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What do you think of "Inaction" in the treatment of atrial fibrillation? The heart speaks the bean language.

medlive-Cardiology @ 2020/05/22

At home and abroad, it is generally considered that less than 48h is a safe time window for patients with paroxysmal atrial fibrillation. The so-called "unprotected cardioversion" means that such patients can be safely treated without anticoagulation or without TEE. But in fact, in the 2016 guidelines for atrial fibrillation, ESC has already pointed out that anticoagulation is more safe in patients with atrial fibrillation less than 24h or even 12h, based on new evidence.

Author: talking about bean Dad
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Therefore, at present, for patients with paroxysmal atrial fibrillation without hemodynamic disorder, no preexcitation, no other taboo, and less than 48h within the time of onset, low-molecular-weight heparin anticoagulation is usually injected subcutaneously, while intravenous amiodarone is used to restore atrial fibrillation and restore sinus rhythm as early as possible. The plan is consistent with the subjective wishes of doctors and patients, and does not violate the principles of treatment. It seems reasonable, but for bean dad, " Govern by doing nothing that goes against nature "Maybe a better treatment option.


What is "rule by doing nothing"?


The rule of virtue is from "Tao Te Ching". It does not mean that nothing is done, but refers to much interference and no action. "Inaction" in the treatment of atrial fibrillation refers to the method of "wait and see", that is, the strategy of waiting for self conversion.
At present, a large number of studies have confirmed that the spontaneous conversion rate of paroxysmal atrial fibrillation within 48h can reach as high as 50%-77%. Take a randomized placebo-controlled clinical study published in the European Journal of Cardiology. A total of 100 patients with paroxysmal atrial fibrillation within 48h were included in the study. All patients were divided into two groups: Waiting for conversion strategy group and Amiodarone group 。 The former only took pulse rate (whether greater than 100 times / min) to give intravenous digitalis as appropriate, while the latter gave high dose of amiodarone (125mg/h, 3g/24h).

The study showed that in the waiting strategy group, about 64% (32/50) patients voluntarily revert to sinus rhythm during admission to 24h. Of these, 91% (29/32) patients voluntarily converted within 8h. Although the conversion rate of atrial fibrillation to 24h was 92% in the amiodarone group, the high dose of 3G in 24h is apparently not available in most hospitals (domestic guidelines do not exceed 2.2g in 24h). In addition, Glave et al's research confirmed that intravenous amiodarone with 5mg/kg load +1.2g/24h had no significant difference in the conversion rate of atrial fibrillation at admission to 24h compared with placebo group (68% vs 60%) (p=0.532).

Therefore, based on the usage and dosage of amiodarone in the real world (many doctors do not load at all, even intravenous drip is not recommended at the recommended speed, much lower than the dosage of amiodarone used above). The application of amiodarone to atrial fibrillation may not be better than waiting strategy. 。 The use of amiodarone in the real world may be more like a placebo, accompanied by adverse drug reactions, treatment time and treatment costs.

In addition, even if positive drugs are used to convert atrial fibrillation, Amiodarone is not the only or best choice. Although amiodarone is more widely used, it works late. Many studies have shown that intravenous 8h is better than placebo. Propafenone and Britt are more effective than amiodarone: the former is suitable for patients with non organic heart disease (including pre excitation and atrial fibrillation), oral administration 2-6. H is effective, and 0.5-2h is effective after intravenous injection. The average time of conversion is less than 30min, which can be applied to cardiac surgery, pacemaker implantation, radiofrequency ablation, atrial fibrillation and pre excitation atrial fibrillation. The domestic expert consensus recommendation is also applicable in some patients with coronary heart disease and heart failure. Britt is superior to propafenone in terms of the effect of conversion.



Which atrial fibrillation is more suitable for "govern by doing nothing"?


Many studies confirm that Atrial fibrillation duration <24h It is the best predictor of spontaneous conversion of atrial fibrillation.
A total of 356 patients with persistent atrial fibrillation (<72h) were enrolled in the study by Danias et al. The results showed that 68% of the patients were converted to sinus rhythm by themselves. Among all patients who voluntarily revert to sinus rhythm, the duration of atrial fibrillation is 66%, 24-48h is 17%, >48h is 17%, <24h is the highest.
Logistic multiple regression analysis showed that the duration of atrial fibrillation <24h was the only predictor of spontaneous conversion of atrial fibrillation. There was no significant difference in left atrial size between the self conversion group and the non conversion group. The left ventricular systolic function was more common in the self conversion group.


How long is it appropriate to govern by doing nothing?

Some teachers may ask, "let the bullets fly for a while". How long is the "one minute"? Huh? According to the results of the literature research, the individual thinks that At least 6-8h should be observed. It can also be delayed to 24h (the time of atrial fibrillation can not exceed 24h or 48h). It will then consider whether, when and how to reverse the problem.
Therefore, for patients with paroxysmal atrial fibrillation without atrial fibrillation, no preexcitation, no other taboo, and less than 48h within the time of onset, especially for atrial fibrillation with duration less than 24h, there is no need for active cardioversion because of the high probability of self conversion. Course of treatment.

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