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1、Management of Atrial Fibrillation： Update in the EBM proof,ChangSheng Ma Department of Cardiology, Beijing Anzhen Hospital Capital Medical University, P.R. China,Prevalence of AF is increasing,Go: JAMA, 2001：2370,Miyasaka.Circulation.2006:119,Year,Prevalence of AF is increasing,Prevalence %,Age,Prev
2、alence of AF:the Rotterdam study,Heerinaga.Eur Heart J,2006,949,6808 pts., F/U 6.9 yrs，prevalence 5.5%,Incidence ,Age,Incidence of AF:the Rotterdam study,Heerinaga.Eur Heart J,2006,949,6808 pts., F/U 6.9 yrs，Incidence 9.9,Identified AF：the tip of the iceberg,14802 pts aged 65 or over，randomized to s
3、ystemic screening and opportunistic screening Systemic screening group:9866 pts. Opportunistic screening group: 4936 pts. F/U 12 mons Rate of new AF case in systemic screening 1.63%， Rate of new AF case in opportunistic screening 1.04%,Fitzmaurice.BMJ.2007,383,Risk for stroke increased in lone AF,Ja
4、hangir. Circulation. 2007:3050,Meta-analysis: antithrombotic therapy of AF,Hart.Ann Intern Med,2007,857,Real world of warfarin in the elderly,The first 90 days associated with major hemorrhage 21% pts withdrawn warfarin for safety issue The higher risk of stroke, the higher incidence of major hemorr
5、hage,Hylek. Circulation.2007,2689,HR for ICH was 4.06 for Asians,Asians were at greater risk for warfarin-ralated ICH,Shen. JACC.2007:309,Prospective，randomize，control 973 pts 75 years old with AF Randomized into warfarin arm (INR 2.0-3.0) and Aspirin arm(75mg/d) Mean F/U 2.7 yrs Primary outcome：fat
6、al or disabling stroke, intracranial haemorrhage, or arterial embolism,Warfarin versus aspirin for stroke prevention in the elderly with AF,(The Birmingham Atrial Fibrillation Treatment of the Aged Study,BAFTA study),Mant.Lancet,2007,493,Warfarin versus aspirin for stroke prevention in the elderly w
7、ith AF,Mant.Lancet,2007,493,Mant.Lancet,2007,493,Warfarin versus aspirin for stroke prevention in the elderly with AF,Anticoagulation in clinical practice,2.03/100person-yrs,1.17/100person-yrs,Go.JAMA 2003:2685,Rivaroxaban,Enoxaparin,873 pts Endpoints included DVT,PE,all cause mortality Safety：major
8、 hemorrhage,Endpoints,Safety,Eriksson. Circulation. 2006: 2374,%,Rivaroxaban New promise of anticoagulation？,Prospective RIKS-HIA 60764 pts，AF 21459 pts,CHF 22345 pts,AF+CHF16960 pts F/U 1 yr Higher mortality rate in AF without CHF pts taking digoxin (RR1.42) Similar mortality rate in CHF or AF+CHF
9、pts with or without digoxin,Digoxin and mortality in AF: A prospective cohort study,Hallberg.Euro J Clin Pharmacol,2007,959,Hallberg.Euro J Clin Pharmacol,2007,959,Digoxin and mortality in AF: A prospective cohort study,Adverse effects of oral amiodarone,Zimetbaum.NEJM.2007:935,Nichol G . Heart. 200
10、2:535 J Am Coll Cardiol. 2003:20,AADs is insufficient to maintain sinus rhythm,Amiodarone increased mortality of HF SCDHeFT研究,Bardy. NEJM,2005: 225,Dronedarone：Substitution of amiodarone？,Derivative of amiodarone, not composed of iodine Eliminate the effects of amiodarone on thyroid and pulmonary fu
11、nctions Half-time 24 hours,22.6% discontinuation because of GI tract complications,Touboul.PACE.2002:574(A),Dronedarone for maintenance of SR in AF：multicenter, double-blind, randomized trials,Singh.NEJM.2007,987,Catheter ablation is superior to antiarrhythmic durg,A prospective, multicenter, random
12、ized, controlled study,ablation+AADs,AADs,137 AF pts (CAF 33%) Randomization CPVA+isthmus ablation Transtelephonic ECG ，Holter F/U 1 yr Ablation +AAD success rate 55.9% Success rate of AADs 8.7%,Stabile.Eur Heart J.2006:216,APAF Trial,29%,Pappone. JACC. 2006:2340,86%,22%,Oral.NEJM.2006:934,146 CAF E
13、vent recorder F/U CPVA:74% AAD:4%,Catheter ablation decrease the incidence of stroke,755 pts The incidence of stroke/TIA was 1.1% 0.9% occurred whithin 2 weeks of RFCA 79% of pts without risk factor for stroke and 68% of pts with 1 risk factor in sinus discontinued warfarin Patients with sinus rhyth
14、m was thromboembolic event free after the procedure,Oral.Circulation.2006:759,Pappone . JACC.2003:185,N=589,N=582,Catheter ablation reduce stroke,Pappone . JACC.2003:185,Catheter ablation improve prognosis,No risk factor： ASA 81- 325mg One moderate risk factor：ASA 81- 325mg or warfarin Any high risk
15、 factor or more than one moderate risk factor: warfarin,Principles of anticoagulation,AmiodaroneAblation ！,No OHD yes HTN yes（concomitanc with LVH amiodaroneablation ） CAD yes HF amiodaroneablation,Maintain Sinus Rhythm,Catheter ablation is a reasonable alternative to pharmacological therapy to prev
16、ent recurrent AF (IIa,C),Fuster. Circulation.2006 :e257,Indications for catheter ablation,The presence of symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication in rare clinical situations, it may be appropriate to perform catheter ablation of AF as first line
17、 therapy selected symptomatic patients with heart failure and/or reduced ejection fraction LA thrombus is a contraindication,HRS/EHRA/ECAS Expert Consensus Statement,AF Ablation as first-line therapy? (Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation Trial, CABANA),Ongoing NIH sponsored CABANA study: mortality study of AF ablation vs. antiarrhythmics vs. rate control/coumadin as first-line therapy for AF Main study to enroll 3,000 patients at 100 centers Patients will be followed for 2.5-5 years,Thank You!,