Lip G Y, Zarifis J, Watson R D, Beevers D G
University Department of Medicine, City Hospital, Birmingham.
Heart. 1996 Feb;75(2):200-5. doi: 10.1136/hrt.75.2.200.
To investigate variations in the management of patients with atrial fibrillation among consultant physicians.
Questionnaire survey.
Consultant physicians in England, Wales, and Scotland.
214 consultant physicians (88 cardiologists and 126 non-cardiologists) were surveyed between May and July 1994. Most physicians (47.7%) reported that they saw one to five patients with atrial fibrillation weekly. Some 52% of cardiologists and 40% of non-cardiologists considered that the main factor influencing their decision of whether or not to anticoagulate was the clinical history--that is, heart failure, valve disease, or stroke. When encountering a patient admitted acutely with new onset atrial fibrillation, significantly more cardiologists (66% v 52%, chi 2 = 6.89, P = 0.03) would immediately start anticoagulant treatment, most favouring intravenous heparin. Most physicians would also introduce antiarrhythmic treatment or digoxin, but more cardiologists would attempt immediate pharmacological (39% v 18% of non-cardiologists, P < 0.001) or later electrical (86% v 69%, chi 2 = 11.7, P = 0.003) cardioversion to sinus rhythm, while non-cardiologists tended to prefer "rate control" with digoxin. Although many physicians would not continue antiarrhythmic treatment post-cardioversion, more cardiologists than non-cardiologists would do so (the commonest choice being class III agents) (31% v 17%, P = 0.04). Fewer non-cardiologists would continue anticoagulant treatment post-cardioversion (27% v 69% of cardiologists, chi 2 = 39.8, P < 0.0001). When treating patients with atrial fibrillation, decisions about anticoagulation were usually related to the perceived relative risk of thromboembolism versus haemorrhage derived for each of six case management scenarios in the questionnaire. There was, however, general agreement between cardiologists and non-cardiologists in the use of antithrombotic treatment in the management of lone atrial fibrillation, paroxysmal atrial fibrillation, and patients with atrial fibrillation and mitral valve disease or thyrotoxicosis.
There is considerable variation in the management of atrial fibrillation, with more cardiologists than non-cardiologists considering cardioversion to sinus rhythm (and the use of antiarrhythmic and anticoagulant treatment post-cardioversion) and thrombo-prophylaxis with anticoagulation. Guidelines on the management of this common arrhythmia are clearly required.
调查顾问医师对心房颤动患者的治疗差异。
问卷调查。
英格兰、威尔士和苏格兰的顾问医师。
1994年5月至7月间,对214名顾问医师(88名心脏病专家和126名非心脏病专家)进行了调查。大多数医师(47.7%)报告称,他们每周诊治1至5名心房颤动患者。约52%的心脏病专家和40%的非心脏病专家认为,影响他们决定是否进行抗凝治疗的主要因素是临床病史,即心力衰竭、瓣膜病或中风。当遇到新发心房颤动急性入院的患者时,明显更多的心脏病专家(66%对52%,χ² = 6.89,P = 0.03)会立即开始抗凝治疗,大多数倾向于静脉注射肝素。大多数医师也会采用抗心律失常治疗或使用地高辛,但更多的心脏病专家会尝试立即进行药物复律(39%对18%的非心脏病专家,P < 0.001)或稍后进行电复律(86%对69%,χ² = 11.7,P = 0.003)以恢复窦性心律,而非心脏病专家则倾向于用地高辛进行“心率控制”。尽管许多医师在复律后不会继续进行抗心律失常治疗,但心脏病专家比非心脏病专家更倾向于这样做(最常用的选择是Ⅲ类药物)(31%对17%,P = 0.04)。较少的非心脏病专家会在复律后继续进行抗凝治疗(27%对69%的心脏病专家,χ² = 39.8,P < 0.0001)。在治疗心房颤动患者时,关于抗凝的决定通常与问卷中六种病例管理场景各自的血栓栓塞与出血相对风险认知有关。然而,在孤立性心房颤动、阵发性心房颤动以及合并二尖瓣疾病或甲状腺毒症的心房颤动患者的抗栓治疗使用方面,心脏病专家和非心脏病专家之间存在普遍共识。
心房颤动的治疗存在相当大的差异,与非心脏病专家相比,更多的心脏病专家考虑恢复窦性心律(以及复律后使用抗心律失常和抗凝治疗)和采用抗凝进行血栓预防。显然需要制定关于这种常见心律失常治疗的指南。