2011最新ACCFAHA_房颤的治疗指南英文版.pdf

issn: 1524-4539 copyright 2011 american heart association. all rights reserved. print issn: 0009-7322. online 72514 circulation is published by the american heart association. 7272 greenville avenue, dallas, tx doi: 10.1161/cir.0b013e318214876d 2011;123;e269-e367; originally published online mar 7, 2011; circulation wann, sidney c. smith, jr and silvia g. priori james e. lowe, s. bertil olsson, eric n. prystowsky, juan luis tamargo, l. samuel kenneth a. ellenbogen, jonathan l. halperin, g. neal kay, jean-yves le huezey, valentin fuster, lars e. rydn, davis s. cannom, harry j. crijns, anne b. curtis, association task force on practice guidelines report of the american college of cardiology foundation/american heart 2006 guidelines for the management of patients with atrial fibrillation: a 2011 accf/aha/hrs focused updates incorporated into the acc/aha/esc /cgi/content/full/123/10/e269 located on the world wide web at: the online version of this article, along with updated information and services, is /reprints reprints: information about reprints can be found online at 410-528-8550. e-mail: fax:kluwer health, 351 west camden street, baltimore, md 21202-2436. phone: 410-528-4050. permissions: permissions 123:104123; doi:10.1161/cir.0b013e3181fa3cf4) and the “2011 accf/aha/hrs focused update on the management of patients with atrial fibrillation (update on dabigatran)” (circulation. 2011;123:11611167; doi:10.1161/cir.0b013e31820f14c0). updated sections are indicated in the table of contents and text. 2011 accf/aha/hrs focused updates incorporated into the acc/aha/esc 2006 guidelines for the management of patients with atrial fibrillation a report of the american college of cardiology foundation/american heart association task force on practice guidelines 2006 writing committee members developed in partnership with the european society of cardiology and in collaboration with the european heart rhythm association and the heart rhythm society valentin fuster, md, phd, facc, faha, fesc, co-chair; lars e. ryde n, md, phd, facc, faha, fesc, co-chair; davis s. cannom, md, facc; harry j. crijns, md, facc, fesc*; anne b. curtis, md, facc, faha; kenneth a. ellenbogen, md, facc; jonathan l. halperin, md, facc, faha; g. neal kay, md, facc; jean-yves le huezey, md, fesc; james e. lowe, md, facc; s. bertil olsson, md, phd, fesc; eric n. prystowsky, md, facc; juan luis tamargo, md, fesc; l. samuel wann, md, macc, faha, fesc 2011 writing group members developed in partnership with the heart rhythm society l. samuel wann, md, macc, faha, chair; anne b. curtis, md, facc, faha; kenneth a. ellenbogen, md, facc, fhrs; n.a. mark estes iii, md, facc, fhrs?; michael d. ezekowitz, mb, chb, facc; warren m. jackman, md, facc, fhrs; craig t. january, md, phd, facc; james e. lowe, md, facc; richard l. page, md, facc, fhrs; david j. slotwiner, md, facc; william g. stevenson, md, facc, faha; cynthia m. tracy, md, facc *european heart rhythm association representative. heart rhythm society representative. accf/aha representative. recused from 2011 update section , recommendations for dronedarone. ?accf/aha task force on performance measures representative. accf/aha task force on practice guidelines liaison. #former task force member during this writing effort. the 2011 focused updates to this document were approved by the leadership of the american college of cardiology foundation, american heart association, and the heart rhythm society, and the sections that have been updated are indicated with hyperlinks to the focused updates where applicable. the american heart association requests that this document be cited as follows: fuster v, ryde n le, cannom ds, crijns hj, curtis ab, ellenbogen ka, halperin jl, kay gn, le heuzey j-y, lowe je, olsson sb, prystowsky en, tamargo jl, wann ls. 2011 accf/aha/hrs focused updates incorporated into the acc/aha/esc 2006 guidelines for the management of patients with atrial fibrillation: a report of the american college of cardiology foundation/american heart association task force on practice guidelines. circulation. 2011;123:e269e367. this article has been copublished in the journal of the american college of cardiology. copies: this document is available on the world wide web sites of the american college of cardiology () and the american heart association (). a copy of the document is also available at /presenter.jhtml?identifier?3003999 by selecting either the “topic list” link or the “chronological list” link. to purchase additional reprints, call 843-216-2533 or e-mail . expert peer review of aha scientific statements is conducted at the aha national center. for more on aha statements and guidelines development, visit /presenter.jhtml?identifier?3023366. permissions: multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the american heart association. instructions for obtaining permission are located at /presenter.jhtml?identifier? 4431. a link to the “permission request form” appears on the right side of the page. (circulation. 2011;123:e269e367.) 2011 by the american college of cardiology foundation, the american heart association, inc., and the european society of cardiology. circulation is available at doi: 10.1161/cir.0b013e318214876d e269 at novartis global on may 16, 2011 downloaded from accf/aha task force members alice k. jacobs, md, facc, faha, chair; jeffrey l. anderson, md, facc, faha, chair-elect; nancy albert, phd, ccns, ccrn; christopher e. buller, md, facc#; mark a. creager, md, facc, faha; steven m. ettinger, md, facc; robert a. guyton, md, facc; jonathan l. halperin, md, facc, faha; judith s. hochman, md, facc, faha; frederick g. kushner, md, facc, faha; erik magnus ohman, md, facc; william g. stevenson, md, facc, faha; lynn g. tarkington, rn#; clyde w. yancy, md, facc, faha table of contents preamble (updated) . . . . . . . . . . . . . . . . . . . . . . . . .e273 1. introduction (updated) . . . . . . . . . . . . . . . . . . .e274 1.1. organization of committee and evidence review (updated) . . . . . . . . . . . . . . . . . . .e274 1.2. contents of these guidelines . . . . . . . . . . . . .e274 1.3. changes since the initial publication of these guidelines in 2001 . . . . . . . . . . . . . . . .e275 2. definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e276 2.1. atrial fibrillation . . . . . . . . . . . . . . . . . . . . . .e276 2.2. related arrhythmias. . . . . . . . . . . . . . . . . . .e276 3. classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e277 4. epidemiology and prognosis . . . . . . . . . . . . . . . . .e278 4.1. prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . .e278 4.2. incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . .e278 4.3. prognosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . .e279 5. pathophysiological mechanisms . . . . . . . . . . . . . .e280 5.1. atrial factors . . . . . . . . . . . . . . . . . . . . . . . . .e280 5.1.1. atrial pathology as a cause of atrial fibrillation . . . . . . . . . . . . . . . . .e280 . pathological changes caused by atrial fibrillation. . . . . . . . . . . . . . . .e281 5.1.2. mechanisms of atrial fibrillation . . . .e281 . automatic focus theory. . . . . . .e281 . multiple-wavelet hypothesis. . . . . . . . . . . . . . . . .e282 5.1.3. atrial electrical remodeling . . . . . . . .e282 5.1.4. counteracting atrial electrical remodeling . . . . . . . . . . . . . . . . . . . . .e283 5.1.5. other factors contributing to atrial fibrillation . . . . . . . . . . . . . . . . .e284 5.2. atrioventricular conduction . . . . . . . . . . . . . .e284 5.2.1. general aspects . . . . . . . . . . . . . . . . . .e284 5.2.2. atrioventricular conduction in patients with preexcitation syndromes . . . . . . . . . . . . . . . . . . . . . .e284 5.3. myocardial and hemodynamic consequences of atrial fibrillation . . . . . . . .e285 5.4. thromboembolism. . . . . . . . . . . . . . . . . . . . . .e285 5.4.1. pathophysiology of thrombus formation. . . . . . . . . . . . . . . . . . . . . . .e285 5.4.2. clinical implications . . . . . . . . . . . . . .e286 6. causes, associated conditions, clinical manifestations, and quality of life . . . . . . . . . . . .e287 6.1. causes and associated conditions . . . . . . . . .e287 6.1.1. reversible causes of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . .e287 6.1.2. atrial fibrillation without associated heart disease. . . . . . . . . .e287 6.1.3. medical conditions associated with atrial fibrillation . . . . . . . . . . . . . . . . .e287 6.1.4. atrial fibrillation with associated heart disease. . . . . . . . . . . . . . . . . . .e287 6.1.5. familial (genetic) atrial fibrillation . . . . . . . . . . . . . . . . . . . . . .e287 6.1.6. autonomic influences in atrial fibrillation . . . . . . . . . . . . . . . . .e287 6.2. clinical manifestations . . . . . . . . . . . . . . . . . .e288 6.3. quality of life . . . . . . . . . . . . . . . . . . . . . . . .e288 7. clinical evaluation . . . . . . . . . . . . . . . . . . . . . . . .e288 7.1. basic evaluation of the patient with atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . .e288 7.1.1. clinical history and physical examination. . . . . . . . . . . . . . . . . . . . . .e288 7.1.2. investigations. . . . . . . . . . . . . . . . . . .e289 7.2. additional investigation of selected patients with atrial fibrillation . . . . . . . . . . .e289 7.2.1. electrocardiogram monitoring and exercise testing . . . . . . . . . . . . . . . . .e289 7.2.2. transesophageal echocardiography . . . .e289 7.2.3. electrophysiological study . . . . . . . . .e291 8. management (updated) . . . . . . . . . . . . . . . . . . .e291 8.1. pharmacological and nonpharmacological therapeutic options . . . . . . . . . . . . . . . . . . . .e292 8.1.1. pharmacological therapy. . . . . . . . . .e292 . drugs modulating the renin-angiotensin- aldosterone system. . . . . . . . .e292 . hmg coa-reductase inhibitors (statins). . . . . . . . . .e292 8.1.2. heart rate control versus rhythm control . . . . . . . . . . . . . . . . . . . . . . . .e292 . distinguishing short-term and long-term treatment goals . . . . . . . . . . .e292 e270circulationmarch 15, 2011 at novartis global on may 16, 2011 downloaded from . clinical trials comparing rate control and rhythm control . . . . . . . . . . . . . . . . . .e292 . effect on symptoms and quality of life . . . . . . . . . . . .e294 . effects on heart failure . . . . .e294 . effects on thromboembolic complications . . . . . . . . . . . . .e294 . effects on mortality and hospitalization. . . . . . . . . . . . .e294 . implications of the rhythm- control versus rate- control studies . . . . . . . . . . . .e295 8.1.3. rate control during atrial fibrillation (updated) . . . . . . . . . . .e295 . pharmacological rate control during atrial fibrillation. . . . . . . . . . . . . . . .e295 .1. beta blockers . . . . .e296 .2. nondihydropyridine calcium channel antagonists . . . . . . .e298 .3. digoxin . . . . . . . . . .e298 .4. antiarrhythmic agents. . . . . . . . . . .e298 .5. combination therapy. . . . . . . . . .e298 .6. special considerations in patients with the wolff-parkinson- white (wpw) syndrome . . . . . . . .e299 . pharmacological therapy to control heart rate in patients with both atrial fibrillation and atrial flutter . . . . . . . . . . . . . . . . . . .e299 . regulation of atrioventricular nodal conduction by pacing . . . . . . .e299 . av nodal ablation . . . . . . . . .e299 8.1.4. preventing thromboembolism . . . . . . .e300 . risk stratification . . . . . . . . . .e301 .1. epidemiological data. . . . . . . . . . . . .e301 .2. echocardiography and risk stratification . . . . . .e302 .3. therapeutic implications. . . . . . .e303 . antithrombotic strategies for prevention of ischemic stroke and systemic embolism . . . . . . . . . . . . . . . .e304 .1. anticoagulation with vitamin k antagonist agents. . . . . . . . . . .e305 .2. aspirin for antithrombotic therapy in patients with atrial fibrillation. . . . . . . .e306 .3. other antiplatelet agents for antithrombotic therapy in patients with atrial fibrillation. . . . . . . .e307 .4. combining anticoagulant and platelet-inhibitor therapy (updated) . . . . . .e308 .5. emerging and investigational antithrombotic agents (updated) . . . . . .e310 .6. interruption of anticoagulation for diagnostic or therapeutic procedures. . . . . . . .e310 . nonpharmacological approaches to prevention of thromboembolism (updated) . . . . . . . . . . . . . .e311 8.1.5. cardioversion of atrial fibrillation . . . .e311 . basis for cardioversion of atrial fibrillation. . . . . . . . . . .e311 . methods of cardioversion . . . .e311 . pharmacological cardioversion . . . . . . . . . . . . .e311 . agents with proven efficacy for cardioversion of atrial fibrillation . . . . . . . .e313 .1. amiodarone. . . . . . .e313 .2. dofetilide . . . . . . . .e315 .3. flecainide . . . . . . . .e315 .4. ibutilide. . . . . . . . . .e316 .5. propafenone. . . . . . .e316 . less effective or incompletely studied agents fuster et alacc/aha/esc practice guidelinese271 at novartis global on may 16, 2011 downloaded from for cardioversion of atrial fibrillation. . . . . . . . . . .e316 .1. quinidine. . . . . . . . .e316 .2. procainamide. . . . . .e316 .3. beta blockers . . . . .e317 .4. nondihydropyridine calcium channel antagonists (verapamil and diltiazem) . . . . . . . .e317 .5. digoxin . . . . . . . . . .e317 .6. disopyramide . . . . .e317 .7. sotalol. . . . . . . . . . .e317 8.1.6. pharmacological agents to maintain sinus rhythm . . . . . . . . . . . . . . . . . . .e317 . agents with proven efficacy to maintain sinus rhythm . . . . . . . . . . . . . . . . . .e317 .1. amiodarone. . . . . . .e317 .2. beta blockers . . . . .e318 .3. dofetilide . . . . . . . .e318 .4. disopyramide . . . . .e319 .5. flecainide . . . . . . . .e319 .6. propafenone. . . . . . .e319 .7. sotalol. . . . . . . . . . .e319 . drugs with unproven efficacy or no longer recommended. . . . . . . . . . . . .e320 .1. digoxin . . . . . . . . . .e320 .2. procainamide. . . . . .e320 .3. quinidine. . . . . . . . .e320 .4. verapamil and diltiazem . . . . . . . .e320 8.1.7. out-of-hospital initiation of antiarrhythmic drugs in patients with atrial fibrillation . . . . . . . . . . . .e320 8.1.8. drugs under development . . . . . . . . . .e322 . atrioselective agents. . . . . . . .e323 . nonselective ion channel blocking drugs . . . . . . . . . . . .e323 . recommendations for dronedarone for the prevention of recurrent atrial fibrillation (new section) . . . . . . . . . .e323 8.2. direct-current cardioversion of atrial fibrillation and flutter . . . . . . . . . . . . . . . . . .e323 8.2.1. terminology . . . . . . . . . . . . . . . . . . . .e323 8.2.2. technical aspects . . . . . . . . . . . . . . . .e324 8.2.3. procedural aspects . . . . . . . . . . . . . . .e324 8.2.4. direct-current cardioversion in patients with implanted pacemakers and defibrillators . . . . . . . . . . . . . . . . .e325 8.2.5. risks and complications of direct- current cardioversion of atrial fibrillation . . . . . . . . . . . . . . . . . . . . . .e325 8.2.6. pharmacological enhancement of direct-current cardioversion . . . . . . . .e325 . amiodarone. . . . . . . . . . . . . . .e326 . beta-adrenergic antagonists . . . . . . . . . . . . . . .e326 . nondihydropyridine calcium channel antagonists . . . . . . . . . . . . . . .e326 . quinidine. . . . . . . . . . . . . . . . .e326 . type ic antiarrhythmic agents . . . . . . . . . . . . . . . . . . .e327 . type iii antiarrhythmic agents . . . . . . . . . . . . . . . . . . .e327 8.2.7. prevention of thromboembolism in patients with atrial fibrillation undergoing cardioversion . . . . . . . . . .e327 8.3. maintenance of sinus rhythm . . . . . . . . . . . .e328 8.3.1. pharmacological therapy (updated) . . . . . . . . . . . . . . . . . . . .e329 . goals of treatment . . . . . . . . .e329 . endpoints in antiarrhythmic drug studies . . . . . . . . . . . . . .e329 . predictors of recurrent af . . . .e329 . catheter-based ablation therapy for atrial fibrillation (new section) . . . . . . . . . . .e330 8.3.2. general approach to antiarrhythmic drug therapy . . . . . . . . . . . . . . . . . . .e330 8.3.3. selection of antiarrhythmic agents in patients with cardiac diseases . . . .e330 . heart failure . . . . . . . . . . . . . .e330 . coronary artery disease . . . . .e331 . hypertensive heart disease. . . . .e331 8.3.4. nonpharmacological therapy for atrial fibrillation . . . . . . . . . . . . . . . . .e331 . surgical ablation. . . . . . . . . . .e331 . catheter ablation . . . . . . . . . .e332 .1. complications of catheter-based ablation . . . . . . . . . .e333 .2. future directions in catheter-based ablation therapy for atrial fibrillation. . . . . . . .e333 . suppression of atrial fibrillation through pacing . . . . . . . . . . . .