那么,若是在急诊室出诊的你碰上了新发房颤,会如何处置?
患者评估
急诊处理 —— 血流动力学是否稳定
1)转律
一般而言,对于无器质性心脏病患者,可使用氟卡尼、普罗帕酮、伊布利特、维纳卡兰等药物,新发房颤时也可考虑使用多非利特,上述药物无效或出现不良反应时可选择胺碘酮;
伴有中度器质性心脏病的患者可考虑伊布利特、维纳卡兰,后者可用于轻度心功能不全的患者(NYHA ≤ II 级),但需除外伴低血压或严重主动脉瓣狭窄的患者,上述药物无效或出现不良反应时可选择胺碘酮;
伴严重器质性心脏病、心衰患者及缺血性心肌病患者,应选择胺碘酮复律。
2)控制心室率
3)抗凝
CHA2DS2-VASc 评分 ≥ 2 分的男性和评分 ≥ 3 分的女性在复律前尽早开始抗凝治疗;
而 CHA2DS2-VASc 评分 0 分的男性和评分 1 分的女性可考虑复律前抗凝或不抗凝,且不需长期抗凝治疗。
卒中中高危的急性房颤患者应抗凝治疗;
对于卒中低危患者,若既往房颤发作持续时间 < 24 小时或本次房颤发作时间 < 24 小时可暂不抗凝;而既往房颤时间 ≥ 24 小时或本次房颤发作时间 ≥ 24 小时应抗凝,为后续复律治疗做准备;
对于无卒中危险因素者,即使在 48 小时内复律,为避免左房机械顿抑可能形成血栓,推荐复律后仍进行 4 周抗凝治疗。
参考文献:
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