Lévy S, Ricard P, Yapo F, Mansouri C
Service de cardiologie, hôpital Nord, Marseille.
Arch Mal Coeur Vaiss. 1996 Feb;89 Spec No 1:19-24.
Atrial fibrillation (AF), carries a serious risk of systemic embolic complications, especially cerebral. Antiarrhythmic therapy is the most used method for restoring or maintaining sinus rhythm, and for preventing recurrences or of controlling the ventricular response. A clinical classification was recently suggested to define when to use antiarrhythmic drugs. In a first episode of symptomatic AF (Class I), it is not possible to assess the chances of recurrence and preventive antiarrhythmic therapy would not seem justified. In recurrent paroxysmal AF, the arrhythmias may be asymptomatic (Class IIa) and antiarrhythmic therapy may be questionned. When the attacks are infrequent (< 1 every 3 months, Class IIb), episodic pharmacological intervention to restore sinus rhythm or to slow the ventricular rate may be valuable, but the efficacy and safety of such treatment should be assessed. In Class IIc, appropriate antiarrhythmic treatment to prevent recurrence is often indicated. Atrial fibrillation resistant to one or more antiarrhythmic drugs (Class III) may also be subdivised into three subgroups as for Class II. In addition to the use of alternating of antiarrhythmic drugs not previously used, it is justifiable to consider investigations to determine the mechanism of resistant AF use only drugs of the which slow the ventricular rate. The choice of antiarrhythmic drug may be guided by the concepts of the Silician Gambit, taking into consideration the mechanism of AF and the therapeutic objective. In AF, the mechanism is reentry, the vulnerable parameter the atrial refractory period. To increase the refractory period, the target should be the sodium or potassium currents. The status of left ventricular function is an important parameter in the choice of an antiarrhythmic agent.
心房颤动（AF）具有发生全身性栓塞并发症尤其是脑栓塞的严重风险。抗心律失常治疗是恢复或维持窦性心律、预防复发或控制心室率最常用的方法。最近有人提出一种临床分类方法来确定何时使用抗心律失常药物。在症状性房颤的首发 episode（I 类）中，无法评估复发几率，预防性抗心律失常治疗似乎不合理。在复发性阵发性房颤中，心律失常可能无症状（IIa 类），抗心律失常治疗可能存在疑问。当发作不频繁（每 3 个月少于 1 次，IIb 类）时，恢复窦性心律或减慢心室率的间歇性药物干预可能有价值，但应评估此类治疗的疗效和安全性。在 IIc 类中，通常需要进行适当的抗心律失常治疗以预防复发。对一种或多种抗心律失常药物耐药的心房颤动（III 类）也可像 II 类一样细分为三个亚组。除了交替使用以前未使用过的抗心律失常药物外，考虑进行检查以确定耐药性房颤的机制并仅使用减慢心室率的药物是合理的。抗心律失常药物的选择可根据西西里策略的概念来指导，同时考虑房颤的机制和治疗目标。在房颤中，机制是折返，易损参数是心房不应期。为了延长不应期，目标应该是钠电流或钾电流。左心室功能状态是选择抗心律失常药物的一个重要参数。
