医药-心房颤动-内科讲课2017.pptVIP

导管消融患者术前、术中和术后——都应接受抗凝治疗 AF患者导管消融或手术消融成功，卒中风险高的患者，应持续进行抗凝治疗预防卒中(IIaC) 计划进行导管消融的AF患者，术中应持续服用VKA(IIaB)或NOAC(IIaC)抗凝治疗，保持有效的抗凝治疗 所有导管(IIaB)或手术(IIaC)消融术后的AF患者，均应该接受至少8周口服抗凝治疗 AF复律前，应至少抗凝治疗3周 推荐 类别 等级 AF复律患者卒中的预防 AF复律前，应尽快启动肝素或NOAC进行抗凝治疗 IIa B AF/房扑复律前，应至少抗凝治疗3周 I B 若需尽早复律，可行食管超声心动图(TOE)排除心脏血栓，代替复律前长时间的抗凝治疗 I B AF发作＜48h内，可不进行TOE，直接进行早期复律 IIa B 伴卒中风险的患者，复律后仍需要长期抗凝治疗；若患者无卒中风险，复律后抗凝治疗4周 I B TOE显示有心脏血栓，应至少抗凝治疗3周 I C 电复律前应再次进行TOE检查，确保血栓消失 IIa C 房颤治疗的目标 对房颤的全面管理应关注多个方面的影响 短期目标:改善症状 长期目标:改善预后 减少房颤负荷 预防血栓栓塞 减少致残率和心血管住院率 降低死亡率 * Dronedarone is a benzofuran derivative structurally related to amiodarone but without the iodine on the benzene ring and with a sulfonamide group added to the benzofuran ring Dronedarone was originally developed with the aim of leveraging amiodarone’s antiarrhythmic efficacy and cardiac safety but with improved organ toxicity The electrophysiological properties of dronedarone are similar to those of amiodarone and their structural differences may be responsible for the improved clinical profile of dronedarone compared to amiodarone The most significant structural changes are the removal of iodine and the addition of a methane sulfonyl group. The removal of iodine should result in freedom of amiodarone’s iodine-related organ toxicity, and the second molecular change is thought to decrease lipophilicity, thus shortening the half-life and reducing tissue accumulation A consequence of this toxicity is that amiodarone administration requires dose titration to determine the minimum effective dose, as adverse effects are often dose-related. On the other hand, due to its amended profile, dronedarone is administered as a fixed dosing regimen with no loading dose or need for titration. Reference Kathofer et al. Cardiovasc Drug Rev 2005;23(3):217-30. Wegener F et al. J Cardiovasc Electrophysiol. 2006;17(S2):S17-S20 In ANDROMEDA, more deaths were observed in the dronedarone arm compared with placebo. This imbalance in mortality rates was observed in the early cour