Antiarrhythmic Drug Therapy——Professor Yanyan Yang’s Interpretation of the Latest Chinese Atrial Fibrillation Guide

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Atrial fibrillation (atrial fibrillation) is a high-frequency disease. The guidelines emphasize the overall management of AF, including ventricular rate and rhythm control, anticoagulation therapy, radiofrequency ablation, and lifestyle interventions.Professor Yang Yanmin from the National Cardiovascular Center and Fuwai Hospital of the Chinese Academy of Medical Sciences explained the antiarrhythmic drug treatment section in Atrial Fibrillation: Current Knowledge and Treatment Recommendations (2018).Atrial Fibrillation Rhythm vs Ventricular Rate Control 1. Location of Rhythmic Control Numerous clinical trials have shown that there is no significant difference between ventricular rate control or rhythmic control in terms of cardiovascular endpoint events.The 2016 ESC Atrial Fibrillation Management Guidelines state that to date, all subjects with joint rhythm control have had a neutral outcome in terms of endpoint events.At present, the indication for rhythm control is to improve symptoms in patients who still have symptoms after ventricular rate control.2. Drug maintenance sinus rhythm strategy re-examines randomized clinical trials with patient selection bias, such as including only patients who are willing to treat, including more patients who fail to maintain sinus rhythm.Moreover, the follow-up time of randomized clinical trials was short, and some studies have shown that the rhythm control group did not show clinical benefits until the fifth year.In addition, anti-arrhythmic drugs (AAD) successfully maintained a low percentage of sinus rhythm, and maintaining sinus rhythm to improve clinical outcomes was diluted by the toxic side effects of AAD.If patients can maintain sinus rhythm, clinical outcomes can be improved.Therefore, the reason why the strategy of maintaining sinus rhythm does not show its advantage lies in the lack of a truly safe and effective rhythm control strategy.3. Atrial fibrillation catheter ablation and AAD (CABANA) research. Catheter ablation therapy for AF has made rapid progress. The results of some small-scale clinical trials such as CACAF, RAAFT, APAF, and 4A have shown that catheter ablation has been significantly reduced compared with traditional drug treatment.The possibility of AF recurrence.However, there is a lack of large-scale clinical evidence on the effects of catheter ablation on survival and stroke, quality of life, and medical costs.The CABANA Study is a multicenter, prospective, randomized, open-label clinical study initiated by the National Institutes of Health (NIH) to compare the long-term effects of catheter ablation and AAD treatment on AF mortality, stroke, quality of life, and medical costs.Period influence.From November 2009 to April 2016, 2204 patients with paroxysmal or persistent atrial fibrillation were enrolled. They were randomly divided into groups of 1: 1 for ablation or medication (ventricular rate or rhythm control), with an average follow-up of 48 months.The results showed that the radiofrequency ablation group was not better than drug treatment in reducing the composite endpoint, but the results of ITT analysis showed that catheter ablation was superior to drug treatment.In maintaining sinus rhythm, catheter ablation is more effective than medication.4. Can rhythm control reduce cardiovascular events?The 2018 American Heart Association (AHA) published a scientific statement on AF load stressing that the description of atrial fibrillation with or without atrial fibrillation is too unilateral, and that the impact of AF load on clinical outcomes should be emphasized.Although we do not yet have conclusive evidence that maintaining sinus rhythm reduces stroke risk and mortality, rhythm control is still used for symptomatic atrial fibrillation.However, ongoing research intends to find further evidence.The EAST-AFNET 4 study has enrolled more than 2500 patients to evaluate whether early, comprehensive rhythm control with AAD or catheter ablation can reduce adverse cardiovascular events compared to conventional treatment.Atrial Fibrillation Rhythm Control 1. ESC Guidelines for Atrial Fibrillation 2010 • Symptoms cannot be tolerated through ventricular rate control, EHRA ≥ 2 points (I, B) • Atrial fibrillation-related heart failure, to improve symptoms (IIa, B) • SymptomsYoung patients, do not rule out the possibility of catheter ablation, choose rhythmic control as the initial treatment (IIa, C)? AF is secondary to basic diseases such as ischemia and hyperthyroidism, these factors have been corrected, rhythmic control can be considered (IIa, C) 2. 2014 AHA / ACC / HRS Guidelines for Atrial Fibrillation? Persistent symptoms associated with AF are the strongest indications of rhythm control? Difficulties in heart rate control? Young patients? Tachycardia cardiomyopathy? First episode of atrial fibrillation? Patient willingness 3. AtrialFibrillation: Current Understanding and Recommendations for Treatment-2018 The methods for the conversion of AF to sinus rhythm include autocardia, pharmacological, electrical, and catheter ablation.For hemodynamically stable patients with newly developed atrial fibrillation (usually within 1 week of atrial fibrillation), cardioversion may precede cardioversion.Drugs have a 50% effective rate for renewed atrial fibrillation, but less effective for persistent atrial fibrillation.For atrial fibrillation with severe hemodynamic disorders, cardioversion is the preferred method.Recommendations for pharmacological cardioversion: Class I: ① For patients without a history of ischemic or structural heart disease, flukanib and propafenone are recommended as cardioversion drugs for atrial fibrillation (level of evidence A); ② ischemic and /Or patients with structural heart disease, amiodarone is recommended as a cardioversion agent for AF (evidence level A).Class Ⅱa: ① In patients without a history of ischemic or structural heart disease, iblitide is recommended as a cardioversion drug for atrial fibrillation (level of evidence B); ② selected recent episodes of atrial fibrillation and no obvious structuralPatients with ischemic heart disease or after a safety evaluation may consider a single oral flukanib or propafenone (“pocket” method) for patient self-retroversion (level of evidence B).Class Ⅱb: Wienakaran is used in patients with mild heart failure (cardiac function class Ⅰ or Ⅱ), coronary heart disease, left ventricular hypertrophy and atrial fibrillation (evidence level B).Class III: ① Digoxin and Sotalol are used for cardioversion (level of evidence A); ② Out-of-hospital quinidine, procainamide, and propiramine are used for pharmacology (level of evidence B); ③Dofetilide is used outside the hospital (level of evidence B).Anticoagulant therapy before and after cardioversion is recommended: Category Ⅰ: ① For patients with AF or atrial flutter that last for ≥48 hours or for unknown time, warfarin should be applied at least 3 weeks before cardioversion and 4 weeks after cardioversion (INR 2.0 ~ 3.0)Or NOAC anticoagulation (level of evidence B); ② For patients with atrial fibrillation or atrial flutter for ≥ 48 h or unknown time with hemodynamic instability, immediate cardioversion is required, and anticoagulation should be started as soon as possible. Heparin or lowMolecular Heparin (Level of Evidence C); ③ Whether all patients with AF require long-term anticoagulation after cardioversion depends on the assessment of the risk of thromboembolism (Level of Evidence C); ④ When early reversion is planned, TEE should be performedIf the thrombus in the heart is ruled out, cardioversion can be performed in advance (evidence level B); ⑤ Patients with thrombus detected by TEE should effectively anticoagulate for at least 3 weeks (evidence level C).Class Ⅱa: ① Heparin or NOAC anticoagulation should be started as soon as possible before each atrial fibrillation or atrial fibrillation (evidence level B); ② Patients who have confirmed that AF persists for <48 h can be directly reinstated without TEELaw (level of evidence B).Atrial Fibrillation Ventricular Rate Control Ventricular rate control is currently the main strategy for the management of AF and is one of the basic goals of AF treatment. It can usually significantly improve the symptoms associated with AF.Clinicians should choose a treatment strategy based on the patient's underlying disease, general conditions, and patient wishes.Atrial fibrillation ventricular rate control includes acute ventricular rate control and long-term ventricular rate control.For patients with atrial fibrillation requiring acute ventricular rate control, the cause of the increased ventricular rate should be evaluated, and appropriate drugs should be selected based on the clinical characteristics, symptoms, LVEF and hemodynamic characteristics of the patient.Long-term ventricular rate control methods include long-term oral medication to control ventricular rate and atrioventricular node ablation + permanent pacemaker implantation.Beta blockers can be used as a first-line treatment for all patients with AF.Non-dihydropyridine calcium antagonists have a negative inotropic effect and should be avoided in patients with left ventricular systolic dysfunction and decompensated heart failure.Amiodarone has many potential organ toxicity and drug interactions, which limits its long-term application value in ventricular rate control. It is only used as an alternative drug when other drugs are used to control ventricular rate.In conclusion, Professor Yang Yanmin pointed out: Atrial fibrillation rhythm control and ventricular rate control still need to be individualized; reducing the burden of atrial fibrillation and reducing adverse cardiovascular events have already begun to emerge; although the overall status of antiarrhythmic drugs is not high, it is still impossibleInadequate adjuvant therapy; In addition, some new target drugs are worth looking forward to.The above content is only authorized by for exclusive use, please do not reprint without authorization of the copyright party..


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