SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
Am J Emerg Med. 2023 Dec;74:57-64. doi: 10.1016/j.ajem.2023.09.012. Epub 2023 Sep 18.
Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia.
This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician.
Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease - especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHADS-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions.
An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.
心房颤动（AF）可导致中风、心力衰竭和死亡。当 AF 伴快速心室率/反应（RVR）时，可导致灌注不足和心肌缺血等并发症。急诊医师在这种心律失常的诊断和管理中发挥着关键作用。
本文评估了有关伴 RVR 的 AF 的关键循证更新，以便为急诊临床医生提供参考。
区分原发性和继发性伴 RVR 的 AF 并评估血流动力学稳定性是 ED 评估和管理的重要组成部分。肌钙蛋白有助于确定不良结局的风险，但对于急性冠状动脉综合征或冠状动脉疾病风险低的患者，不需要进行普遍的肌钙蛋白检测——尤其是那些反复发生与既往事件相似的阵发性 AF 的患者。对于血流动力学不稳定的患者，应进行紧急电复律。对于血流动力学稳定的患者，应进行节律或心率控制。对于选择的患者，择期电复律是一种安全的选择，并且可以减轻 AF 症状和 AF 复发的风险。对于未进行电复律的伴 RVR 的 AF 患者，应使用β受体阻滞剂或钙通道阻滞剂来控制心率。管理中的一个重要组成部分是抗凝，并且有几种工具（例如 CHADS-VASc）可用于辅助决策。直接口服抗凝剂是抗凝的一线药物类别。处置可能具有挑战性，并且有几种风险评估工具（例如 RED-AF、AFFORD 和 AFTER（复杂、改良和实用）评分）可用于辅助处置决策。
了解关于伴 RVR 的 AF 的最新文献更新，可以帮助急诊临床医生更好地为这些患者提供护理。
