Goals of Atrial Fibrillation Treatment Almost all cardiovascular diseases can lead to atrial fibrillation, and if atrial fibrillation is not well controlled it can lead to heart failure, thromboembolism, and other complications. The fundamental goal of atrial fibrillation treatment is to reduce the rate of stroke, hospitalization, and death in patients, while a goal that should not be overlooked is to improve the quality of life of patients. The goals of atrial fibrillation treatment can be specifically categorized as follows: Finding and correcting the cause of the disease: Many diseases, especially heart-related diseases, can lead to atrial fibrillation, and it is crucial to treat the cause of atrial fibrillation, actively treating the primary heart disease in order to make atrial fibrillation easy to revert back to sinus rhythm and maintain it for a long period of time after revert back to sinus rhythm. In ischemic heart disease, hypertensive heart disease, cardiomyopathy and other causes of atrial fibrillation, when myocardial ischemia improves, heart failure is corrected, good blood pressure control of atrial fibrillation resumption of the chances of a significant increase in the long term to maintain sinus rhythm. Rheumatic heart disease mitral stenosis and atrial fibrillation patients, the implementation of surgical removal of the cause of many patients can maintain sinus rhythm for a long time after the resumption of rhythm. Restoration and maintenance of sinus rhythm: Restoration of sinus rhythm is the best outcome in the treatment of atrial fibrillation. Trying to restore and maintain sinus rhythm in patients with atrial fibrillation significantly improves cardiac function and quality of life, reduces thromboembolic complications, and terminates the structural changes in the atria (atrial remodeling) that can halt the progression of atrial fibrillation, so any patient with atrial fibrillation should be tried in sinus rhythm restoration therapy. Control of ventricular rate: Although the ideal treatment for patients with atrial fibrillation is restoration of sinus rhythm, in atrial fibrillation with large left atrial internal diameters, uncorrected mitral stenosis, and other organic heart disease the rate of successful restoration of rhythm is low, or if restored to sinus rhythm is difficult to maintain, in which case medications can be used as a second step to slow down the faster ventricular rate to improve symptoms. Prevention of thromboembolic complications: the main complication of atrial fibrillation is thromboembolic complications, the most serious is cerebral infarction, for the inability to restore sinus rhythm, can be in the control of ventricular rate at the same time according to the patient’s condition to choose the appropriate anticoagulant drugs to prevent thrombosis and cerebral infarction. Restoration of sinus rhythm The methods of restoring sinus rhythm in atrial fibrillation mainly include drug resuscitation, electrical resuscitation and surgical treatment. In order to choose a suitable resuscitation method for a particular case of atrial fibrillation, it is necessary to select the appropriate resuscitation method according to the characteristics of atrial fibrillation episodes, comorbidities and the patient’s intention, etc. The following common resuscitation methods of atrial fibrillation will be introduced respectively. Although drug resuscitation is more accepted by most patients with atrial fibrillation, studies have shown that the success rate of drug resuscitation and long-term maintenance of sinus rhythm is very low, the proportion of 6 months is still successful in maintaining sinus rhythm is about 50%, and 70-75% of atrial fibrillation will recur in 1 year, and anti-arrhythmic drugs taken for a long time, the side effects of the drugs will significantly increase the chances of occurrence of even increase the mortality rate, and drug-induced arrhythmogenic effects and cardiac external Arrhythmogenic and extracardiac effects are also common. For patients with permanent atrial fibrillation, atrial fibrillation that does not easily maintain sinus rhythm, atrial fibrillation with contraindications to cardioversion, and atrial fibrillation with a rapid ventricular rate, treatment to slow and control the ventricular rate is necessary. Ventricular rate slowing results in a reduction of symptoms and an improvement in hemodynamic status, with the goals of preventing tachycardia and reducing the arrhythmogenic risk of antiarrhythmic drugs. The goal of ventricular rate control in patients with atrial fibrillation The so-called ventricular rate control is to allow the existence of atrial fibrillation while controlling the ventricular rate within a certain range, ventricular rate control in atrial fibrillation is not to say that the ventricular rate is the better, the general view is that the goal of atrial rate control in atrial fibrillation is: ventricular rate control in the resting state of 60 to 80 beats per minute, and the ventricular rate control in the light, moderate activity is 90 to 110 beats per minute, and the clinical application of this needs to be The clinical application needs to be adjusted according to the specific situation of the patient. Commonly used drugs for atrial fibrillation ventricular rate control β-blockers are the most commonly used drugs for controlling atrial fibrillation ventricular rate in the clinic, and these drugs can effectively reduce the heart rate of patients with atrial fibrillation. However, because of their relatively large inhibitory effect on the heart, they are prone to lead to bronchospasm, decreased exercise tolerance and other deficiencies, so they should be used with caution in elderly patients, patients with chronic lung disease, and patients with previous atrioventricular block of degree II or higher. Commonly used β-blockers and routine dosages are shown in Table 2, but patients with specific dosage adjustments need to consult a physician at the atrial fibrillation clinic. (1) hemodynamic disorders or severe symptoms, but drug treatment failed to work as soon as possible to repeat the rhythm; (2) no obvious hemodynamic disorders do not need to repeat the rhythm, but taking into account the restoration of the rhythm can be expected to maintain a normal sinus rhythm to improve cardiac function, relief of symptoms can be considered to elective restoration, including: (1) atrial fibrillation ventricular rate (more than 120 beats / min), the use of cediran, bethanechol, etc., difficult to control, or atrial fibrillation repeatedly triggered by the heart, or the fast rate (more than 120 beats / min), difficult to control, or atrial fibrillation induced by the heart, such as cediran, bethanechol and so on, and so on. ① fast ventricular rate in atrial fibrillation (more than 120 beats/minute), difficult to control with drugs such as sildenafil, bethanechol, or atrial fibrillation repeatedly induced heart failure or angina pectoris medication is ineffective, reversion to sinus rhythm may improve symptoms; ② patients with pre-excitation syndrome combined with atrial fibrillation; ③ chronic atrial fibrillation disease duration of less than one year, cardiac ultrasonography, patients with an internal diameter of the left atrium less than 45mm; ④ other diseases (hyperthyroidism, myocardial infarction, pneumonia, pulmonary embolism, etc.) induced by atrial fibrillation in the underlying causes Patients whose atrial fibrillation still persists after removal of the underlying cause; ⑤ Patients who still have atrial fibrillation 4 to 6 weeks after mitral valve surgery. (1) Before elective resuscitation: the doctor in charge will explain the advantages and disadvantages of resuscitation and the possible complications to the patient and his family, and the patient should sign an informed consent form and fast for at least 6 hours before resuscitation. (2) the application of anticoagulants before and after atrial fibrillation resuscitation: as the heart from atrial fibrillation rhythm resumed for sinus rhythm after the atrium to restore the diastolic function, if the resuscitation of atrial thrombus already existed before the resuscitation of atrial thrombus, resuscitation of thrombus dislodgement leading to cerebral embolism, peripheral vascular embolism may be, the statistical data show that atrial fibrillation resumed for the sinus rhythm triggered by the embolism incidence rate of 1% to 5%. It is generally believed that atrial fibrillation lasting more than 48 hours has the possibility of thrombosis, so the start time of the current atrial fibrillation episode is not clear or has been more than 48 hours of the patient, before the resumption of oral warfarin need to be 3 weeks (to control the INR range of 2 to 3), and continue to take after the resumption of the rhythm for 4 weeks. If there is no thrombus on transesophageal ultrasound, the patient can be resuscitated directly, and heparin should be applied intravenously before resuscitation. If the transesophageal echocardiogram shows signs of thrombus, strict anticoagulation (usually oral warfarin, followed by transesophageal echocardiogram 3 months after the standardization) is required before the decision to reset the rhythm is made. If the patient’s hemodynamic instability requires immediate resuscitation, intravenous heparin needs to be applied once before, and anticoagulation is continued for at least 4 weeks after reversal. (3) Sedation before resuscitation: Appropriate sedation before resuscitation can eliminate the patient’s nervousness and reduce the discomfort caused by electrical resuscitation, and the method of intravenous injection of Valium is generally used in the clinic, and the specific dosage is determined by the patient’s sensitivity to the drug. (4) Application of antiarrhythmic drugs before and after resuscitation: The use of antiarrhythmic drugs before electrical resuscitation can improve the success rate of resuscitation, reduce the energy of discharge, and can understand the patient’s tolerance of drugs to facilitate the selection of antiarrhythmic drugs after resuscitation, therefore, the doctor before resuscitation of atrial fibrillation will be based on the patient’s atrial fibrillation to choose the appropriate antiarrhythmic drugs. Regardless of the type of atrial fibrillation, antiarrhythmic drugs are needed to maintain sinus rhythm after resumption of atrial fibrillation, otherwise it is very easy to recur. Calcium channel blockers are commonly used as diltiazem (Hebexan) or verapamil (Ibogaine), with the former at a dose of 90mg 1-2 times/day and the latter at a dose of 80-120mg once/8 hours, which are the first line of drugs for rapid control of the ventricular rate. Diltiazem is more commonly used because of its low cardiac depressant effect, and should be administered either intravenously or orally depending on the urgency of the condition. Verapamil is less commonly used because of its low bioavailability. Digitalis analogs The commonly used intravenous preparation is sildenafil injection, and the oral preparation is digoxin (common dose 0.125-0.25 mg once/day). This class of drugs is less effective than the previous two classes in controlling the ventricular rate during activity, and is often used in patients with atrial fibrillation accompanied by poor cardiac function. Precautions for controlling ventricular rate in atrial fibrillation Atrial fibrillation combined with preexcitation If the patient has an extremely fast ventricular rate (300-400 beats/minute) and is hypotensive, DC cardioversion should be performed immediately. If the ventricular rate is moderately increased and the blood pressure is stable cardioplegia and amiodarone can be applied intravenously. Cediran and verapamil are prone to induce ventricular fibrillation in atrial fibrillation with preexcitation, leading to adverse outcomes, and should therefore be contraindicated in this situation. It should be noted that ventricular rate control in atrial fibrillation is a palliative treatment when atrial fibrillation is not completely cured, and the patient’s risk of thrombosis is not relieved when atrial fibrillation persists, so ventricular rate control often needs to be performed in conjunction with anticoagulation to prevent thrombosis.