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.

2 , , , . (Table 1, Figure 1). 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.

3 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. 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.

4 120-360 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. 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.

5 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. , , beta-blocker non-dihydropyridine calcium channel antagonist (level of evidence: B).

6 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.

7 Ibutilide 1 mg 10 , 1 mg (60 kg mg/kg)QT , torsades de pointes, Propafenone 450-600 mg 1* , 1:1 , proarrhythmia; * 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.

8 Digoxin Vaughan Williams class ICFlecainide 50-200 mg 12 CYP2D6 : (quinidine, fluoxetine, tricyclics); 7-10% . 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).

9 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).

10 3. (level of evidence: B).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.