Mackstaller L L, Alpert J S
University of Arizona College of Medicine, Tucson, USA.
Clin Cardiol. 1997 Jul;20(7):640-50. doi: 10.1002/clc.4960200711.
The prevalence of elderly individuals in the populations of developed countries is increasing rapidly, and atrial fibrillation (AF) is quite common in these elderly patients: currently, 11% of the U.S. population is between the ages of 65 and 85 years; 70% of people with AF are between the ages of 65 and 85 years. AF causes symptoms secondary to hemodynamic derangements that are the result of increased ventricular response and loss of atrial booster function. AF can lead to reversible impairment of left ventricular function, cardiac chamber dilatation, clinical heart failure, and thromboembolic events. AF requires treatment in order to prevent these potential complications. Type Ia, Ic, and III antiarrhythmics are capable of converting AF to normal sinus rhythm (NSR). Amiodarone has the greatest efficacy and safety for converting AF and maintaining NSR while digoxin and verapamil are ineffective in restoring NSR. Quinidine, flecainide, disopyramide, and sotalol have also been shown to maintain NSR after conversion of AF. Proarrhythmia is a definite concern with the latter four agents. Alternative therapy for AF includes anticoagulation with warfarin or aspirin for the prevention of thromboembolic events, and a variety of agents to control the ventricular response. All medications used to treat AF carry significant risks in the elderly, whether from proarrhythmia, overdosing because of compliance errors, or hemorrhage secondary to anticoagulation. Treatment of AF must be based on a careful risk-benefit evaluation. The physician must know the capability of the particular patient as well as drug mechanisms and effects in the elderly. The decision to convert patients from AF to NSR or to leave the patient in AF and control the ventricular response represents a complex intellectual challenge. Factors favoring one or the other of these two clinical strategies are discussed. Multicenter clinical trials, for example, the Atrial Fibrillation Follow-up Investigation Rhythm Management (AFFIRM) trial, are currently underway to assess various clinical strategies for maintenance of NSR following conversion from AF. Amiodarone is one of the drugs under investigation.
发达国家人口中老年人的比例正在迅速增加，心房颤动（AF）在这些老年患者中相当常见：目前，美国11%的人口年龄在65至85岁之间；70%的房颤患者年龄在65至85岁之间。房颤会导致因心室反应增加和心房辅助功能丧失而引起的血流动力学紊乱继发症状。房颤可导致左心室功能可逆性损害、心腔扩张、临床心力衰竭和血栓栓塞事件。房颤需要治疗以预防这些潜在并发症。Ia类、Ic类和III类抗心律失常药物能够将房颤转为正常窦性心律（NSR）。胺碘酮在转复房颤和维持NSR方面具有最大的疗效和安全性，而地高辛和维拉帕米在恢复NSR方面无效。奎尼丁、氟卡尼、丙吡胺和索他洛尔也已被证明在房颤转复后能维持NSR。后四种药物肯定会引起心律失常。房颤的替代治疗包括使用华法林或阿司匹林进行抗凝以预防血栓栓塞事件，以及使用多种药物控制心室反应。所有用于治疗房颤的药物在老年人中都有重大风险，无论是由于心律失常、因依从性错误导致的过量用药，还是抗凝继发的出血。房颤的治疗必须基于仔细的风险效益评估。医生必须了解特定患者的能力以及药物在老年人中的作用机制和效果。决定将患者从房颤转为NSR还是让患者维持房颤并控制心室反应是一项复杂的智力挑战。本文讨论了支持这两种临床策略中某一种的因素。例如，多中心临床试验，即房颤随访节律管理（AFFIRM）试验，目前正在进行，以评估房颤转复后维持NSR的各种临床策略。胺碘酮是正在研究的药物之一。
