| Background:Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice, the feature is a disorder of the rhythm of electrical activation of the cardiac atria, including fast and the irregular atrial activation. Although AF is uncommon before the age of60years, its prevalence increases markedly thereafter, affecting about10%of the population by80years of age. According to the2010ESC Clinical Guidelines for the management of AF, AF can be classified into5types:first diagnosed AF, paroxysmal, persistent, longer-standing persistent and permanent AF. Every patient who presents with AF for the first time is considered a patient with first diagnosed AF. Paroxysmal AF terminates spontaneously, with episodes typically lasting less than48hours and up to7days. Persistent AF requires cardioversion (pharmacologic or electrical) to terminate and the episodes last more than7days. Longer-standing persistent AF has lasted over1year. Permanent AF describes continuous AF that has a fail rhythm control strategy. According to past clinical guidelines there is a describing term "lone AF" which defines patients who develop AF in the absence of cardiopulmonary or systemic disease that can lead to AF.Although AF is not directly life-threatening, the presence of AF is associated with higher long-term risk of stroke, heart failure, and all-cause mortality. With the aging population, this disease burden contributes enormously to mortality. Recent clinical trial evidence suggests that the presence of AF is an independent predictor of mortality. Therefore AF is an important clinical subject.Today, therapy for AF is multidimensional with treatment options spanning from pharmacologic therapy to invasive electrophysiological intervention. Pharmacologic therapy principally includes anticoagulation with warfarin and control of heart rate or rhythm, and so on. There is the debate regarding whether to pursue the strategy of control of the ventricular rate (rate control) or the strategy of maintenance of sinus rhythm (SR)(rhythm control). But we need know rate control strategy is sometimes the best approach, especially in patients with permanent AF who has received drugs and operation and failed. By contrast, efforts to restore and maintain sinus rhythm using antiarrhythmic drugs—the rhythm control approach—may be important and ideal in patients who are young or highly symptomatic and in those with new-onset AF. In addition, Investigation regarding to anticoagulation treatment of patients with AF shows, warfarin therapy is only2%, aspirin for38%,60%of patients did not use both. The fail is mainly related to an increased risk of bleeding, the need for frequent monitoring INR, poor dependence, and medical environment. So theoretically speaking, rhythm control should be the first choice of AF treatment. Therefore, we need to f ongoing research, and develop better drug treatment.Radiofrequency catheter ablation (RFCA) is a rhythm control strategy, Successful catheter ablations can make patients with AF converting sinus rhythm. In recent years RFCA has made great success in patients with AF, especially since2006, there was popularization of RFCA, and its indication expanded, the operation success rate increased, operative complications and mortality reduced. However, recent studies don’t suggest catheter ablation therapy could significantly reduce mortality in patients with atrial fibrillation. Thus far, there was no very direct comparison of drugs therapy and catheter ablation therapy, and current data all was from experienced doctors in the larger clinical centers all over the world. On the28th annual meeting of American Heart Rhythm Association (HRS), HRS convened the heart research center in other countries and released the first international joint statement about RFCA and surgical ablation operation for the treatment of AF; studies have shown that three-quarters of patients with AF received inappropriate treatment. Emphasize that RFCA in patients with AF was more complicated than other arrhythmias, so the success rate of operation and operation safety needed that operating doctors passed very strict professional training. Furthermore, RFCA still had some complications (included disability and lethal).The advice, in the two latest AF guidelines published respectively in2010and2011, is still very conservative about RFCA for AF indication, and thinks that drugs was still a first-line treatment in persistent AF, and RFCA was second-line treatment. In2011ACCF/ACC/HRS Guidelines, catheter ablation performed in experienced centers is useful in maintaining sinus rhythm in selected patients with significantly symptomatic, paroxysmal AF who have failed treatment with an antiarrhythmic drug and have normal or mildly dilated left atria, normal or mildly reduced LV function, and no severe pulmonary disease. Other patients firstly should consider the drugs therapy. RFCA is a promising approach that can be used as an alternative or as an adjunct to antiarrhythmic drugs. Furthermore, combined with China’s medical level, patients’ economic conditions, it was still difficult generalizing RFCA in patient with AF. So the traditional drug therapy would be still the main treatment for patients with AF, especially the persistent AF.Drug treatment can rectify the hemodynamic, control and maintain sinus rhythm, control rate, and prevent thromboembolism. Currently, drugs for atrial fibrillation are various, such as amiodarone, sotalol, et al. But we often give patients with AF to only one drug, so there are low converting rat and high recurrence rate. AF is a complicated pathological change, its basic pathogenesis was atrial electrical remodeling (AER) and atrial structural remodeling (ASR).The AER refers to atrial electricity physiological changes which induced by AF and contribute to maintainance and recurrence of AF. ASR, including that atrial enlargement and fibrillation, is important reason to difficult cardioversion and no easily maintain sinus rhythm. Therefore, it is two key links to reverse AER and ASR. AER can be corrected in a few days, but ASR can continue, so it is the key to persistent AF treatment recovering anatomy reconstruction.Objective1)To compare left atrial diameter(LAD) and left ventricular end-diastolic diameter(LVEDD) in normal persons and patients with AF, and know atrial anatomy changes showing left heart enlargement in patients with AF, meanwhile, review pathophysiology and pathogenesis of the left atrial reconstruction, basing above theory, guide the deeper clinical research.2) To investigate the effect of amiodarone and amiodarone combining with other medical drugs in treatment of atrial fibrillation.3) Through the above research, we try to study a comprehensive treatment of AER and ASR, and investigate a new treatment of AF.MethodsA total of119patients with atrial fibrillation were divided into the single drug group (n=54) and multiple drug group (n=65).Single drug group received the treatment of amiodarone, and multiple drug group received the treatment of amiodarone, glucose insulin potassium and diuretics. We observed the recovery rate of atrial fibrillation and the maintenance rate of sinus rhythm after6months.Part1:The relation between AF and LAD and LVEDDControl group enrolled a total of119persons who received a series of check in Health Check Center of our hospital from February2010to June2010. All cases, through the physical examination, blood biochemistry, electrocardiogram, x-ray, cardiac ultrasound, holter and other laboratory examinations, excluded respiratory and cardiac system diseases, such as coronary heart disease, valvular disease, pulmonary heart disease and so on.AF group was performed in119patients with AF with history, physical exam, chest X-ray film and holter, these patients even received treatment in our hospital during January2010to March2011. There was not a significant difference between the two groups in sex, age, weight. We compared LAD and LVEDD of two groups (control group collected cardiac ultrasound data when they received health check; the data of AF group collected in first-time consultancy).Part2:Comparative effect of amiodarone and amiodarone combined with other drugs in treatment of atrial fibrillation(1) AF group were randomized into two equal groups:the single medicine group (n=54) and the multiple drug group (n=65). Exclusion criteria were contraindication of defibrillation,including hypotension, atrioventricular block, Sick Sinus Syndrome, acute myocardial infarction, ventricular rate<60beats/min, and severe heart, liver, renal failure.(2) Administration:①Single medicine group:First, intravenous amiodarone of150mg diluted100ml saline was used. If AF yet continued, repeated same doses. In the next day amiodarone was given to patients by oral administration at a dosage of600mg/d, the dosage was respectively instead of400mg/d and200mg/d at the end of one week and second week. If the cardioversion was not successful after two weeks, patients were discontinued the treatment. A4-week dosage regimen of oral anticoagulant therapy with asprin or warfarin was given to all patients in the course of the treatment. Then, carries on the regular revisit tracing reexamination situation to all cases in one month, three month, six month, and recorded the result of thyroid function,chest X-ray film, electrocardiogram and holter.②The multiple drug group:used glucose insulin potassium (10%GS250ml,10%KC17ml,25%MgSO45ml, routine insulin6U) and nitroglycerin of2mg by intravenous administration at a frequency of once daily for a total of7consecutive days. At the same time low dose diuretics (hydrochlorothiazide of12.5mg and spironolactone of10mg once every night) was given. The dosage and administration of amiodarone and follow-up were the same as pure medicine group. A4-week dosage regimen of oral anticoagulant therapy with asprin or warfarin was given to all patients in the course of the treatment.(3) Observed the resuscitation rate and the maintenance rate of two groups. Traced cardiac ultrasound reexamination situation to all case in one month, three months, six months respectively, and recorded the result of LAD and LVEDD before cardioversion and six months after successful cardioversion. Thyroid function, chest X-ray film, electrocardiogram and holter also needed be taken.(4) Statistical analysis was done by SPSS13.0. The enumeration data were described with percentage, while measurement data were expressed as Mean±SD (χ±S). The enumeration data were compared with the X2test. Two samples t-test was adopted for the comparison of difference in measurement data when the test of homogeneity of variances is P<0.05, whereas the measurement data were compared with Satterthwaite’s t test. The difference was very significant, if the p-value was lower than0.05.Results(1) The comparison result of the AF group with control group. Comparising to the control group, the left atrial diameter and the left ventricular end-diastolic diameter of patients with AF was significantly enlarged from46.3±5.7mm to30.1±6.8mm,from52.3±6.0mm to49.7.3±3.2mm respectively(P<0.01).(2) The comparison result of the multiple drug group with the pure medicine group. There was a significant increase in the conversion rate (from80%vs.94%) and a significant decrease in the conversion duration from55.4±18.6to38.6±15.3(h) in multiple drug group. The maintenance rate was also increased from81%to95%in multiple drug group. The left atrial diameter was decreased from46.1±6.3to41.7±5.9(mm).The left diastolic diameter was also decreased from52.1±6.8to45.3±5.5(mm) in multiple drug group. But those phenomena were not found in single drug group.Conclusion(1) The LAD and LVEDD were correlated with occurrence and maintain of AF.(2) The multiple drug group was better than that of single drug group in the recovery rate and the maintenance rate in treatment of atrial fibrillation. The effect is probably related to improve ASR and reduced left atrial diameter and left ventricular diameter.Above on, this treatment had a certain value for generalization. |
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