房颤治疗策略.pptVIP

Treating Atrial FibrillationRichard Schilling AF burden Framingham Lifetime risk of developing AF = 25% Mortality: SMR =1.9 ♀ 1.5 ♂ NHS audit 1% of budget spent on AF - € 688, 000, 000 in 2000 ↓↓Quality of life Symptoms of AF Side effects of medication ATRIAL FIBRILLATIONIncidence Nice guidance for management of AF Issued on June 2006 Aimed to give a UK based simple guidance on management of AF Attempts to be evidence based And applicable to the majority of patients Key aims of management Diagnosis - everyone with irregular pulse gets ECG Identify secondary causes (thyroid, hypertension, valve disease) Treatment Stroke prevention Rate control Rhythm control where appropriate Diagnosis AF can only be diagnosed on an ECG recorded during symptoms/signs Even asymptomatic patients should have an ECG Consider 24 hour to 7 day Holter if intermittent (depending on frequency) Or ask patient to attend A+E during symptoms and get a copy of ECG Investigation TFT Echo If young If rhythm control strategy If unsure of stroke risk If structural heart disease suspected Stroke prevention Rate control vs rhythm control RACE Mortality 22.6% vs 17.2% 39% vs 10% in SR AFFIRM Mortality 23.8% vs 21.3 % ↑ hospitalisation ↑ Side effects SR has a prognostic benefit Rhythm control - problem Cardioversion and drugs maintains SR in 42% at one year (amiodarone) Side effects require stopping amiodarone in 25% Anticoagulation stopped too early Treatment decision tree Advantages of Warfarin over Aspirin Advantages of Warfarin over Aspirin rhythm vs rate control Persistent AF rate control Rhythm control Rate control vs Rhythm control AF is dangerous SR is better and confers mortality benefit Conventional therapies are poor at maintaining SR The population is aging What specialist treatments are available? Antiarrhythmic drugs Pacemaker Catheter ablation Surgical ablation AV node ablation and pacing AV node ablation and pacing “hides” the AF Easy to perform (99%) success No atrial transpor