TOPC 심방세동의 약물 치료

1 MAIN TOPIC REVIEWS14 The Official Journal of Korean Heart Rhythm Society Nam-Ho Kim, MDDepartment of Internal Medicine, Wonkwang University Medical School, Iksan, Korea (rhythm control) (rate control) . , (thromboembolism) . 2014 (AHA/ACC/HRS) .1 (Rate Control) , , - . beta-blockers, non-dihydropyridine calcium channel antagonists, digoxin, amiodarone, sotalol . , , , . (Table 1, Figure 1).

2 Received: September 18, 2014 Revision Received: November 20, 2014 Accepted: December 15, 2014 Corresponding author: Nam-Ho Kim, MD, Division of Cardiology, Department of Internal Medicine, Wonkwang University Medical School, 344-2 Shinyong-dong, Iksan, Jeonbuk 570-711, KoreaTe l: +82-63-859-2523, Fax: +82-63-855-2025E-mail: of AF patients is aimed at reducing symptoms and at preventing severe complications associated with AF. Prevention of AF-related complications relies on antithrombotic therapy, control of ventricular rate, and adequate therapy of concomitant cardiac diseases. These therapies may already alleviate symptoms, but symptom relief may require additional rhythm control therapy by cardioversion, antiarrhythmic drug therapy, or ablation therapy. In this paper, I would like to introduce the 2014 AHA ACC HRS guideline focuses on medical treatment of atrial Words: atrial fibrillation anti-arrhythmic agents guideline15 MAIN TOPIC 1.

3 Common medication dosage for rate control of atrial fibrillation Beta-blockersMetoprolol tartrate2 mg , 3 25-100 mg BIDM etoprolol XL (succinate) 50-400 mg QDAtenolol 25-100 mg QDEsmolol1 500 g/kg, 50-300 g/kg/min Propranolol1 1 mg, 2 3 10-40 mg TID QIDN adolol 10-240 mg QDCarvedilol mg BIDB isoprolol mg QDNon-dihydropyridine calcium channel antagonistsVerapamil2 mg/kg , 30 mg , mg/kg/min : 180-480 mg QDDiltiazem2 mg/kg , 5-15 mg/h : 120-360 mg QDDigitalis mg , 24 mg mg QDOthersAmiodarone1 300 mg, 24 10-50 mg/h100-200 mg QD BID, twice daily; QD, once daily; QID, four times a day; TID, three times a 1. Approach to selecting drug therapy for ventricular rate control Beta blockers should be instituted following stabilization of patients with decompensated HF.

4 The choice of beta blocker (cardio- selective, etc.) depends on the patient s clinical condition. Digoxin is not usually first-line therapy. It may be combined with a beta blocker and/or a non-dihydropyridine calcium channel blocker when ventricular rate control is insufficient and may be useful in patients with HF. In part because of concern over its side-effect profile, use of amiodarone for chronic control of ventricular rate should be reserved for patients who do not respond to or are intolerant of beta blockers or non-dihydropyridine calcium antagonists. Beta-blockerDiltiazemVerapamil Beta-blockerDiltiazemVerapamilAmiodarone Beta-blockerDigoxin Beta-blockerDiltiazemVerapamilMAIN TOPIC REVIEWS16 The Official Journal of Korean Heart Rhythm Society Class I1.

5 , , beta-blocker non-dihydropyridine calcium channel antagonist (level of evidence: B).2. beta-blocker non-dihydropyridine calcium channel blocker . (level of evidence: B).3. (level of evidence: C).Table 2. Recommended drug doses for pharmacological cardioversion of atrial fibrillation Amiodarone 600-800 mg 10 g , 200 mg QD , , , QT , torsades de pointes ( ), , , INR 150 mg 10 , 1 mg/min 6 , mg/min 18 Dofetilide CrCl (mL/min)>6040-6020-40<20 ( g BID)500250125 QT , torsades de pointes; , , Flecainide 200-300 mg 1* , 1:1 , proarrhythmia; Ibutilide 1 mg 10 , 1 mg (60 kg mg/kg)QT , torsades de pointes, Propafenone 450-600 mg 1* , 1:1 , proarrhythmia.

6 * Recommended given in conjunction with a beta blocker or non-dihydropyridine calcium channel antagonist administered 30 minutes before administering the Vaughan Williams Class IC agent. BID, twice daily; QD, once daily17 MAIN TOPIC 3. Dosage and safety considerations for maintenance of sinus rhythm in atrial fibrillation Vaughan Williams class IADisopyramide : 100-200 mg 6 : 200-400 mg 12 QT , QT CYP3A4 : (verapamil, diltiazem, ketoconazole, macrolide anti-biotics, protease inhibitors, ) (rifampin, phenobarbital, phenytoin) Quinidine 324-648 mg 8 QT CYP2D6 : tricyclic antidepressants, metoprolol, antipsychotics P-glycoprotein : digoxin Vaughan Williams class ICFlecainide 50-200 mg 12 CYP2D6 : (quinidine, fluoxetine, tricyclics); 7-10%.

7 Propafenone : 150-300 mg 8 : 225-425 mg 12 CYP2D6 : (quinidine, fluoxetine, tricyclics); 7-10% . Poor metabolizer . P-glycoprotein : digoxin CYP2C9 : warfarin (INR 25% )Vaughan Williams class IIIA miodarone : 2-4 400-600 mg ; 1 100-200 mg : 150 mg 10 ; 6 1 mg/min; 18 mg/min ; 24 mg/min QT CYP : warfarin (INR 0-200% ), statin, P-glycoprotein : digoxin Dofetilide 125-500 g 12 QT QT CYP3A : (verapamil, hydrochlorothiazide, cimetidine, ketoconazole, trimethoprim, prochlorperazine, megestrol).

8 Amiodarone 3 Dronedarone 400 mg 12 long-standing AF/flutter QT CYP3A : (verapamil, diltiazem, ketoconazole, macrolide antibiotics, protease inhibitors, ) (rifampin, phenobarbital, phenytoin) CYP3A, CYP2D6, P-glycoprotein : statins, sirolimus, tacrolimus, beta-blockers, digoxin Sotalol 40-160 mg 12 QT QT ( )MAIN TOPIC REVIEWS18 The Official Journal of Korean Heart Rhythm SocietyClass IIa1. ( <80 / ) (level of evidence: B).2. amiodarone (level of evidence: B).3. (level of evidence: B).

9 Class IIb1. ( <110 / ) (level of evidence: B).2. amiodarone (level of evidence: C).Class III1. (level of evidence: C).2. Non-dihydropyridine calcium channel antagonist (decompensated heart failure) (level of evidence: C).3. digoxin, Figure 2. Strategies for rhythm control in patients with paroxysmal and persistent AF Catheter ablation is only recommended as first-line therapy (dotted line) for patients with paroxysmal AF (Class IIa recommendation). Depending on patient preference when performed in experienced centers.

10 Dofetilide, flecainide, propafenone, sotalol are not recommended with severe LVH (wall thickness > cm). Defetilide, sotalol should be used with caution in patients at risk for torsades de pointes ventricular tachycardia. Flecainide, propafenone should be combined with AV nodal blocking agents. DofetilideDronedaroneFlecainidePropafeno neSotalol Amiodarone AmiodaroneDofeilideDronedaroneSotalolAmi odaroneDofetilide 19 MAIN TOPIC calcium channel antagonist, amiodarone . (level of evidence: B).4. Dronedarone . , , , (level of evidence: B). (Rhythm Control).