Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times.
Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times.
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DOI：
10.4070/kcj.2017.0040
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发表时间：
2017-09
影响因子：
2.9
通讯作者：
Gopinathannair R
中科院分区：
文献类型：
--
作者：
Batul SA;Gopinathannair R
心房颤动（AF）和心力衰竭（HF）是全球范围内日益增长的心血管疾病流行病。AF和HF的患病率呈指数级增加，与心脏风险因素负担增加和结构性心脏病患者生存率提高相关。AF与HF的不良预后结局相关，在轻度至中度左心室（LV）功能障碍中最为明显，其中“心房踢血”的丧失转化为生活质量较差和死亡率增加。在没有潜在的结构性心脏病的情况下，心律失常可以独立地促进心肌病的发展。这两种情况加在一起，由于停滞、炎症和细胞功能障碍，导致血栓栓塞的风险很高。口服抗凝剂（OAC）预防卒中仍然是治疗的主要手段。药物速率和节律控制仍然受到可变疗效、不耐受和不良反应的限制。房颤的导管消融导致了范式转变，有证据表明优于药物治疗。虽然其治疗阵发性房颤的成功率很高，但在持续性房颤中仍不理想。更好地了解房颤的机制以及消融技术的创新可能会改善未来的患者结局。难治性病例可能受益于房室交界处消融和双心室起搏。风险因素修正的价值，特别是在肥胖、睡眠呼吸暂停、高血压和糖尿病方面，怎么强调都不为过。HF专家和电生理学家之间的密切跨学科合作是这一具有挑战性的人群获得良好长期结局的重要组成部分。
Atrial fibrillation (AF) and heart failure (HF) are growing cardiovascular disease epidemics worldwide. There has been an exponential increase in the prevalence of AF and HF correlating with an increased burden of cardiac risk factors and improved survival rates in patients with structural heart disease. AF is associated with adverse prognostic outcomes in HF and is most evident in mild-to-moderate left ventricular (LV) dysfunction where the loss of “atrial kick” translates into poorer quality of life and increased mortality. In the absence of underlying structural heart disease, arrhythmia can independently contribute to the development of cardiomyopathy. Together, these 2 conditions carry a high risk of thromboembolism due to stasis, inflammation and cellular dysfunction. Stroke prevention with oral anticoagulation (OAC) remains a mainstay of treatment. Pharmacologic rate and rhythm control remain limited by variable efficacy, intolerance and adverse reactions. Catheter ablation for AF has resulted in a paradigm shift with evidence indicating superiority over medical therapy. While its therapeutic success is high for paroxysmal AF, it remains suboptimal in persistent AF. A better mechanistic understanding of AF as well as innovations in ablation technology may improve patient outcomes in the future. Refractory cases may benefit from atrioventricular junction ablation and biventricular pacing. The value of risk factor modification, especially with regard to obesity, sleep apnea, hypertension and diabetes, cannot be emphasized enough. Close interdisciplinary collaboration between HF specialists and electrophysiologists is an essential component of good long-term outcomes in this challenging population.