專題討論12:心房顫動之臨床處置與展望
The Present and The Future of Atrial Fibrillation Management

程 序 表

S12-2
Rhythm Control versus Rate Control in the Management of Atrial Fibrillation: Any Winner by New Evidences?
張坤正
中國醫藥大學附設醫院

   In patients with atrial fibrillation (AF), the loss of the regular and organized contraction of the left atrium along with the resultant fast and irregular ventricular rate may lead to both immediate and long-term adverse consequences. The AF-related complications include hemodynamic deterioration secondary to increased heart rate and loss of atrioventricular synchrony, an increased risk for stroke and systemic thromboembolic events, and progressive dysfunction of the left atrium and left ventricle. These detrimental effects ultimately lead to an increased mortality in AF patients.

  For each patient with AF, the two principal goals of therapy are to control the arrhythmia to ameliorate symptoms and to prevent thromboembolism. To control the arrhythmia, rate and rhythm strategies have been shown to improve symptoms. Rate control seeks to reduce the heart rate to the optimal level without trying to convert to sinus rhythm; while rhythm control aims at restoring and maintaining the regular sinus rhythm. When comparing the two approaches, the AFFIRM study showed that management of AF with the rhythm-control strategy offers no survival advantage over the rate-control strategy. The Atrial Fibrillation and Congestive Heart Failure Trial compared the benefits of rhythm control with rate control in a randomized, multicenter trial of 1376 patients with AF and congestive heart failure This trial also showed no benefit for use of a routine strategy of rhythm control in patients with AF and systolic heart failure compared with a strategy of rate control.

  Both rate- and rhythm-control strategies may improve symptoms, but neither has been conclusively shown to improve survival compared to the other. Indeed, antiarrhythmic treatment needs to be tailored individually for AF patients on the basis of their age, co-morbidities, and AF burden and duration.