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心房撲動的處理原則
1.
心房撲動(Atrial flutter)的處理原則 台中榮總 心臟內科 謝育整醫師
吳茲睿主任 心房撲動(atrial flutter, AFL)是一種常見的心房心律不整,它的 機轉是心房大迴旋波(macro-reentrant)引起的規則性心房心搏過速, 心電圖上可見心房軸向在 II、III、aVF、V1 產生規則鋸齒狀的快速 (250-350/min)去極化波形。由於心房撲動經常與心房顫動(atrial fibrillation, AF)交替轉換,因此,這兩種心律不整也常被合稱為 “atrial fib-flutter”,心房撲動的主要治療目標包括: (1). 轉換回正常竇性節律:不論使用電氣(體內或體外電擊)或藥物 整復術(cardioversion),在實施前必須先給予病患連續三週服用足量 (INR:2-3)的抗凝血劑(warfarin),以避免在轉換回正常竇性節律時, 心房的收縮將左心房血栓輸送到體循環產生栓塞(如附表一)。對於心 臟結構正常而產生陣發性心房撲動的病患,也可由病患自行服用 ClassⅠ 抗心律不整藥(如 propafenone),又稱為口袋內藥丸法(pill-in- pocket),來轉回正常竇性節律。心導管電氣燒灼治療的適應症包括: 對於藥物反應不佳、服藥產生藥物副作用及不願長期服藥的病患。近 年來由於電燒灼技術大幅進步,只要有症狀且沒有可逆原因的心房 撲動,都可以第一線使用電燒灼治療,成功率可達 90%以上。
2.
(2). 維持正常竇性節律:使用 ClassⅠ(如
propafenone)及 ClassⅢ(如 sotalol、amiodarone)抗心律不整藥物,可維持竇性節律。然而,這些 藥物本身卻可能引發心室心律不整而必須小心使用。若在住院中開始 使用 sotalol 或 propafenone 後,門診追蹤則須定期測量 QTC 延長的情 況,而 amiodarone 引發的肝、肺及甲狀腺毒性也須定期監測。 (3). 控制心室速率:目的是防止長期的心搏過速引發左心室功能 惡化,並控制病患的症狀(如心悸、頭昏等)。用藥原則與心房顫動相同, 包括使用乙型阻斷劑、非 DHP 離子阻斷劑、毛地黃或鈣 amiodarone。 (4). 防止血栓產生:心房撲動的病患經常處於心房撲動(AFL)與 顫動(AF)的交替轉換,因此單純的心房撲動引起的血栓風險很難單 獨評估。依照美國及歐洲心臟學會的治療準則,心房撲動的抗凝血治 療原則比照心房顫動,CHADS2 2 分以上的病患就應使用抗凝血劑, 將 INR 維持在 2-3 之間。
3.
附表一: 心房撲動/顫動且即將接受心臟整復術治療病患的抗凝血治療準則(美國 及歐洲心臟學會) 第 I
級: 依現有證據確認為有效的治療方式 -若心房撲動/顫動的時間超過 48 小時或時間未知,則不論使用電氣(體內或體外電擊)或藥物整 復術(cardioversion),在實施前必須先給予病患至少三週服用足量(INR:2-3)的抗凝血劑,並在 整復術實施後服用至少四週。 -若心房撲動/顫動的時間超過 48 小時,因血流動力學不穩定而須立刻進行整復術 (cardioversion) 1. 同時給予單一及維持劑量的傳統肝素 heparin 治療後,讓 APTT 維持在標準 的值 1.5-2.0 倍。 2. 在整復術實施後連續服用至少四週足量(INR:2-3)的抗凝血劑。 3. 低分子量肝素 heparin 的治療成效證據有限。 -若心房撲動/顫動的時間小於 48 小時且血流動力學不穩定,則整復術可直接實行,再給予病患 抗凝血劑治療。 第 IIa 級: 依現有證據傾向為有效的治療方式 -若心房撲動/顫動的時間超過 48 小時,整復術(cardioversion)前後的抗凝血劑治療必須考慮病患 的血栓風險。 -另一個替代整復術前抗凝血劑治療的方式,即是在整復術實施前,先用食道超音波偵測左心房 血栓是否存在。 1. 如果左心房沒有血栓,給予單一及維持劑量的傳統肝素 heparin 治療後(APTT 維持在標準 的值
4.
1.5-2.0 倍),可直接實行整復術,肝素 heparin
治療須持續到口服抗凝血劑生效(INR:2-3),且 口服抗凝血劑在整復術實施後連續服用至少四週,而低分子量肝素 heparin 在此情況的治療 成效證據有限。 2. 如果左心房有血栓,在整復術實施前必須先給予病患至少三週服用足量(INR:2-3)的抗凝血劑, 並在整復術實施後服用至少四週,更長的整復術後抗凝血劑治療期間也是適當的,因為此類 病患的血栓風險仍高。 -心房撲動病患的抗凝血治療準則等同心房顫動病患。