已阅读5页,还剩39页未读, 继续免费阅读
版权说明:本文档由用户提供并上传,收益归属内容提供方,若内容存在侵权,请进行举报或认领
文档简介
Cardioversion of Atrial Fibrillation Clinical Issues,Christopher Granger, MD Director, Cardiac Care Unit Duke University Medical Center December 2007,Cardioversion of Atrial Fibrillation Clinical Issues,When and why cardiovert? Why not wait for spontaneous cardioversion? When and why acutely cardiovert? How to acutely cardiovert Electrical Pharmacologic Both,AFFIRM Baseline Characteristics,Age = 69.7 9.0 yrs 39% female 2 days of AF in 69% CHF class II in 9% Symptomatic AF in 88%,Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) Trial (n=522),Van Gelder, I. et al. N Engl J Med 2002;347:1834-1840,CV death, HF, thromboembolic complications, bleeding, pacemaker, and SAEs.,Trials of Rate vs Rhythm Control,ACC/AHA/ESC Guidelines 2006,Implications of Trials: Guideline Statement,Theoretically, rhythm control should have advantages over rate control, yet a trend toward lower mortality was observed in the rate-control arm of the AFFIRM study and did not differ in the other trials from the outcome with the rhythm control strategy. This might suggest that attempts to restore sinus rhythm with presently available antiarrhythmic drugs are obsolete. The RACE and AFFIRM trials did not address AF in younger, symptomatic patients with little underlying heart disease, in whom restoration of sinus rhythm by cardioversion antiarrhythmic drugs or non-pharmacological interventions still must be considered a useful therapeutic approach. One may conclude from these studies that rate control is a reasonable strategy in elderly patients with minimal symptoms related to AF. An effective method for maintaining sinus rhythm with fewer side effects would address a presently unmet need.,ACC/AHA/ESC Guidelines 2006,Results No difference in primary endpoint of CV death between groups (Figure) Cardioversion 39% vs 8% Also no difference in total mortality (31.8% vs. 32.9%, p = 0.73), stroke (2.6% vs. 3.6%, p = 0.32), worsening heart failure (27.6% vs. 30.8%, p = 0.17), or composite (42.7% vs. 45.8%, p = 0.20) Higher hospitalization rates (46% vs 39% p=.006) and cost with rhythm control Bradyarrhythmias in rhythm control group Conclusions Among patients with heart failure and atrial fibrillation, use of rhythm control was not associated with differences in CV mortality compared with rate control Results were similar to AFFIRM trial, which also showed no impact on mortality with rhythm control vs. rate control for management of atrial fibrillation,AF-CHF,%,Trial Design: AF-CHF was a randomized trial of rhythm control (n = 682) vs. rate control (n = 694) in patients with heart failure and atrial fibrillation. Rhythm control included use of electrical cardioversion combined with antiarrhythmic drugs, including amiodarone as first-line therapy. Primary endpoint was CV death, with mean follow-up of 3 years.,Rhythm Control,Rate Control,CV Death (HR 1.06, p = 0.59),Bradyarrhythmia (p = 0.007),Presented at AHA Roy 2007,When and Why Acutely Cardiovert?,AF Begets AF,AF causes changes in atrial electrophysiology that promote AF maintenance,Wijffels Circulation 1995; 92: 1954-68,Lip GY Lancet 2007;370:604-18,Lip GY Lancet 2007; 370:604-18,Paroxysmal AF 48 hours (n=100) Amiodarone IV (3 gm) vs IV placebo,Cotter EHJ 1999; 20:1833-42,Paroxysmal AF 1 week (n=100) Amiodarone IV (1.2 gm) vs placebo,Galve JACC 1996;27:1079-82,30/50 (60%) placebo patients converted,32/50 (64%) placebo patients converted,High Rates of Spontaneous Cardioversion for Recent-onset AF,Likelihood of Spontaneous Conversion of Atrial Fibrillation to Sinus Rhythm,Danias J Am Coll Cardiol. 1998;31:588-92,356 pts with AF 72 h Symptoms of 24 h was only independent predictor of spontaneous conversion (OR: 1.8, p 0.0001), 24 h 24 - 72 h Total,292 64 356,73% 45% 68%,AF duration,n,Conversion,How often does spontaneous conversion occur over 8 weeks?,Klein A et al. N Engl J Med 2001;344:1411-1420,Klein A et al. N Engl J Med 2001;344:1411-1420,Clinical Outcomes at 8 Weeks among Patients with Atrial Fibrillation of More Than 2 Days Duration,Spontaneous Conversion of Patients with AF Scheduled for Electrical Cardioversion An ACUTE Trial Ancillary Study,Tejan-Sie J Am Coll Cardiol 2007;42:1638-1643,Conversion According to Duration of Pre-existing AF,Daily Conversion According to Strategy,Spontaneous Conversion of Patients with AF Scheduled for Electrical Cardioversion An ACUTE Trial Ancillary Study,Tejan-Sie J Am Coll Cardiol 2007;42:1638-1643,Multivariable Model Predicting Spontaneous Conversion,Conversion of Recent-Onset AF to Sinus Rhythm: Effects of Different Drug Protocols,Mean conversion time: Flecainide: 2.6 hrs Propafenone: 3.0 hrs,Conversion rates to sinus rhythm (%),* p 0.05 vs placebo * p 0.01 vs placebo,Boriani Pacing Clin Electrophysiol. 1998;21(11 Pt 2):2470-4,*,*,417 hospitalized pts with AF onset 7 days,Cardioversion of atrial flutter and fibrillation after ibutilide infusion (67 y/o, 15 days duration, half with prior episode),Stambler Circulation. 1996;94:1613-1621,Predictors of Cardioversion with Ibutilide 201 patients treated,Zaqqa AJC 2000,Saliba J Am Coll Cardiol 1999;34:2031-34,Biphasic shock Refractory to standard cardioversion (failed 2 attempts) 3 month in 55% SR in 46 (84%) of the 55 pts,Oral NEJM 1999;340:1849-54,100 consecutive patients 50 assigned conventional DC 50 pretreated with 1 mg ibutilide,Cardioversion success (%),How often does spontaneous conversion occur after months of AF?,AF 7 to 360 days duration (110 average) CHF, recent MI, bradycardia excluded,Lancet. 2000;356:1789-94,Rhythm or rate control in atrial fibrillation: Pharmacological Intervention in Atrial Fibrillation (PIAF) Trial,Lancet. 2000;356:1789-94,Amiodarone group: 23% converted during amio load 76% had electrical cardioversion,Primary outcome: no difference,665 patients, 68 y/o Persistent AF, 76% 1yr On warfarin,Spontaneous Conversion 28 Days,N Engl J Med 2005;352:1861-72,Electrical More effective (90%) Quick One procedure with TEE Cardioversion itself safe,Pharmacological Works well for recent onset, for atrial flutter Avoid sedation Less expensive Early maintenance enhanced by some drugs,Advantages and Disadvantages,What do the Guidelines Say?,Fuster V, Rydn LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College
温馨提示
- 1. 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等,如果需要附件,请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸,网页内容里面会有图纸预览,若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间,仅对用户上传内容的表现方式做保护处理,对用户上传分享的文档内容本身不做任何修改或编辑,并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容,请与我们联系,我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
最新文档
- 音准仪校准规范
- 安全教育活动小班教案7篇
- 项目经理岗位说明书
- 云南省曲靖市大同中学2022年高一数学文模拟试题含解析
- 蜘蛛开店课件
- 《他们那时候多有趣啊》课件
- 浙江省杭州市西湖区两校2023-2024学年八年级上学期期中语文试题(含答案解析)
- 我们家的男子汉-课件
- 语文六年级(上)23《月光曲》学生预学案设计
- 环保应急预案
- 高考模拟卷(四)-备战2024年高考地理阶段性模拟仿真冲刺卷(浙江专用)(原卷版)
- 工厂虫害分析报告
- 中小学校2022年思政课程建设实施方案
- 互联网金融企业风险分析与控制-以蚂蚁金服为例
- 新闻采编业务培训课件模板
- 复兴之路教学课件
- 语言活动:魔法妈妈
- 2024年山东东营市光明电力服务有限责任公司招聘笔试参考题库附带答案详解
- 高中主题班会-民族文化自信-中华民族共同体意识的形成与铸牢课件
- 医保慢病管理实施方案
- 通辽客运从业资格证试题
评论
0/150
提交评论