The First Affiliated Hospital of Henan College of Traditional Chinese Medicine Author: Care Min Qiu Chengjie Atrial fibrillation, referred to as atrial fibrillation, is one of the most common cardiac arrhythmias, and although the overall incidence is only 0.4%, the incidence of atrial fibrillation increases gradually with age. The prevalence of atrial fibrillation is as high as 10% in people older than 75 years of age. Large-scale research studies in China have shown that the prevalence of atrial fibrillation is 0.77%, and the incidence of atrial fibrillation is higher in men (0.9%) than in women (0.7%), and the incidence of atrial fibrillation above the age of 80 years is 7.5%. Atrial fibrillation will become one of the most prevalent cardiovascular diseases in the next 50 years. For China, which is about to enter an aging society, the prevention and treatment of atrial fibrillation is a major challenge for the majority of cardiovascular doctors. Care Min, Department of Cardiology, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine As research on atrial fibrillation continues to progress, the concept of atrial fibrillation treatment continues to change. Although both the 2010 ESC Guidelines for the Treatment of Atrial Fibrillation and the 2011 ACCF/AHA/HRS Guidelines for the Treatment of Atrial Fibrillation have made significant changes to the recommendations for radiofrequency ablation treatment of AF, the high cost of the procedure has deterred many patients with AF in China, which is a developing country with an inadequate health insurance system. Therefore, pharmacological treatment of AF remains the most important and feasible treatment option for patients with AF in China. The antiarrhythmic drugs (AADs) used to treat AF share common properties, as they are all ion channel blockers that correct arrhythmias by affecting Na+, Ca2+ and K+ transport in the cardiomyocyte membrane, affecting the periods of cardiomyocyte action potential, and inhibiting autoregulation and/or aborting folding. Due to the lack of selectivity in the action of ion channel blockade, it acts on both atria and ventricles, and has the potential risk of proarrhythmia while antiarrhythmia, and mostly has negative inotropic effects. Therefore, it is mainly used in the acute phase of arrhythmia, with poor long-term prevention effect and more adverse effects. The AADs currently used clinically to revert atrial fibrillation and maintain sinus rhythm are mainly class Ic (propafenone) and class III (amiodarone). Propafenone has a significant effect on the conversion of atrial fibrillation during acute episodes by significantly blocking Na+ channels, prolonging repolarization time and slowing conduction, but its negative inotropic effect on ventricular muscle limits its use in patients with organic heart disease. It is also generally contraindicated in combination with other AAD drugs, with the potential risk of cardiac depression. Amiodarone is widely used in the treatment of patients with atrial fibrillation in organic heart disease because of its antiarrhythmic effects by inhibiting multiple potassium currents and prolonging the duration of action potentials, and its relative drug safety. However, its thyroid toxicity and interstitial lung fibrosis side effects also limit the long-term use of this drug. Because of these limitations, more effective and safe antiarrhythmic drugs are needed to treat atrial fibrillation. Research on antiarrhythmic drugs has shifted in several directions. First, the unrecognized effects of older drugs such as carvedilol are gradually being recognized. Second, improvement of existing drugs, such as amiodarone, to improve their safety and efficacy as much as possible. Third, new anti-arrhythmic drugs with new therapeutic mechanisms are developing in the direction of being more effective than existing drugs. Fourth, the development and application of traditional Chinese medicine, which is full of great research and development potential. Finally, drugs without antiarrhythmic effects such as angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor antagonists, HMG CoA enzyme inhibitors and fish oil have shown some inhibitory effects in patients with certain subtypes of atrial fibrillation. Dronedarone, a new type of multichannel blocker, blocks various K+ channels, Na+ and Ca2+ channels, but not competitively blocks α and β receptors, which prolongs the QT interval or QTc, slows down sinus rhythm and prolongs atrioventricular conduction time. The ATHENA study confirmed the safety of dronedarone because it does not contain iodine and avoids iodine-related toxicities, with the same incidence of thyroid function abnormalities as placebo, no cases of interstitial pulmonary fibrosis, and no extracardiac adverse effects. However, subsequent studies have shown that dronedarone is less effective than amiodarone in maintaining sinus rhythm and that it increases mortality in patients with heart failure. Ibutilide is a newly introduced class III antiarrhythmic drug, but its mechanism of action is different from that of other class III antiarrhythmic drugs, and even more so from other classes of antiarrhythmic drugs. It is a homologue of β-adrenergic receptor antagonist and a methanesulfonamide compound. Ibutilide inhibits repolarization by rapidly activating the delayed rectifier K+ efflux (Ikr), the main ion flow for cell repolarization. Ibutilide has the effect of promoting both slow Na+ inward flow and Ca2+ inward flow during the plateau phase, which counteracts some of the K+ outward flow and prolongs the plateau phase of the cardiomyocyte action potential, thereby prolonging the cardiomyocyte action potential time course and the effective inactivity period. Since its approval for atrial fibrillation and atrial flutter within 90 d of onset, a large number of clinical studies have shown that the success rate of rapid atrial fibrillation and atrial flutter with ibrit is higher than that with placebo and other AADs. Arrhythmias have been a difficult problem for the medical community, and despite the continuous development and marketing of new AADs, the problem of drug-induced arrhythmogenesis has not been overcome. Radiofrequency ablation for arrhythmias, especially for atrial fibrillation, has made great progress, but the high cost of the procedure has limited its clinical dissemination. Chinese medicine in the treatment of arrhythmias is the treasure of Chinese medicine, and the accumulation of years of clinical application practice has established the status of Chinese medicine in the treatment of arrhythmias, confirmed that Chinese medicine treatment of arrhythmias does not trigger new arrhythmias at the same time, and successfully solved the problem of drug safety in AAD. The combination of Chinese and Western medicine in the treatment of cardiac arrhythmias can provide a new methodological option for clinical practice and will bring new opportunities for the treatment of cardiac arrhythmias, especially atrial fibrillation. Traditional Chinese medicine has a unique understanding of the treatment of cardiac arrhythmias. Atrial fibrillation belongs to the category of palpitation disease in the concept of Chinese medicine, and the ancient people believed that the pathogenesis of atrial fibrillation is a deficiency of the heart’s yin, yang, qi, and blood, and the heart loses its nourishment and is weak in agitation. In addition, phlegm and blood stasis can cause palpitations. Palpitations are caused by phlegm in fright and drink in palpitation. The palpitations are caused by poor blood flow and internal obstruction of stagnant blood. Accordingly, patients with palpitations in atrial fibrillation can be divided into four types: deficiency of the heart and spleen, stagnation of Qi and blood stasis, incompetence of the heart and Yang, and water-drinking over the heart. Those with deficiency of both heart and spleen are treated by tonifying blood to nourish the heart and benefiting qi to calm the mind; those with qi stagnation and blood stasis are treated by invigorating blood to remove stasis and regulating qi to open the ligaments; those with heart yang dysfunction are treated by warming heart yang; those with water-drinking to overwhelm the heart are treated by invigorating heart yang and removing qi to facilitate water. At present, it is found that the main Chinese patent medicines used for the treatment of atrial fibrillation are heart stabilizing granules, ginseng and pine heart capsules, huangyangning and huangliansu. Heart-stabilizing granules not only have the local effect of benefiting Qi and nourishing the heart, but also have the overall effect of regulating the body’s Qi and blood, invigorating blood and restoring blood vessels. Modern research has shown that: Heart Stabilizer Granules fully meet the world’s recognized criteria for the most ideal current anti-arrhythmic drug. Heart Stabilizer Granules can prolong the effective myocardial inactivity (na and potassium channel block); inhibit the triggering activity (inhibit late sodium current); and reduce the cross-ventricular wall repolarization dispersion at higher concentrations (inhibit late sodium current). The results have been published in Pharmacology and Therapeutics, the world’s leading journal in the field of pharmacotherapeutics. It has good antiarrhythmic effects on a wide range of cardiac arrhythmias. It can regulate Na+, Ca2+ and K+ ion channels, shorten the time course of action potential, significantly prolong the repolarization process of action potential, delay the post-depolarization, and reduce the occurrence of arrhythmias, which is similar to the effect of amiodarone without similar side effects. Acute toxicity tests have shown that the cumulative maximum tolerance in animals is 230 times higher than that in humans. It can be taken alone or in combination with western drugs. Domestic studies have shown that heart-stabilizing granules have the effects of class I, III and IV antiarrhythmic drugs and inhibit a variety of ion channels, which is consistent with the efficacy of its clinical multi-center arrhythmia treatment, with its therapeutic effect on a variety of arrhythmias reaching more than 80%. It has good clinical efficacy in the treatment of atrial fibrillation. Ginseng Heart Capsule is an effective drug for the treatment of cardiac arrhythmias developed under the guidance of Chinese medicine theory of complex disease, which is based on the addition and reduction of the formula of Shengveisan and Dingxin Tang. It has the efficacy of benefiting qi and nourishing yin, stabilizing palpitation and restoring pulse, activating blood circulation, clearing the heart and calming the mind. Modern pharmacological research shows that: Ginseng and Pine Heart Capsule has the effects of improving blood supply to myocardium, reducing autoregulation of myocardial cells, improving metabolism of myocardial cells and regulating neuroendocrine, which can significantly relieve palpitations, shortness of breath, weakness, insomnia and other symptoms caused by arrhythmias. It also has the characteristics of integrated regulation of anti-arrhythmia, playing a significant role in regulating various cardiac ion channels such as sodium, calcium and potassium, improving the metabolic disorders of cardiac muscle cells, adjusting the function of cardiac pacing and conduction system and regulating the autonomic function of the heart. Ginseng Heart Capsule has the advantage of both multiple ion channel blocking and non-ion channel regulation, which is the electrophysiological basis for its clinical fast and slow treatment of cardiac arrhythmias. Its anti-arrhythmia evidence-based medical research was conducted in 36 large general tertiary hospitals across China, and the research results showed that Ginseng Heart Capsule was significantly better than the control group in treating non-organic premature ventricular beats, and significantly better than Western slow rhythm in treating organic premature ventricular beats; its efficacy in treating paroxysmal atrial fibrillation was comparable to that of Western cardioplegia, and it was also effective in treating slow arrhythmias such as sinus bradycardia, diseased sinus, conduction block, and slow-fast syndrome, for which there is no effective drug treatment, It also has good efficacy in the treatment of slow arrhythmias such as sinus bradycardia, sinus disease, conduction block, slow fast syndrome, etc., filling the gap of drug treatment for slow arrhythmias. Another study showed that the efficacy of Ginseng Heart Capsules combined with western medicine in the treatment of arrhythmias was significantly better than that of western medicine alone, and the treatment period was shortened and the dose of the medicine applied was reduced, and no significant arrhythmogenic effect was observed. It is also effective in controlling the ventricular rate in patients with persistent atrial fibrillation, and has the effect of treating both the symptoms and the root cause, without obvious adverse effects and with good safety. Xanthanine is an alkaloid extracted from Xanthaceae and its congeners, also known as cyclic vincristine D, cyclic evergreen xanthanine D, xanthanine, etc. It is a new drug successfully developed in China in recent years for the treatment of cardiovascular diseases, with the function of moving qi and blood and relieving pain, mainly used for the treatment of chest pain due to qi stagnation and blood stasis, pulse knot generation, coronary heart disease, arrhythmia, etc. Electrophysiological studies have shown that the main effects of Huang Yang Ning Tablets on myocardium are prolongation of action potential duration (APD) and effective expiration period (ERP), which are classified as Class III anti-arrhythmic drugs according to the classification method of Wellian ms. It has both positive inotropic effect and long-term use within a certain blood concentration without negative inotropic and arrhythmogenic effects of general antiarrhythmic drugs; and has the effect of dilating coronary vessels, lowering blood pressure and increasing coronary blood flow to improve myocardial oxygen supply against myocardial ischemia. Studies have shown that safranin can prolong the action potential duration and effective inactivity of cardiomyocytes, and can inhibit arrhythmias induced by various factors including aconitine in isolated atria. Therefore, safranin has a good application prospect in the treatment of atrial fibrillation, especially in combination with hypertension and coronary artery disease. Berberine hydrochloride, also known as safranin, is a very familiar old traditional medicine in clinical practice, which has the effect of clearing heat and detoxifying and anti-infection. In recent years, it has been found that there are many new uses for berberine. With the continuous research on this drug, clinical observation has revealed that berberine has significant anti-arrhythmic efficacy. The mechanism of action of berberine against arrhythmia has not been fully clarified. Berberine can increase the action of acetylcholine, which in turn can increase the potassium conductance of the membrane, increase the potassium ion outflow from cardiomyocytes, improve myocardial function and enhance myocardial contraction. Animal cell electrophysiology experiments demonstrated that berberine could widen the time course of ventricular myocardial work potential (mainly in phase 2) and prolong the effective expiration period in guinea pigs. Berberine prolonged the atrial and ventricular ERP (effective expiration period) and functional expiration period respectively, but had no effect on the relative expiration periods of atria and ventricles. The prolongation of myocardial APD (action potential duration) and ERP and the increase of ERP/APD ratio, which facilitates the interruption of the folding loop and makes it less prone to formation, may be the main mechanism of the antiarrhythmic effect of berberine. In order to maintain sinus rhythm and prevent the recurrence of atrial fibrillation while reducing the arrhythmogenic effects and toxic side effects of antiarrhythmic drugs, some studies have reported that oral berberine tablets have been given to patients with atrial fibrillation, especially to the elderly, using the vasodilating and cardiac depressant effects of berberine, with good results. The drug has no adverse effects on heart rate, blood pressure, liver and kidney function, or blood picture. Most antiarrhythmic drugs have the disadvantage of weakening myocardial contractility, while berberine strengthens myocardial contractility and can be used in patients with heart failure. It has obvious safety advantages compared with anti-arrhythmic western drugs, breaking through the status quo of western drugs for arrhythmias that limit long-term use due to serious adverse effects. Another important issue in atrial fibrillation is anticoagulation, because patients with atrial fibrillation have a greater chance of dislodging thrombus from the left atrium, and the possibility of forming an embolism is greater, especially in stroke; antithrombotic drug therapy is still a basic and effective means to prevent the risk of stroke in patients with atrial fibrillation at this stage, and commonly used drugs include warfarin, aspirin and clopidogrel. The rational choice of warfarin anticoagulation or aspirin antiplatelet therapy has been a thorny issue for clinicians. The available evidence suggests that either warfarin or aspirin can significantly reduce the risk of stroke in patients with atrial fibrillation, with a greater benefit than warfarin (62% vs. 22%), but the rate of warfarin use in patients with atrial fibrillation in China is only 1.7%, a far cry from that in the United States (38.1%), a phenomenon that is not unrelated to the concerns of Chinese physicians and patients about the risk of bleeding with warfarin. The 2010 European guidelines for the management of atrial fibrillation recommend that patients with indications for refusal of oral warfarin therapy may take aspirin 75–100 mg/d in combination with clopidogrel 75 mg/d (IIa, B) to prevent the risk of stroke; the 2011 US related guidelines recommend that in patients with atrial fibrillation for whom warfarin anticoagulation is not indicated, the combination of aspirin resistance and clopidogrel may reduce serious vascular events such as stroke (IIb, B). The recent emergence of new anticoagulants, such as the direct thrombin inhibitor dabigatran and the selective direct factor Xa inhibitors rivaroxaban and apixaban, have shown promising preliminary clinical results and offer new hope for safer and more effective stroke prevention and treatment in atrial fibrillation. Chinese medicine plays a more important role in the anticoagulation treatment of atrial fibrillation, especially in the balance between anticoagulation and bleeding. In one study, 106 patients with chronic atrial fibrillation were randomly divided into 60 patients in the treatment group and 46 patients in the control group. On the basis of treatment of the primary disease and ventricular rate control, the treatment group received Tongxinluo capsules (2 capsules/time, 3 times/d) orally, and the control group received Warfarin tablets (3 mg/time, 1 time/d) orally. Both groups were followed up for 4 years to observe the occurrence of complications such as thromboembolism and bleeding. The difference in anticoagulation efficacy between the treatment group and the control group was not statistically significant (P〉0.05), but the treatment group had fewer adverse effects. It was concluded that taking Tongxinluo capsules was safer and more convenient than Warfarin tablets for the same antithromboembolic complication efficacy. Eighty-eight patients with atrial fibrillation were selected and randomly divided into a treatment group and a control group. After 1 month of treatment, the coagulation-related indexes (PT, APTT, TT, FIB) of the two groups were compared in different periods. Results: The PT and APTT of the treatment group were compared with those of the control group at 1 month of treatment, P < 0.05; the effects on TT and FIB were not significantly different, P > 0.05; the coagulation indexes were not significantly different at the 5th day of treatment. Suggestion: Yi Qi and Blood Activation Formula has a better anticoagulant effect on patients with atrial fibrillation.