ACLS-2023 ACC/AHA/ACCP/HRS 心房顫動 Af 處置指引

2026-04-10
今天在FB社團看到有人講到這篇指引. 順便撈出來看看

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

(還有一篇是ACEP的指引.比較精簡  Atrial Fibrillation-Updated on 02/21/2024)
google中文翻譯. 本來將 ischemic stroke 翻譯為"卒中". 但這不是台灣醫師的習慣說法. 還是改成中風.

十大要點
1. 心房顫動（房顫）的分期：以往僅基於心律失常持續時間的房顫分類雖然有用，但往往側重於治療幹預。新提出的分期分類將心房顫動視為疾病連續體，需要在不同的階段採取多種策略，包括預防、生活型態和危險因子介入、篩檢和治療。

2. 心房顫動危險因子介入與預防：本指引認為生活方式和危險因子介入是心房顫動管理的重要支柱，有助於預防心房顫動的發生、進展和不良後果。該指南強調在整個疾病進程中進行風險因素管理，並據此提出更具指導性的建議，包括肥胖管理、減重、體能訓練、戒菸、適度飲酒、高血壓和其他合併症的管理。


3. 靈活運用臨床風險評分，並拓展CHA2DS2-VASc評分以外的其他評分系統以預測卒中和全身性栓塞：目前，抗凝血治療的建議是基於使用經驗證的臨床風險評分（例如CHA2DS2-VASc評分）評估的年度血栓栓塞事件風險。然而，對於年度風險評分處於中等水平且仍不確定是否需要抗凝血治療的患者，可以考慮其他風險變數以輔助決策，或使用其他臨床風險評分來提高預測準確性，促進醫患共同決策，並將其納入電子病歷。

4. 考慮中風危險因子調控：對於缺血性中風為中低風險（<2%）的Af患者，應考慮可能影響其中風危險因子，例如房顫的特徵（如房顫負荷）、不可改變的風險因素（如性別）以及其他動態或可改變的因素（如血壓控制），這些因素有助於醫患共同決策。


5. 早期節律控制：隨著新的、一致的證據不斷湧現，本指南強調對房顫患者進行早期和持續管理的重要性，重點在於維持竇性心律並最大限度地減少房顫負荷。


6. 導管消融術作為特定患者的第一線治療，其建議等級為1級：近期隨機對照研究已證實，對於適當選擇的患者，導管消融術在節律控制方面優於藥物治療。鑑於最新證據，我們提高了推薦等級。

7. 對於EF降低的心臟衰竭患者，導管消融治療心房顫動的建議等級為 1 級：近期隨機研究已證實，導管消融在控制射血分數降低的心臟衰竭患者的節律方面優於藥物治療。鑑於這些數據，我們提高了該類患者的建議等級。


8. 針對器械檢測到的房顫的推薦意見已更新：鑑於近期研究，我們針對器械檢測到的房顫患者提供了更具指導性的推薦意見，這些意見考慮了發作持續時間和患者潛在血栓栓塞風險之間的相互作用。這包括對透過植入式裝置和穿戴式裝置檢測到心房顫動的患者的考慮。


9. 左心耳封堵器的建議等級提高：鑑於關於左心耳封堵器安全性和有效性的更多數據，與 2019 年房顫重點更新相比，對於長期存在抗凝禁忌症的患者，左心耳封堵器的推薦級別已提升至 2a 級。

10. 對於在疾病或手術期間發現心房顫動的患者（誘發因素），建議：重點在於非心臟疾病或其他誘發因素（如手術）期間發現心房顫動後心房顫動復發的風險。
Top 10 Take-Home Messages
1. Stages of atrial fibrillation (AF): The previous classification of AF, which was based only on arrhythmia duration, although useful, tended to emphasize therapeutic interventions. The new proposed classification, using stages, recognizes AF as a disease continuum that requires a variety of strategies at the different stages, from prevention, lifestyle and risk factor modification, screening, and therapy.
2. AF risk factor modification and prevention: This guideline recognizes lifestyle and risk factor modification as a pillar of AF management to prevent onset, progression, and adverse outcomes. The guideline emphasizes risk factor management throughout the disease continuum and offers more prescriptive recommendations, accordingly, including management of obesity, weight loss, physical activity, smoking cessation, alcohol moderation, hypertension, and other comorbidities.
3. Flexibility in using clinical risk scores and expanding beyond CHA2DS2-VASc for prediction of stroke and systemic embolism: Recommendations for anticoagulation are now made based on yearly thromboembolic event risk using a validated clinical risk score, such as CHA2DS2-VASc. However, patients at an intermediate annual risk score who remain uncertain about the benefit of anticoagulation can benefit from consideration of other risk variables to help inform the decision, or the use of other clinical risk scores to improve prediction, facilitate shared decision making, and incorporate into the electronic medical record.
4. Consideration of stroke risk modifiers: Patients with AF at intermediate to low (<2%) annual risk of ischemic stroke can benefit from consideration of factors that might modify their risk of stroke, such as the characteristics of their AF (eg, burden), nonmodifiable risk factors (sex), and other dynamic or modifiable factors (blood pressure control) that may inform shared decision-making discussions.
5. Early rhythm control: With the emergence of new and consistent evidence, this guideline emphasizes the importance of early and continued management of patients with AF that should focus on maintaining sinus rhythm and minimizing AF burden.
6. Catheter ablation of AF receives a Class 1 indication as first-line therapy in selected patients: Recent randomized studies have demonstrated the superiority of catheter ablation over drug therapy for rhythm control in appropriately selected patients. In view of the most recent evidence, we upgraded the Class of Recommendation.
7. Catheter ablation of AF in appropriate patients with heart failure with reduced ejection fraction receives a Class 1 indication: Recent randomized studies have demonstrated the superiority of catheter ablation over drug therapy for rhythm control in patients with heart failure and reduced ejection failure. In view of the data, we upgraded the Class of Recommendation for this population of patients.
8. Recommendations have been updated for device-detected AF: In view of recent studies, more prescriptive recommendations are provided for patients with device-detected AF that consider the interaction between episode duration and the patient's underlying risk for thromboembolism. This includes considerations for patients with AF detected via implantable devices and wearables.
9. Left atrial appendage occlusion devices receive higher level Class of Recommendation: In view of additional data on safety and efficacy of left atrial appendage occlusion devices, the Class of Recommendation has been upgraded to 2a compared with the 2019 AF Focused Update for use of these devices in patients with long-term contraindications to anticoagulation.
10. Recommendations are made for patients with AF identified during medical illness or surgery (precipitants): Emphasis is made on the risk of recurrent AF after AF is discovered during noncardiac illness or other precipitants, such as surgery.