2011房颤治疗进展.ppt

Management of Atrial Fibrillation in 2010  John D. Hummel, MD Ohio State University Medical Center Ross Heart Hospital Columbus, Ohio Learning Objectives Understand the risk factors for atrial fibrillation. Understand the guidelines for anticoagulation and where there is latitude for physician decision making. Be able to determine when patients should be evaluated for curative ablation. Atrial Fibrillation Projected Number of Adults With AF in the US: 1995 to 2050. Atrial Fibrillation: Costs to the Health Care System Classification of Atrial FibrillationACC/AHA/ESC Guidelines DIAGNOSTIC WORKUPIdentify Causes and Risk Factors Minimum Evaluation History and physical – BP, CV dz Electrocardiogram – WPW, LVH, MI Echocardiogram – LVH, LAE, EF, Valve Dz Labs – TSH, Renal fxn, LFTs (Clearance,ETOH) [D-dimer, ESR] Additional Testing ETT – CAD, Exercise induced SVT / AF Holter / Event Monitor – Confirm AF and Sxs TEE – LA clot [CXR] EPS – SVT triggered AF Incidence of AF Based on Presence or Absence of OSA Goals of Therapy Relieve symptoms Prevent Stroke Prevent Heart Failure AF: TREATMENT OPTIONS Risk Factors for Thromboembolism in AF D-Dimer Prediction of Risk Dabigatran vs. Warfarin AF THERAPY AFFIRM Trial: Rate vs Rhythm ControlManagement Strategy Trial Design 5-year, randomized, parallel-group study comparing rate control vs. AARx attempt at NSR Primary endpoint: overall mortality Patient population 4060 patients with AF and risk factors for stroke Minimal symptoms Mean Age = 69 yo Hx of hypertension: 70.8% CAD: 38.2% Enlarged LA: 64.7% Depressed EF: 26.0% AFFIRM: All-Cause Mortality AFFIRM: Adverse Events Implications AFFIRM has demonstrated that rate control is an acceptable primary therapy in a selected high-risk subgroup of AF patients with minimal symptoms Continuous anticoagulation seems warranted in all patients with risk factors for stroke Asymptomatic recurrences Atrial fibrillation: Why Control Rate? RACE II Hypothesis: Lenient rate control