1. Acute heart failure and atrial fibrillation
Recent literature defines acute heart failure as a group of clinical syndromes with acute onset and/or exacerbation of signs and symptoms of heart failure. Based on the current definition of acute heart failure, in addition to acute left heart failure due to traditional organic heart disease causes, some other clinical emergencies are also categorized as acute heart failure, such as acute onset or exacerbation of chronic heart failure and acute onset or exacerbation of right heart failure due to non-organic heart disease.
Atrial fibrillation is the most common arrhythmia in clinical practice, accounting for approximately 1/3 of hospitalizations for arrhythmias. according to statistics, there are approximately 4.5 million patients with atrial fibrillation in Europe, 2.2 million in the United States, and an estimated 8 million patients with atrial fibrillation in China, exceeding the number of patients in Europe and the United States combined. The combination of atrial fibrillation with rapid ventricular rate leads to a decrease in cardiac output, especially in patients with left ventricular hypertrophy or reduced left ventricular compliance, which causes hypotension and pulmonary stasis and induces acute heart failure.
2. Principles of management of acute heart failure combined with atrial fibrillation
2.1 General treatment
① Position: those with obvious respiratory distress at rest should be in semi-recumbent or sitting position with legs down to reduce the amount of cardiac return and reduce cardiac preload.
②Oxygenation: high flow oxygenation (6-8 L/min) for those without carbon dioxide retention, and low flow oxygenation (1-2 L/min) for those with combined carbon dioxide retention.
③Open intravenous access to ensure the demand of medication, and do cardiac monitoring.
④Incoming and outgoing volume management: fluid intake in the acute phase is usually within 1500 ml, and the negative balance of incoming and outgoing volume is maintained at about 500 ml per day. Under the negative balance, attention should be paid to avoid the occurrence of hypovolemia, hypokalemia and hyponatremia.
⑤ Correct the electrolyte and acid-base imbalance. Especially in acute heart failure combined with hypokalemia or acidosis, malignant arrhythmia is likely to occur.
2.2 Drug therapy
①Sedatives: e.g. morphine 2.5 mg or 5 mg subcutaneously or intravenously. It is not recommended for those with carbon dioxide retention.
②Bronchial antispasmodics: such as dihydroxypropyl theophylline.
(③ diuretics: in acute heart failure, more use of tab diuretics, such as furosemide, torasemide, etc., can be effective in a relatively short period of time, thereby rapidly reducing the preload of the heart. After the acute period, the diuretics can be gradually changed to thiazide diuretics and potassium-protective diuretics. Pay attention to side effects such as hypotension and electrolyte disorders caused by diuretics.
④Vasodilators: such as nitrates, uradil, etc. It can effectively reduce the peripheral vascular resistance and lower the afterload of the heart.
⑤ Positive inotropic drugs: For patients with acute heart failure combined with atrial fibrillation, digitalis drugs, such as Cediran, are preferred. It can both increase cardiac output and reduce filling pressure, and also effectively slow down the ventricular rate.
(6) Anti-arrhythmic drugs: If acute heart failure combined with new-onset atrial fibrillation without hemodynamic disorders can choose amiodarone intravenous push to reset or maintain sinus rhythm, at this time, it is not advisable to choose Ibutilide or propafenone. If acute heart failure is combined with chronic atrial fibrillation, digitalis or amiodarone can be chosen to control the ventricular rate.
2.3 Electrical resuscitation
In acute heart failure combined with new-onset atrial fibrillation, electrical cardioversion should be performed immediately if hemodynamic disturbances occur.
In acute heart failure combined with atrial fibrillation, the underlying cardiovascular disease should be promptly corrected, and various triggers should be controlled and eliminated. Once the diagnosis is confirmed, general treatment should be given first, and further comprehensive treatment including vasoactive drugs, positive inotropic drugs and antiarrhythmic drugs should be given.