Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 138

In the reperfusion era, the incidence of new AF or atrial flutter in acute MI, usually paroxysmal AF/atrial flutter, is ~10%. This incidence is increased in patients with HF, large MI (including RV MI), pericarditis, or older age. AF is associated with an increased in-hospital as well as long-term mortality, which is partly related to the associated pump failure and the late VT/VF.¹⁴⁶ Post-MI AF has been associated with a striking increase in the risk of in-hospital but also long-term stroke across multiple studies, even when AF is only transient.¹⁴⁶ In the GUSTO-1 trial, the in-hospital stroke risk was 3.1% with AF vs. 1.3 % without AF.¹⁴⁷ Another study addressed patients with inferior MI and preserved EF who had transient AF, i.e., AF that spontaneously reverted to sinus rhythm before hospital discharge; these patients had a much higher risk of AF at 1 year than patients without transient AF (22% vs. 1.3%) and a high risk of stroke under aspirin therapy (~10% vs. 2%), despite a normal EF. This suggests that AF occurring during MI is not a transient phenomenon, but rather a chronic process with a high stroke risk.¹⁴⁸

This high risk of stroke supports anticoagulation for peri-MI AF and is further supported by another registry analysis.¹⁴⁹ However, in the era of PCI and routine dual antiplatelet therapy, the role of anticoagulation for transient, peri-MI AF is unclear. The in-hospital use of unfractionated heparin is encouraged to reduce the in-hospital stroke risk, and chronic NOAC therapy is considered along with clopidogrel in patients with a low bleeding risk, while keeping aspirin therapy short (1 week-1 month).

β-Blockers are used for rate control, but are not appropriate in patients with acute HF. In ill patients with acute HF, some degree of tachycardia may be tolerated to prevent a shock state (heart rate of 100–110 bpm). Anti-congestive measures and afterload reduction improve the AF rate; if needed, digoxin and IV amiodarone may be added for rate control.