symtoms: irregular pulse, entricular rate >120bmp, no P-wave on ECG, rapid or irregular QRS
Acute or recent-onset AF (lone AF)
定義：recent-onset AF, 48小時
處置：
處置：
- Haemodynamic compromise (such as symptomatic hypotension, acute heart failure, unstable angina, loss of consciousness or shock)： Electrical direct current (DC) cardioversion＋heparin （成功率高達但一年內復發機率也高）
- Haemodynamic stable：Pharmacological cardioversion: flecainide(有CAD建議用), amiodarone(有LVH建議用) or propafenone（有心臟病不能用）
Persistent and permanent AF
Are symptomatic有症狀的
Are under 65 or 70 years of age年輕的Present with AF for the first time (ie, lone AF)第一次心房顫動的Present with AF secondary to a precipitating factor(that has been treated or corrected)心房顫動不是原發性的
Have congestive heart failure 有心衰竭的
Have congestive heart failure 有心衰竭的
一般 persistence AF會做elective DC cardioversion (在做之前必須先吃抗凝血藥4週，例如warfarin INR>2 for 4 weeks） 如果此次cardioversion失敗，在下一次預計cardioversion前先吃四週antiarrhythmic medicine (such as amiodarone or sotalol) 會提升成功機會。如果再失敗，就必須長期服用抗心律不整藥，此時beta blocker是首選。
如果beta blocker無法控制，考慮加上second line:
Amiodarone (in the presence of structural heart
disease)(increase refractory peroid)
Flecainide or sotalol (in the absence of structural heart disease)
Flecainide or sotalol (in the absence of structural heart disease)
(2)Rate control (ventricular thickness >5cm the successful chance is thin for cardioversion)
目標：60 to 80 beats/min at rest / 90 and 115 beats/min during moderate exercise （目標依年紀可調整）
NICE 建議rate control用在：
Are over 65 years of age 年紀大的
Have coronary artery disease有冠心病Have contraindications to antiarrhyth micmedicines 有藥物禁忌症
Are unsuitable for cardioversion 不適合做cardioversion
藥品有：
Have coronary artery disease有冠心病Have contraindications to antiarrhyth micmedicines 有藥物禁忌症
Are unsuitable for cardioversion 不適合做cardioversion
藥品有：
Standard beta-blockers (such as atenolol or bisoprolol)
Rate-controlling calcium channel blockers (such as verapamil or diltiazem)
Digoxin只建議用在sedentary病人or合併有心衰竭的AF
Rate-controlling calcium channel blockers (such as verapamil or diltiazem)
Digoxin只建議用在sedentary病人or合併有心衰竭的AF
Paroxysmal AF (self-limiting)
處置：
infrequent but symptomatic：pill-in-the-pocket
例如：flecainide or propafenone （使用前要排除有left-ventricular dysfunction or valve disease）
處置：
infrequent but symptomatic：pill-in-the-pocket
例如：flecainide or propafenone （使用前要排除有left-ventricular dysfunction or valve disease）
more frequent episodes
beta blocker
若控制不佳，考慮加上第二種藥：Flecainide, propafenone, setalol (保留在有CAD), amiodarone (保留在有structural heart disease ）
Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. New England Journal of Medicine 2002;347:1825–33.
beta blocker
若控制不佳，考慮加上第二種藥：Flecainide, propafenone, setalol (保留在有CAD), amiodarone (保留在有structural heart disease ）
Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. New England Journal of Medicine 2002;347:1825–33.
沒有留言:
張貼留言