%) patients underwent rate control, 22 (26%) medical rhythm control and 44 (52%) DCCV. SR was restored in 33% treated by rate control, 59% medical rhythm control and 95% DCCV (p < 0.001). Restoration of SR was associated with greater improvement in functional class (FC) and Incremental Shuttle Walk Distance (p both <0.05). It also independently predicted superior survival (3-year survival 62% vs 23% in those remaining in AFL/AF, p < 0.0001). In addition, FC III/IV independently predicted higher mortality (HR 2.86, p = 0.007). Right atrial area independently predicted AFL/AF recurrence (OR 1.08, p = 0.01). DCCV was generally well tolerated with no immediate major complications.
Restoration of SR is associated with superior functional improvement and survival in PAH/CTEPH compared with rate control. DCCV is generally safe and is more effective than medical therapy at achieving SR.
毛细血管前性肺动脉高压患者发生心房扑动和心房颤动（AFL/AF）与发病和死亡风险增加相关。心率和节律控制策略尚未进行直接比较。
在ASPIRE注册研究中确定了84例患有肺动脉高压（PAH）或慢性血栓栓塞性肺动脉高压（CTEPH）且新发AFL/AF的患者。首先，比较了早期（2009 - 2013年）和晚期（2014 - 2019年）队列中3种心律失常管理策略（心率控制、药物节律控制和直流电复律，DCCV）的基线特征和窦性心律（SR）恢复率。然后探讨了实现SR的患者与未实现SR的患者的长期结局。
60例（71%）患者发生AFL，24例（29%）发生AF。18例（22%）患者接受心率控制，22例（26%）接受药物节律控制，44例（52%）接受DCCV。心率控制组SR恢复率为33%，药物节律控制组为59%，DCCV组为95%（p < 0.001）。SR恢复与功能分级（FC）和递增式往返步行距离的更大改善相关（p均<0.05）。它还独立预测了更好的生存率（3年生存率在恢复SR的患者中为62%，在仍处于AFL/AF的患者中为23%，p < 0.0001）。此外，FC III/IV独立预测更高死亡率（HR 2.86，p = 0.007）。右心房面积独立预测AFL/AF复发（OR 1.08，p = 0.01）。DCCV通常耐受性良好，无即刻严重并发症。
与心率控制相比，SR恢复与PAH/CTEPH患者更好的功能改善和生存率相关。DCCV通常安全，在实现SR方面比药物治疗更有效。
