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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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IfsuspectedparoxysmalAFwithmultipleepisodesin24hours,consideranambulatory ECG monitor (‘Holter’). If episodes are >24 hours apart, consider using a longer ambulatoryECGorotherECGtechnology(includinganimplantablelooprecorder).
Management
Acutemanagement
Aim to correct any reversible causes of recent-onset AF, such as infection and hypovolaemia,andconsidertheneedforanticoagulation(Box4.2).Anoverviewofacute managementiscoveredinFig.4.2.
Fig.4.2Theacutemanagementofatrialfibrillation.
Box4.2Anticoagulationintheacutephase
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Do not delay emergency electrical cardioversion solely for achieving anticoagulation if haemodynamicallyunstable Givelow-molecular-weightheparin(LMWH)untilfullriskassessmentcanbecarriedout.
Haemodynamicallyunstable
Urgentcardioversionisrequired(seeChapter123).
Haemodynamicallystable
Acuteratecontrol
There is no clear evidence of an optimal target ventricular rate. A resting heart rate of <110bpmisacceptable.SeeFig.4.3,Box4.3,andTable4.1.
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Fig. 4.3 Choice of rate control therapy. BB, beta-blocker; CCB, calcium channel blocker; HF, heart failure.
Box4.3Whichratecontroltherapytochoose?
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Beta-blockersorcalciumchannelblockersarefirstline Calcium channel blockers are contraindicated in pulmonary oedema or when left ventricular ejectionfractionis<40% Digoxinmayalsobeusedfirstlineifthepatient issedentaryand/orabeta-blockerorcalcium channelblockercannotbegiven Anytwo ofbeta-blocker,diltiazem, anddigoxinmay be usedincombinationifratecontrolis inadequatewithasingleagent.Specialistadviceisneededasthismaycausebradycardia. DrugdosesarelistedinTable4.1.
Source:datafromNICECG180.
Table4.1Drugdosesforratecontrolinatrialfibrillation
Drug Oraldose IVdose(boluses)
Bisoprolol 1.25–10mgdaily
Metoprolol 2.5–10mg
Diltiazem(standardrelease) 120mgdaily(unlicensed)
Verapamil(standardrelease) Upto120mgTDS 2.5–10mg
Digoxin 62.5–250mcg 500mcg(max.1.5mg/24hours)
Acuterhythmcontrol
If a rate control strategy has not worked, or if symptoms persist despite the heart rate beingbroughtdown,rhythmcontrolshouldbeconsidered.
Thismaybeachievedusingelectricalorpharmacologicalcardioversion. A rhythm control strategy is also more preferablethan rate control for thefollowing
patientgroups:
AFwithreversiblecause HeartfailurecausedbyAF New-onsetAF(within48hours).
Electricalcardioversion
This requires short-acting general anaesthesia or conscious sedation with anaesthetic support.
It may be used in conjunction with antiarrhythmic therapy (e.g. amiodarone) to
increasethechanceofsuccessandlowertheenergyrequirement.
If elective cardioversion is planned for AF which has been present for >48 hours, anticoagulationshouldbegivenfor3weeksuntilcardioversiontakesplace,andthenthe needforlong-termanticoagulationshouldbeassessed(see‘Long-termanticoagulation’).
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Anticoagulationmaynotbenecessaryinthissettingifatransoesophagealechocardiogram hasexcludedthepossibilityofaclotintheleftatriumorleftatrialappendage.
Pharmacologicalcardioversion
Flecainide can be given in an acute setting or may be self-administered by the patient (‘pillinthepocket’)asasinglebolus(oral,100–150mg)inanoutpatientsetting.
Thisiscontraindicatedinpatientswithstructural,valvular,orischaemicheartdisease. Amiodaroneisanalternativechoicein thesepatients(IV, 5mg/kgover 20–120minutes, maximum1.2g/24hours).
Treatmentafterstabilization
Long-termrhythmcontrol
If onset of AF was >48 hours ago, electrical cardioversion can be considered after a period of at least 3 weeks of anticoagulation. To increase the success rate of electrical cardioversion,theuseofamiodaronefor4weeksbeforeandupto12monthsaftercan beconsidered.
Long-termratecontrol
Drug choices are similar to those used in acute rate control (Table 4.1). Combination therapyisoftenrequiredtoachieveadequatecontrol.Amiodaroneisnotnormallyoffered aslong-termratecontrol.
Long-termanticoagulation
The decision should be guided by clinical risk scores (Table4.2) and reviewed at least annually.
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Table4.2Strokeversusbleedingrisks
CHA2DS2-VAScstrokeriskscore ORBITbleedingriskscore
Congestiveheartfailure=1 Hypertension(treatedoruntreated)=1 Age≥75=2 Diabetesmellitus=1 StrokeorTIA=2 Vascular(myocardialinfarction,peripheralarterialdisease,aortic
plaque)=1
Age65–74=1 Sex,female=1
Anaemia(<13mg/dLinmen,<12mg/dLin women)=2 Age>74=1 Bleedinghistory=2 GFR<60mL/min/1.73m2=1
Treatmentwithantiplateletagents=1
CHA2DS2-VAScscore:consideranticoagulationifscore≥1inmenandoffertomenandwomenif≥2 ORBITscore:≤2=lowbleedingrisk;3=mediumbleedingrisk;4–7=highbleedingrisk
AdaptedfromLipGYH,NieuwlaatR,PistersR,LaneDA,CrijnsHJGM.Refiningclinicalrisk stratificationforpredictingstrokeandthromboembolisminatrialfibrillationusinganovelriskfactor­basedapproach:theEuroHeartSurveyonatrialfibrillation.Chest.2010Feb;137(2):263–72and O’BrienEC,SimonDN,ThomasLE,HylekEM,GershBJ,AnsellJE,KoweyPR,MahaffeyKW,Chang P,FonarowGC,PencinaMJ,PicciniJP,PetersonED.TheORBITbleedingscore:asimplebedside scoretoassessbleedingriskinatrialfibrillation.EurHeartJ.2015Dec7;36(46):3258–64.
If anticoagulation is recommended, offer a direct oral anticoagulant (DOAC) (rivaroxaban,apixaban,dabigatran,edoxaban)firstline.Ifcontraindicated,nottolerated, orunsuitable,offerwarfarin.
Ifanticoagulationisnotappropriate,leftatrialappendageocclusioncanbeconsidered.
Patientswhoaretakinglong-termanticoagulationshouldbemonitoredandsupported toimproveanyotherriskfactorsforbleedingincludinguncontrolledhypertension,labile international normalized ratio (INR), interacting medications, excessive alcohol intake, andreversiblecausesofanaemia.
Ifthepatientisatriskoffallingorelderly,thesereasonsalonearenotajustificationfor withholdinganticoagulation.
Specialconsiderations
Ablation
Ablation is considered when medical treatment has failed, is not appropriate, or concomitant heart failure is present. This can take the form of atrioventricular node ablation,leftatrialcatheterorsurgicalablation.
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Long-term anticoagulation should be considered if there is a risk of recurrence (see
‘Long-termanticoagulation’).
Postoperativeatrialfibrillation
Rhythmcontrolispreferredoverratecontrolfollowingcardiothoracicsurgery.
Furtherreading
1. Kirchhof P, Benussi S, Kotecha D, et al. (2016). ESC Guidelines for the management of atrial
fibrillationdevelopedincollaborationwithEACTS.EurHeartJ.37:2893–962.
2. Scottish Intercollegiate Guidelines Network (2014). Prevention of stroke in patients with atrial
fibrillation.Availableat:https://www.sign.ac.uk/assets/af_publication.pdf
3. Royal College of Emergency Medicine Learning (2019). Atrial fibrillation. Available at:
https://www.rcemlearning.co.uk/reference/atrial-fibrillation/
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Chapter5
Chronicheartfailure
Guideline: NICE NG106 (Chronic heart failure in adults: diagnosis and
management):https://www.nice.org.uk/guidance/ng106
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
The population of patients who suffer from chronic heart failure (CHF) is increasing. CHF may bedivided into left- and right-sided failure. Left-sided failure often develops duetocoronaryheartdiseaseand,asitworsens,canleadtoright-sidedfailure.CHFmay alsobedividedintoheartfailurewithreducedejectionfraction(HFrEF)(ejectionfraction <40%) and heart failure with preserved ejection fraction (HFpEF) (ejection fraction ≥40%).
Diagnosis
History
Symptoms include dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling, andreduced exercisetolerance. Lesscommonly,patientsmayreportnocturnal cough,wheezing,andweightgain.
TheNewYorkHeartAssociation(NYHA)classification dividesCHFintofour classes basedonsymptomsandfunctionallimitation(Table5.1).
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Table5.1TheNYHAfunctionalclassificationsystem
Class Description
I Nolimitation
II Slightlimitation
III Markedlimitation
IV Symptomspresentatrest
Source:DolginM,NewYorkHeartAssociationNYH,FoxAC,GorlinR,LevinRI,NewYorkHeart Association.CriteriaCommittee.Nomenclatureandcriteriafordiagnosisofdiseasesoftheheartand greatvessels.9thed.Boston,MA:LippincottWilliamsandWilkins;March1,1994.
Examination
Generalsigns:cachexia,tachypnoea Necksigns:elevatedJVP,hepatojugularreflux Cardiacsigns:laterallydisplacedapexbeat,S3,S4,galloprhythm,pansystolicmurmur Respiratory signs: bilateral coarse crepitations, pleural effusion (dull percussion, reduced air
entry)
Abdominalsigns:hepatomegaly,ascites Peripheralsigns:peripheraloedema(ankle,sacral).
Investigations
Bedside
Electrocardiography(ECG)
ItisunusualtohaveCHFwithanormalECG.Pathologicalchangesmayinclude:
PathologicalQwaves(previousinfarction) LBBB AF Non-specificST/Twavechanges.
Considerforevaluationofriskfactors
Urinalysis:mayshowglycosuria(diabetes)orproteinuria(renaldisease) Peakflow:COPD.
Bloods
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FBC U&E(inanticipationofdiuretictherapy) LFT(maybeabnormalinright-sidedheartfailureormayindicateexcessivealcoholintakewhich canleadtoCHF) TFT(thyrotoxicosisandhypothyroidismareriskfactorsforCHF) HbA1c(diabetesisariskfactorforCHF) NT-proBNPorBNP(Box5.1).
Box5.1NT-proBNPandBNP
The heart produces the hormones NT-proBNP and BNP when the ventricles are stretched. The serum levels of NT-proBNP and BNP have a high negative predictive valueandareprognostic.Theyareusedtostratifytheurgencyofinvestigations:
NT-proBNP<400ng/L(orBNP<100pg/mL):CHFunlikely NT-proBNP400–2000ng/L(orBNP100–400pg/mL):TTE,specialistreviewwithin6weeks NT-proBNP>2000ng/L(orBNP<400pg/mL):TTE,specialistreviewwithin2weeks.
Notethatlevelsmaybelowerinsomepeoplewithobesity orAfrican/African-Caribbeanheritageor whoaretakingdrugssuchasACEinhibitors.Theymaybehigherinpatientsaged>70years,orthose withconditionssuchasCOPD,renaldisease,ordiabetes.
Imaging
TTE should be performed in patients with raised NT-proBNP or an abnormal ECG to assess:
Valvularfunction Systolicanddiastolicventricularfunction Intracardiacshunts(atrialorventricularseptaldefects,orpatentforamenovale) Pulmonaryarterysystolicpressure(suggestiveofright-sidedheartfailureifraised) Wallmotionabnormalities(evidenceofapreviouscardiacevent).
Cardiac MRI, transoesophageal echocardiography, or radionuclide angiography can be consideredifTTEimagesarepoor.
Chest X-ray is recommended to exclude other causes of dyspnoea. There may be evidenceof cardiomegalyandother signswhich aretypicallyseen in acuteheartfailure (seeChapter2).
Management
Lifestyleandsimpleinterventions
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