急診夜未眠: 2014 AHA/ACC/HRS Atrial Fibrillation Guidelines

2014 AHA/ACC/HRS Atrial Fibrillation Guideline from Sun YaiCheng

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary

Circulation 2014;130:2071-2104.

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

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

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

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

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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