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摘要: 随着技术进步，心房颤动(房颤)的诊断和治疗发生了显著变化。在房颤的诊断、筛查方面，植入式心脏监测设备和长程心电图使得房颤的早期识别成为可能；基于光电容积脉搏波(PPG)技术的智能手表等可穿戴设备为房颤筛查及房颤负荷的测量提供了便捷且无创的解决方案。在治疗方面，新型口服抗凝药显著提高了抗凝治疗的安全性与有效性，而左心耳封堵术则为无法使用抗凝药物的患者提供了替代的卒中预防策略。房颤的节律控制治疗，尤其是导管消融手术，其治疗目标已逐步从单纯的症状控制转向改善患者的长期预后，并且独立术者培训周期成倍缩短，严重并发症显著减少。随着经验积累，新的消融术式显著提高了持续性房颤的治疗成功率，而脉冲场消融(PFA)作为新一代消融能量，有望在节律控制治疗中发挥重要作用。本文将重点探讨房颤在诊断、筛查和治疗方面的最新进展。Abstract: With advancements in technology, the diagnosis and treatment of atrial fibrillation (AF) have undergone significant changes.In terms of diagnosis and screening, implantable cardiac monitoring devices and long-term electrocardiograms have made early detection of AF possible.Wearable devices such as smartwatches based on PPG technology provide convenient and non-invasive solutions for AF screening and the measurement of AF burden.In treatment, novel oral anticoagulants have markedly improved the safety and efficacy of anticoagulation therapy, while left atrial appendage closure offers an alternative stroke prevention strategy for patients unable to use anticoagulants.Rhythm control therapies for AF, particularly catheter ablation, have shifted their focus from mere symptom control to improving long-term patient outcomes.Additionally, the training period for independent practitioners has been significantly shortened, and the safety of the technique has greatly improved.With accumulated experience, new ablation techniques have significantly enhanced the success rate of treating persistent AF, and pulsed-field ablation (PFA), as a next-generation ablation modality, holds promise for playing a pivotal role in rhythm control therapies in the future.This article will focus on the latest advances in diagnosis, screening, and treatment of atrial fibrillation.
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Key words:
- atrial fibrillation /
- diagnosis /
- screening /
- treatment
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[1] Soliman EZ, Safford MM, Muntner P, et al. Atrial fibrillation and the risk of myocardial infarction[J]. JAMA Intern Med, 2014, 174(1): 107-114. doi: 10.1001/jamainternmed.2013.11912
[2] Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study[J]. Stroke, 1991, 22(8): 983-988. doi: 10.1161/01.STR.22.8.983
[3] Xu S, Chen Y, Lin R, et al. Burden of atrial fibrillation and its attributable risk factors from 1990 to 2019: An analysis of the Global Burden of Disease study 2019[J]. Front Cardiovasc Med, 2022, 9: 997698. doi: 10.3389/fcvm.2022.997698
[4] Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences(Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology[J]. Circulation, 2001, 104(17): 2118-2150. doi: 10.1161/circ.104.17.2118
[5] January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society[J]. J Am Coll Cardiol, 2014, 64(21): e1-76. doi: 10.1016/j.jacc.2014.03.022
[6] January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[J]. J Am Coll Cardiol, 2019, 74(1): 104-132. doi: 10.1016/j.jacc.2019.01.011
[7] Schwennesen HT, Andrade JG, Wood KA, et al. Ablation to Reduce Atrial Fibrillation Burden and Improve Outcomes: JACC Review Topic of the Week[J]. J Am Coll Cardiol, 2023, 82(10): 1039-1050. doi: 10.1016/j.jacc.2023.06.029
[8] Chew DS, Li Z, Steinberg BA, et al. Arrhythmic Burden and the Risk of Cardiovascular Outcomes in Patients With Paroxysmal Atrial Fibrillation and Cardiac Implanted Electronic Devices[J]. Circ Arrhythm Electrophysiol, 2022, 15(2): e010304. doi: 10.1161/CIRCEP.121.010304
[9] Wong JA, Conen D, Van Gelder IC, et al. Progression of Device-Detected Subclinical Atrial Fibrillation and the Risk of Heart Failure[J]. J Am Coll Cardiol, 2018, 71(23): 2603-2611. doi: 10.1016/j.jacc.2018.03.519
[10] Willems S, Borof K, Brandes A, et al. Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial[J]. Eur Heart J, 2022, 43(12): 1219-1230. doi: 10.1093/eurheartj/ehab593
[11] Joglar JA, Chung MK, Armbruster AL, et al. 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[J]. J Am Coll Cardiol, 2024, 83(1): 109-279. doi: 10.1016/j.jacc.2023.08.017
[12] Zhao Z, Li Q, Li S, et al. Evaluation of an algorithm-guided photoplethysmography for atrial fibrillation burden using a smartwatch[J]. Pacing Clin Electrophysiol, 2024, 47(4): 511-517. doi: 10.1111/pace.14951
[13] 李起帆, 左嵩, 赖一炜, 等. 采用可穿戴设备连续光电容积脉搏波算法检测心房颤动的临床价值[J]. 中华心血管病杂志, 2024, 52(5): 513-518. doi: 10.3760/cma.j.cn112148-20230911-00150
[14] Zhu L, Nathan V, Kuang J, et al. Atrial Fibrillation Detection and Atrial Fibrillation Burden Estimation via Wearables[J]. IEEE J Biomed Health Inform, 2022, 26(5): 2063-2074. doi: 10.1109/JBHI.2021.3131984
[15] Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery(EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology(ESC)Developed with the special contribution of the European Heart Rhythm Association(EHRA)of the ESC[J]. Eur Heart J, 2021, 42(5): 373-498. doi: 10.1093/eurheartj/ehaa612
[16] Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery(EACTS)[J]. Eur Heart J, 2024, 45(36): 3314-3414. doi: 10.1093/eurheartj/ehae176
[17] Brachmann J, Morillo CA, Sanna T, et al. Uncovering atrial fibrillation beyond short-term monitoring in cryptogenic stroke patients: three-year results from the cryptogenic stroke and underlying atrial fibrillation trial[J]. Circ Arrhythm Electrophysiol, 2016, 9(1): e003333.
[18] Perez MV, Mahaffey KW, Hedlin H, et al. Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation[J]. N Engl J Med, 2019, 381(20): 1909-1917. doi: 10.1056/NEJMoa1901183
[19] Guo Y, Wang H, Zhang H, et al. Mobile Photoplethysmographic Technology to Detect Atrial Fibrillation[J]. J Am Coll Cardiol, 2019, 74(19): 2365-2375. doi: 10.1016/j.jacc.2019.08.019
[20] Attia ZI, Noseworthy PA, Lopez-Jimenez F, et al. An artificial intelligence-enabled ECG algorithm for the identification of patients with atrial fibrillation during sinus rhythm: a retrospective analysis of outcome prediction[J]. Lancet, 2019, 394(10201): 861-867. doi: 10.1016/S0140-6736(19)31721-0
[21] Noseworthy PA, Attia ZI, Behnken EM, et al. Artificial intelligence-guided screening for atrial fibrillation using electrocardiogram during sinus rhythm: a prospective non-randomised interventional trial[J]. Lancet, 2022, 400(10359): 1206-1212. doi: 10.1016/S0140-6736(22)01637-3
[22] Svennberg E, Friberg L, Frykman V, et al. Clinical outcomes in systematic screening for atrial fibrillation(STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial[J]. Lancet, 2021, 398(10310): 1498-1506. doi: 10.1016/S0140-6736(21)01637-8
[23] Svendsen JH, Diederichsen SZ, Hojberg S, et al. Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial[J]. Lancet, 2021, 398(10310): 1507-1516. doi: 10.1016/S0140-6736(21)01698-6
[24] Lopes RD, Atlas SJ, Go AS, et al. Effect of Screening for Undiagnosed Atrial Fibrillation on Stroke Prevention[J]. J Am Coll Cardiol, 2024, 84(21): 2073-2084. doi: 10.1016/j.jacc.2024.08.019
[25] 中华医学会心血管病学分会, 中国生物医学工程学会心律分会. 心房颤动诊断和治疗中国指南[J]. 中华心血管病杂志, 2023, 51(6): 572-618. doi: 10.3760/cma.j.cn112148-20230416-00221
[26] Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation[J]. Chest, 2010, 137(2): 263-272. doi: 10.1378/chest.09-1584
[27] Melgaard L, Gorst-Rasmussen A, Lane DA, et al. Assessment of the CHA2DS2-VASc Score in Predicting Ischemic Stroke, Thromboembolism, and Death in Patients With Heart Failure With and Without Atrial Fibrillation[J]. JAMA, 2015, 314(10): 1030-1038. doi: 10.1001/jama.2015.10725
[28] Siu CW, Lip GY, Lam KF, et al. Risk of stroke and intracranial hemorrhage in 9727 Chinese with atrial fibrillation in Hong Kong[J]. Heart Rhythm, 2014, 11(8): 1401-1408. doi: 10.1016/j.hrthm.2014.04.021
[29] Guo Y, Apostolakis S, Blann AD, et al. Validation of contemporary stroke and bleeding risk stratification scores in non-anticoagulated Chinese patients with atrial fibrillation[J]. Int J Cardiol, 2013, 168(2): 904-909. doi: 10.1016/j.ijcard.2012.10.052
[30] Renoux C, Coulombe J, Suissa S. Revisiting sex differences in outcomes in non-valvular atrial fibrillation: a population-based cohort study[J]. Eur Heart J, 2017, 38(19): 1473-1479.
[31] Lan DH, Jiang C, Du X, et al. Female Sex as a Risk Factor for Ischemic Stroke and Systemic Embolism in Chinese Patients With Atrial Fibrillation: A Report From the China-AF Study[J]. J Am Heart Assoc, 2018, 7(19): e009391. doi: 10.1161/JAHA.118.009391
[32] Kang SH, Choi EK, Han KD, et al. Risk of ischemic stroke in patients with non-valvular atrial fibrillation not receiving oral anticoagulants-Korean nationwide population-based study[J]. Circ J, 2017, 81(8): 1158-1164. doi: 10.1253/circj.CJ-16-1267
[33] Kim D, Yang PS, Kim TH, et al. Ideal Blood Pressure in Patients With Atrial Fibrillation[J]. J Am Coll Cardiol, 2018, 72(11): 1233-1245. doi: 10.1016/j.jacc.2018.05.076
[34] Lee SS, Ae Kong K, Kim D, et al. Clinical implication of an impaired fasting glucose and prehypertension related to new onset atrial fibrillation in a healthy Asian population without underlying disease: a nationwide cohort study in Korea[J]. Eur Heart J, 2017, 38(34): 2599-2607. doi: 10.1093/eurheartj/ehx316
[35] Chao TF, Chiang CE, Chen TJ, et al. Reassessment of Risk for Stroke During Follow-up of Patients With Atrial Fibrillation[J]. Ann Intern Med, 2019, 170(9): 663-664. doi: 10.7326/M18-1177
[36] Chao TF, Liao JN, Tuan TC, et al. Incident Co-Morbidities in Patients with Atrial Fibrillation Initially with a CHA2DS2-VASc Score of 0(Males)or 1(Females): Implications for Reassessment of Stroke Risk in Initially 'Low-Risk' Patients[J]. Thromb Haemost, 2019, 119(7): 1162-1170. doi: 10.1055/s-0039-1683933
[37] Kamel H, Longstreth WT Jr, Tirschwell DL, et al. The Atrial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke randomized trial: Rationale and methods[J]. Int J Stroke, 2019, 14(2): 207-214. doi: 10.1177/1747493018799981
[38] Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2009, 361(12): 1139-1151. doi: 10.1056/NEJMoa0905561
[39] Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation[J]. N Engl J Med, 2011, 365(10): 883-891. doi: 10.1056/NEJMoa1009638
[40] Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2011, 365(11): 981-992. doi: 10.1056/NEJMoa1107039
[41] Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2013, 369(22): 2093-2104. doi: 10.1056/NEJMoa1310907
[42] Kirchhof P, Toennis T, Goette A, et al. Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes[J]. N Engl J Med, 2023, 389(13): 1167-1179. doi: 10.1056/NEJMoa2303062
[43] Schnabel RB, Benezet-Mazuecos J, Becher N, et al. Anticoagulation in device-detected atrial fibrillation with or without vascular disease: a combined analysis of the NOAH-AFNET 6 and ARTESiA trials[J]. Eur Heart J, 2024, 45(46): 4902-4916. doi: 10.1093/eurheartj/ehae596
[44] REACT-AF: Rhythm Evaluation for AntiCoagulaTion With Continuous Monitoring of Atrial Fibrillation[Z]. National Heart L, Blood I. 2023.
[45] Piccini JP, Patel MR, Steffel J, et al. Asundexian versus Apixaban in Patients with Atrial Fibrillation[J]. N Engl J Med, 2025, 392(1): 23-32. doi: 10.1056/NEJMoa2407105
[46] Ruff CT, Patel SM, Giugliano RP, et al. Abelacimab versus Rivaroxaban in Patients with Atrial Fibrillation[J]. N Engl J Med, 2025, 392(4): 361-371. doi: 10.1056/NEJMoa2406674
[47] Osmancik P, Herman D, Neuzil P, et al. Left Atrial Appendage Closure Versus Direct Oral Anticoagulants in High-Risk Patients With Atrial Fibrillation[J]. J Am Coll Cardiol, 2020, 75(25): 3122-3135. doi: 10.1016/j.jacc.2020.04.067
[48] Wazni OM, Saliba WI, Nair DG, et al. Left Atrial Appendage Closure after Ablation for Atrial Fibrillation[J]. N Engl J Med, 2024.
[49] Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation[J]. N Engl J Med, 2002, 347(23): 1825-1833. doi: 10.1056/NEJMoa021328
[50] Carlsson J, Miketic S, Windeler J, et al. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation(STAF)study[J]. J Am Coll Cardiol, 2003, 41(10): 1690-1696. doi: 10.1016/S0735-1097(03)00332-2
[51] Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation[J]. N Engl J Med, 2020, 383(14): 1305-1316. doi: 10.1056/NEJMoa2019422
[52] 马长生, 刘晓霞. 心房颤动进入节律控制时代[J]. 中华心血管病杂志, 2021, 49(3): 205-206. doi: 10.3760/cma.j.cn112148-20210201-00118
[53] Packer DL, Mark DB, Robb RA, et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial[J]. JAMA, 2019, 321(13): 1261-1274. doi: 10.1001/jama.2019.0693
[54] Mark DB, Anstrom KJ, Sheng S, et al. Effect of catheter ablation vs medical therapy on quality of life among patients with atrial fibrillation: the CABANA randomized clinical trial[J]. JAMA, 2019, 321(13): 1275-1285. doi: 10.1001/jama.2019.0692
[55] Marrouche NF, Brachmann J, Andresen D, et al. Catheter Ablation for Atrial Fibrillation with Heart Failure[J]. N Engl J Med, 2018, 378(5): 417-427. doi: 10.1056/NEJMoa1707855
[56] Sohns C, Fox H, Marrouche NF, et al. Catheter Ablation in End-Stage Heart Failure with Atrial Fibrillation[J]. N Engl J Med, 2023, 389(15): 1380-1389. doi: 10.1056/NEJMoa2306037
[57] Al-Kaisey AM, Parameswaran R, Bryant C, et al. Atrial Fibrillation Catheter Ablation vs Medical Therapy and Psychological Distress: A Randomized Clinical Trial[J]. JAMA, 2023, 330(10): 925-933. doi: 10.1001/jama.2023.14685
[58] 李思彤, 李起帆, 赖一炜, 等. 持续性房颤消融技术的争议与评价[J]. 中华心血管病杂志, 2023, 51(9): 909-914.
[59] Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation[J]. N Engl J Med, 2015, 372(19): 1812-1822. doi: 10.1056/NEJMoa1408288
[60] Marrouche NF, Wazni O, McGann C, et al. Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The DECAAF II Randomized Clinical Trial[J]. JAMA, 2022, 327(23): 2296-2305. doi: 10.1001/jama.2022.8831
[61] Kistler PM, Chieng D, Sugumar H, et al. Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial[J]. JAMA, 2023, 329(2): 127-135. doi: 10.1001/jama.2022.23722
[62] Valderrabano M, Peterson LE, Swarup V, et al. Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation: The VENUS Randomized Clinical Trial[J]. JAMA, 2020, 324(16): 1620-1628. doi: 10.1001/jama.2020.16195
[63] Sang C, Liu Q, Lai Y, et al. Pulmonary vein isolation with optimized linear ablation vs pulmonary vein isolation alone for persistent AF: the PROMPT-AF randomized clinical trial[J]. JAMA, 2025, 333(5): 381-389. doi: 10.1001/jama.2024.24438
[64] Ekanem E, Neuzil P, Reichlin T, et al. Safety of pulsed field ablation in more than 17, 000 patients with atrial fibrillation in the MANIFEST-17K study[J]. Nat Med, 2024, 30(7): 2020-2029. doi: 10.1038/s41591-024-03114-3
[65] Reddy VY, Gerstenfeld EP, Natale A, et al. Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation[J]. N Engl J Med, 2023, 389(18): 1660-1671. doi: 10.1056/NEJMoa2307291
[66] Chu M, Zhang S, Gong J, et al. Telemedicine-based integrated management of atrial fibrillation in village clinics: a cluster randomized trial[J]. Nat Med, 2025.
[67] 王珏, 何柳, 马长生. 协作创新助力我国心血管随机对照试验提速[J]. 中华心血管病杂志, 2024, 52(10): 1131-1137. doi: 10.3760/cma.j.cn112148-20240820-00464
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