JCE：导管消融较药物治疗对老年性持续性房颤具有更好的疗效

心房颤动是临床上常见的心律失常，它是患者致死、致残及住院的独立预测因素。统计资料表明房颤的发病率随年龄的增加而增加，年龄小于70岁的发病率为1.2%-2.8%，年龄大于80岁的发病率为7.3%-13.7%，房颤的平均发病年龄为75岁，70%的房颤患者年龄大于65岁。
转复窦性心律和华法林的使用是改善房颤生存率的两个独立预测因素，然而对于老年患者口服抗凝药物存在较大的风险，首先老年人对华法林较为敏感，其血药浓度受到其他合并症的影响，容易导致出血事件发生，而停药后又容易出现血栓栓塞事件；其次老年人多合并肝肾功能不全，增加药物的毒性及副作用，因此转复窦律是老年患者理想的治疗方法，目前关于药物转复和导管消融对老年房颤患者的有效性及安全性的比较还缺乏相关研究，据此Blandino A等进行了一项临床对照研究，主要比较两种治疗方法对患者的有效性、安全性及生活质量的改善情况。
该研究共入选452例年龄大于70岁的持续性房颤患者，其中153例进行了导管消融，定义为组A，259例使用抗心律失常药物，定义为组B。研究的终点事件：1、治疗失败：任何形式的房颤、房扑、房速发作持续时间超过30秒。2、治疗相关并发症发生：治疗后1个月内发生的为急性并发症，治疗1个月后发生的为慢性并发症。结果提示：通过平均60个月的随访，组A患者一次治疗及两次治疗后窦性心律的维持率分别为58%和76%，而组B分别为43%和46%。组A有15例急性并发症发生，占6.7%，而组B为1%，其中主要为脑血栓栓塞，组A发生率为3.3%，组B为0.7%，既往存在脑卒中或TIA是脑血栓栓塞事件发生的独立预测因素。两组长期并发症的发生率分别为7.7%和23.9%，组B的长期并发症主要为抗心律失常药物的副作用。组A患者中无房性心律失常复发的患者有良好的生活质量。
通过该项研究可得出以下结论：对于年龄较大的持续性房颤患者，导管消融较抗心律失常药物相比具有更好的疗效，并可显著改善患者的生活质量，但是急性血栓事件的发生率较高，尤其对于既往存在卒中或TIA者，而使用抗心律失常药物的患者长期并发症发生率较高。

Long-Term Efficacy and Safety of Two Different Rhythm Control Strategies in Elderly Patients with Symptomatic Persistent Atrial Fibrillation.
BACKGROUND
We prospectively compared the efficacy, safety, and quality of life (QoL) impact of catheter ablation versus antiarrhythmic drugs (AAD) in elderly patients with persistent atrial fibrillation (AF).
METHODS AND RESULTS
Four hundred and twelve consecutive patients, aged ≥ 70 years, underwent ablation (Group A, 153 patients) or AAD (Group B, 259 patients). Study endpoints: treatment failure (any AF/AT lasting >30 seconds) and treatment-related adverse events (acute when ≤1 month of procedure and long term when >1 month). At a follow-up of 60 ± 17 months, 43% and 46% patients in Group B versus 58% and 76% in Group A were in sinus rhythm (SR), respectively, after one (P = 0.003) and 2 procedures (P < 0.001). Fifteen acute adverse events occurred (6.7% in Group A vs 1% in Group B, P < 0.001), mainly periprocedural cerebral thromboembolism (3.3% in Group A vs 0.7% in Group B, P = 0.058). Previous TIA/stroke resulted the only independent predictor of periprocedural cerebrovascular accidents (OR 1.2, 95%IC 1.1-1.3). At follow-up, 74 long-term adverse events occurred (7.7% in Group A vs 23.9% in Group B, P < 0.001) with Group B patients more often experiencing AAD-related adverse events (12.7% vs 2.6%, P < 0.001). Group A and absence of AF/AT recurrences significantly improved QoL scores (P < 0.001).
CONCLUSIONS
In elderly persistent AF patients, catheter ablation is more effective in maintaining SR and in improving QoL than AAD but is affected by a higher risk of embolic complications, particularly in patients with previous TIA/stroke. Over time, Group A patients more likely discontinued AAD with a reduction of long-term adverse events.