Atrial fibrillation (Af) is a very common arrhythmia in adults, which can be classified according to the duration of AF episodes as follows
1, paroxysmal atrial fibrillation: refers to the duration of atrial fibrillation within 1 to 2 weeks.
2, persistent atrial fibrillation: refers to the duration of atrial fibrillation in more than 2 weeks ~ within 1 year.
3.Permanent atrial fibrillation: The duration of atrial fibrillation is more than 1 year. Idiopathic or isolated atrial fibrillation refers to atrial fibrillation without the basis of organic heart disease.
There are various treatments for AF, including etiology treatment, rhythm control, ventricular rate control plus anticoagulation, catheter radiofrequency ablation, device treatment (placement of atrial defibrillator, anti AF pacemaker, multi-site or dual atrial pacing, left ear plugger), and surgical treatment.
I. Removal of the cause of atrial fibrillation
For example, correction of mitral valve lesion or hyperthyroidism, treatment of hypertension and coronary artery disease, etc.
Second, prevention and control of atrial remodeling
The metabolic, electrical and anatomical remodeling of the atria is the basis for the transformation of AF from paroxysmal to persistent and permanent, therefore, prevention and control of atrial remodeling can help avoid and prevent the recurrence of AF. Drugs commonly used to prevent atrial remodeling include angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, β-blockers, and statins.
Rhythm control or frequency control
Depending on the stage and nature of atrial fibrillation, the treatment principles and methods are not exactly the same. Rhythm control (rhythm control) and frequency control (rate control) are usually used, and anticoagulation therapy is given at the same time. Both types of therapy have their advantages and disadvantages.
The advantages of rhythm control are: atrial fibrillation is certainly accompanied by varying degrees of hemodynamic disorders, quality of life decreases, heart failure is easily induced, and the incidence of embolism increases; prolonged atrial fibrillation inevitably causes atrial and ventricular remodeling, causing further expansion of the atria and ventricles and aggravating the occurrence and development of cardiac insufficiency. Therefore, patients who are eligible for rhythm conversion should be treated with resuscitation. The symptoms of atrial fibrillation can be eliminated after restoration to sinus rhythm, hemodynamics improve, and the risk of intra-atrial thrombosis and embolism is reduced; the disadvantage is that anti-arrhythmic drugs must be used for a long time to maintain sinus rhythm, arrhythmogenic effects may occur, and there is a possibility of recurrence of atrial fibrillation.
The advantage of the frequency-controlled approach is that ventricular rate control is also a treatment for atrial fibrillation if resuscitation is not possible, or is detrimental to the patient. It is relatively easy to control the ventricular rate, and there are relatively few adverse drug reactions, and symptoms improve after treatment without fear of recurrence; the disadvantages are that the ventricular rate is unstable, hemodynamic improvement is not as good as in sinus rhythm, and lifelong anticoagulation therapy is required.
IV. Treatment countermeasures for different types of atrial fibrillation
1, primary atrial fibrillation: first of all, the ventricular rate should be controlled, and anticoagulation should be administered to patients with anticoagulation indications. The second is to give an opportunity to convert the sinus rhythm, either by drugs or electrical resuscitation. Successful conversion is followed by 1 month of antiarrhythmic drugs (especially for patients with atrial fibrillation of >3 months duration) and 4 weeks of anticoagulation. Long-term application of antiarrhythmic drugs to prevent the recurrence of atrial fibrillation after the resuscitation is not recommended.
2. Recurrent paroxysmal atrial fibrillation: How to treat these patients depends on the severity of symptoms. For patients with asymptomatic or mild symptoms, no organic heart disease, good cardiac function, no slow arrhythmia or AVB of degree II and above, only anticoagulation therapy should be considered, and if necessary, cardioplegia (1~2mg/kg by sedation, 450~600mg/1 dose by mouth) can be administered orally, with the possibility of conversion to sinus rhythm; however, after AMI or cardiac insufficiency, the use of antiarrhythmic drugs including But after AMI or cardiac insufficiency, the use of class I antiarrhythmic drugs, including cardioplegia, is not recommended.
3, persistent atrial fibrillation: the treatment of these patients should be to control the ventricular rate as the first-line intervention countermeasure. However, in patients with first-episode persistent atrial fibrillation, it is necessary to give a chance for resuscitation. If sinus rhythm can be maintained for a longer period of time (3-6 months) after conversion to sinus rhythm, re-rhythm can be considered.
4. Recurrent persistent atrial fibrillation: If the patient is asymptomatic or has mild symptoms, anticoagulation and ventricular rate control therapy are given; if the patient has severe symptoms, pharmacological or electrical resuscitation therapy based on ventricular rate control and anticoagulation therapy should be considered. If resuscitation fails, or if sinus rhythm is difficult to maintain, non-pharmacologic therapy may be considered. Non-pharmacological treatments include catheter ablation therapy, surgical labyrinth surgery or AV node ablation + pacing therapy.
5. Permanent atrial fibrillation: The ventricular rate should be effectively controlled, and the principles of drug selection are described above. For patients with combined chronic cardiac insufficiency or post-infarction, β-blockers or amiodarone are preferred, often combined with digoxin, but isoptin or thiazepam should not be used.
6, isolated or idiopathic) atrial fibrillation: that is, atrial fibrillation without the basis of organic heart disease. Atrial fibrillation episodes of ventricular rate control preferred beta blockers or thiazepam; conversion or maintenance of sinus rhythm preferred cardioplegia, Morelizine, ineffective can be iterated with sotalol.
7, atrial fibrillation combined with preexcitation syndrome: preexcitation syndrome with atrioventricular bypass forward transmission of rapid atrial fibrillation, the first choice of synchronous DC resuscitation, digitalis, calcium antagonists should be disabled; preexcitation syndrome with atrioventricular bypass reverse transmission of rapid atrial fibrillation, the principles of treatment as general atrial fibrillation.
V. Conversion to sinus rhythm
1, electrical resuscitation: acute rapid atrial fibrillation complicated by acute myocardial infarction, severe heart failure, unconsciousness, hypotension or syncope, should be immediately synchronized electrical resuscitation, the first resuscitation energy selection 200J; if not successful, then give 360J, if necessary, can be repeated.
2, drug resuscitation: drug resuscitation usually uses class Ic and class III antiarrhythmic drugs, such as propafenone, amiodarone, dofetilide, etc. The success rate of drug resuscitation is higher in recent atrial fibrillation, especially those occurring within 48h, and drug resuscitation can be tried; electrical resuscitation is recommended for longer duration of atrial fibrillation.