房颤的认知和处理1

房颤的认知和处理,房颤是一种常见的持续性心律失常，表现为心房激动的紊乱。 心电图特点： 1）P波消失，代之为大小、形态、间期极不规则的 f 波。 2）R-R间期极不规则。,创编:P波最好见于 v1，f波最好见于2导。,房颤的分类（“三P”法）阵发性(paroxysmal)房颤： 发作时间小于7天（大多数24小时）可自行转复，并反复发作。持续性(persistent)房颤： 通常发作大于7天(大多数48小时以上)，需要药物或非药物干预才能转复。永久性(permanent)房颤： 发作持续几天或几年，药物或非药物干预不能转复者。,First detected,Paroxysmal1,4(self-termination),Persistent2,4(not self-terminating),permanent3,Figure:Patterns of atrial fibrillation. (1)episodes that generally lastLess than or equal to 7 days (most less than 24h; (2)Usually more Than 7 days; (3)Cardioversion failed or not atempted; and (4)eitherParoxysmal or persistent AF may be recurrent.,孤立性房颤(“Lone AF”)： 年龄60 500 据肾功能，体重和年龄调 40-60 250 整剂量 20-40 125 468天 69% 18%S or P 127（63%） 98天 39% 11%P值 0.001 0.001 =0.06Roy Detal. N Engl J Med 2000,342:913-920,AFFIRM RACE,Recommendations for pharmacological therapy to maintain sinus rhythmClass I: 1)Base selection of pharmacological therapy to maintain sinus rhythm in patients with disabling or otherwise troublesome symptoms during AF predominantly on safety. (Level of evidence:B) 2)Treat precipitating or reversible cause of AF before initiation of antiarrhythmic drug therapy. (Level of evidence:C),Calss IIa: 1)Administer pharmacological therapy to maintain sinus rhythm to prevent progression of tachycardia-induced cardiomyopathy due to AF. (Level of evidence:C) 2)Infrequent and well-tolerated recurrence of AF may in some cases be deemed a successful outcome of anti- arrhythmic drug therapy. (Level of evidence:C) 3)Outpatient initiation of antiarrhythmic drug treatment is appropriate in selected patients. (Level of evidence:C),Class IIb: 1)Administer pharmacological therapy to maintain sinus rhythm in asymptomatic patients to prevent atrial remo- delling. (Level of Evidnece: C) 2)Administer pharmacological therapy to maintain sinus rhythm to prevent thromboembolism or HF in selected patients. (Level of evidence:C) 3)Administer combinations of antiarrhythmic agents to maintain sinus rhythm when single-drug therapy fails. (Level of evidence:C),Class III: 1)Use of a particular pharmacological agent to maintain sinus rhythm in patients with welldefined proarrhythmia risk factors for that agent. (Level of evidence:A) 2)Use of pharmacological therapy to maintain sinus rhythm in patients with advanced sinus node or AV node dys- function in the absence of a functioning electronic cardiac pacemaker. (Level of evidence:C),Heart Disease?,No (or minimal*),Yes+,FlecainidePropafenoneSotalol,Amiodarone,Dofetilide,DisopyramideProcainamideQuinidine,Consider non-pharmacological options,HF,CAD,Hypertension,AmiodaroneDofetilide,Sotalol,LVH greater thanOr equal to 1.4cm,AmiodaroneDofetilide,Yes,No,DisopyramideProcainamideQuinidine,Amiodarone,FlecainidePropafenone,AmiodaroneDofetilideSotalol,Disopyramide,Procainamide,Quinidine,房颤转复后，维持窦律、防止房颤复发，对保护心功能、减少并发症和改善生活质量有重要意义。安全的用药法则： 1）避免脏器的毒性反应（如肺纤维化等）； 2）避免致室性心律失常的作用。药物维持窦律: 1） 无器质性心脏病者-普罗帕酮、氟卡尼、索他洛尔、dofetilide。 2） 有器质性心脏病-索他洛尔、胺碘酮。,非药物疗法预防房颤的复发：心脏起搏植入型心房除颤器（IAD）： 反复发作、药物治疗无效而症状明显的房颤。 同步放电、能量6J。 价格昂贵，需同时服用抗心律失常药物。多部位心房起搏： 高位右心房和冠状窦远端，双心房同步触发性起搏（AAT方式）；右房双灶起搏对有房内阻滞的阵发性房颤有预防作用。抗房颤程序（DAO）可预防房早合并长间隙的阵发性房颤。,起搏预防房颤的可能机制： 1）心房起搏减少心房复极的离散； 2）超速抑制房性早搏和短阵房速，消除房颤的触发因素； 3）如果发生房早，某些心房起搏方式可以改变心房激动的顺序，从而防止心房内激动的发生。,房颤的外科治疗： 左房隔离术(Wil