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What are the updates to the new guidelines?
On February 28, 2022, the Chinese Journal of Arrhythmia published the latest guidelines for the management of atrial fibrillation in China-Atrial Fibrillation: Current Understanding and Treatment Recommendations (2021) /strong> (hereinafter referred to as the “New Guide”)! As an important guiding document for the clinical diagnosis and treatment of atrial fibrillation in my country, what updates have the new guidelines made on the basis of the 2018 version of the guidelines? Come and see~
I. Definition and classification of atrial fibrillation
The new guidelines reference the 2020 European Society of Cardiology (ESC) Guidelines for the Diagnosis and Management of Atrial Fibrillation The definition of has been updated.
1. Definition: Atrial fibrillation is a type of supraventricular tachyarrhythmia associated with uncoordinated atrial electrical activation and ineffective atrial contractions. ECG features of atrial fibrillation include: irregular RR intervals (when atrioventricular conduction is not impaired), P waves without clear repetition, and irregular atrial activation.
Atrial fibrillation ECG recorded by surface ECG or atrial fibrillation ECG recorded by a single-lead ECG recording device for more than 30s can be diagnosed as atrial fibrillation.
2. Classification of atrial fibrillation
Second, the mechanism of atrial fibrillation
The onset and maintenance of atrial fibrillation is influenced by both the trigger and the stroma. It is theorized that atrial fibrillation is driven or induced by trigger foci in the early stage, which in turn causes electrical, structural, and neural remodeling. In contrast, “remodeling” made AF worse and persisted (Figure 1).
Figure 1 Schematic diagram of the mechanism of atrial fibrillation
III. Screening for atrial fibrillation
AF screening facilitates early diagnosis and early intervention, especially in asymptomatic patients. The new guidelines add a new chapter on screening for atrial fibrillation, which systematically describes and makes recommendations:
Note: Opportunistic screening refers to random screening in the general population.
Guidelines recommend screening for people at high risk for atrial fibrillation: including advanced age, heart failure, obesity, hypertension, diabetes, obstructive sleep apnea, structural heart disease, cardiac Surgery, cryptogenic stroke/transient ischemic attack, hereditary arrhythmia patients and special occupational groups (professional athletes), etc.
IV. Imaging examination of atrial fibrillation
Note: TTE is transthoracic echocardiography, and ICE is intracardiac echocardiography.
5. Evaluation of the risk of embolism and bleeding in atrial fibrillation
1. Embolic risk assessment: CHA2DS is recommended2-VASc score
Note: HCM is hypertrophic cardiomyopathy, HFrEF is heart failure with reduced ejection fraction, HFpEF is heart failure with preserved ejection fraction, and OAC isOral anticoagulation, AF is atrial fibrillation, TIA is transient ischemic attack, PAD is peripheral arterial disease, and CAD is coronary heart disease.
2. Bleeding risk assessment: HAS is recommended-BLED score(for patients using oral anticoagulants)< /strong>
Note: INR is the international normalized ratio, and TTR is the percentage of time within the therapeutic target range.
The score of 0~2 belongs to the low-risk group of bleeding, and the score of 3 or more refers to the high-risk group of bleeding. However, a high score is not a contraindication to anticoagulation, but reminds clinicians to try their best to control bleeding risk factors and strengthen the prevention and observation of bleeding complications.
6. Stroke Prevention Strategies
Stroke prevention strategies in patients with atrial fibrillation mainly include anticoagulant therapy and left atrial appendage closure.
1. Anticoagulation
2. Percutaneous left atrial appendage closure
7. Symptom control of atrial fibrillation
Rhythm control and ventricular rate control are the two main treatments for improving symptoms in people with atrial fibrillation.
1. Rhythm control
Rhythm control refers to the restoration and maintenance of sinus rhythm, and the new guidelines state that rhythm control is preferred in the treatment of atrial fibrillation, especially early rhythm control.
For early rhythm control, the new guidelines recommend:
Methods of rhythm control include electrical cardioversion, antiarrhythmic drug (AAD) therapy, and catheter ablation.
(1) Electrical cardioversion
Synchronized direct current cardioversion is an effective method to convert atrial fibrillation, and it is the first choice for atrial fibrillation with severe hemodynamic disturbance and preexcitation syndrome with preexcitation syndrome and rapid ventricular rate. . For hemodynamically stable patients, pharmacological or electrical cardioversion can be used.
(2) AAD treatment:
(3) Long-term AAD treatment
In most patients with paroxysmal or persistent AF, the risk of AF recurrence remains high after restoration of sinus rhythm. Targeted lifestyle changes, control of cardiovascular risk factors and long-term use of AAD therapy can reduce the frequency of AF recurrence and shorten the duration of AF. Recommendations for long-term AAD treatment:
(4) Catheter ablation
Catheter ablation significantly outperforms drugs in maintaining sinus rhythm, new guidelines recommend:
2. Ventricular rate control
Rate control includes both emergency and long-term ventricular rate control, the latter of which is treated with oral medications and atrioventricular node ablation combined with permanent pacemaker implantation.
About the specific medication for atrial fibrillation, due to the limited space of the article, we will explain it in detail in the next issue, so stay tuned~
References:
[1] Chinese Medical Association Cardiac Electrophysiology and Pacing Branch, Chinese Medical Doctor Association Cardiology Professional Committee, China Atrial Fibrillation Center Alliance Atrial Fibrillation Prevention and Control Expert Working Committee. Atrial Fibrillation: Current Understanding and treatment recommendations (2021) [J] . Chinese Journal of Arrhythmia, 2022, 26(1) : 15-88. DOI: 10.3760/cma.j.cn113859-20211224-00264.
This article was first published: Cardiovascular Channel of the Medical Community
This article is organized: Ka Ka
Review of this article: Jiehui Zhao
Editor in charge: Yuan Xueqing, Zhang Li
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