2014年12月30日 星期二

2014 AHA/ACC/HRS Atrial Fibrillation Guidelines



2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary 
Circulation 2014;130:2071-2104.

Thrombo-embolic Risk and Treatment

  • With prior stroke, TIA, or CHA2DS2-VASc score ≥2, oral anticoagulants recommended. Options include:
Warfarin
– Dabigatran, rivaroxaban, or apixaban
  • With nonvalvular AF and CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic therapy
  • With nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with oral anticoagulant or aspirin may be considered
  • After coronary revascularization in patients with CHA2DS2-VASc score ≥2, it may be reasonable to use clopidogrel concurrently with oral anticoagulants but without aspirin

    Rate Control

    • Control ventricular rate using a beta blocker or non-DHP CCBs for paroxysmal, persistent, or permanent AF
    • In hemodynamically unstable patients, electrical cardioversion is indicated
    • A heart rate control (resting heart rate < 80) strategy is reasonable for symptomatic management of AF
    • IV amiodarone can be useful for rate control in critically ill patients without pre-excitation
    • A lenient rate control strategy (resting heart rate < 110) may be reasonable when patients remain asymptomatic and LV systolic function is preserved
    • Non-DHP CCBs should not be used in decompensated HF

    Rhythm Control  

    • With AF or atrial flutter for >48 h or unknown duration, requiring immediate cardioversion, anticoagulate as soon as possible and continue for at least 4 wk
    • DC cardioversion is recommended for AF or atrial flutter with RVR, that does not respond to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or HF
    • Pharmacological cardioversion: Flecainide, dofetilide, propafenone, ibutilide and amiodarone are useful for cardioversion of AF or atrial flutter


      Specific Patient Groups

      AF complicating ACS
      • Urgent cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control
      • With ACS and AF with CHA2DS2-VASc score ≥2, anticoagulation with warfarin is recommended unless contraindicated
      • Amiodarone or digoxin may be considered to slow RVR with ACS and AF and severe LV dysfunction and HF or hemodynamic instability
      WPW and pre-excitation syndromes
      • Cardioversion is recommended for patients with AF, WPW syndrome, and RVR who are hemodynamically compromised
      • IV amiodarone, adenosine, digoxin, or non-DHP CCBs in patients with WPW syndrome who have pre-excited AF is potentially harmful
      Heart failure
      • A beta blocker or non-DHP CCB is recommended for persistent or permanent AF in patients with HFpEF
      • IV digoxin or amiodarone is recommended to control heart rate acutely
      • Digoxin is effective to control resting heart rate with HFrEF
      • Amiodarone may be considered when heart rate cannot be controlled with a beta blocker (or a non-DHP CCB with HFpEF) or digoxin, alone or in combination

      【摘要】Atrial Fibrillation 處置

      • CHA2DS2-VASc score ≥2,給 warfarin
      • CHA2DS2-VASc score 0,不需 warfarin
      • 血液動力學不穩定、心肌缺氧症狀、低血壓→Cardioversion
      • Rate control:beta blocker 或 verapamil or diltiazem 無效,給 amiodarone
      • Rate control:有症狀→HR 控制在 80以下;無症狀→HR 控制在 110以下
      • Rhythm control: propafenone, amiodarone
      • Rhythm control:AF >48hrs,整流後立刻給抗凝劑
      • ACS or HF: IV digoxin or amiodarone 
      • WPW syndrome with AF→Cardioversion!禁用 amiodarone, adenosine, digoxin, beta blocker, non-DHP CCBs

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