Prewencja nawrotu migotania przedsionków po skutecznej kardiowersji – dane z rejestru Cochrane

Kwiecień 22, 2014  |  Udostępnij  | 

Migotanie przedsionków (FA), będące najczęstszą arytmią występującą w populacji ogólnej, jest w ostatnim czasie tematem szczególnie wielu prac badawczych. Dzieje się tak głównie za sprawą wprowadzenia na rynek farmaceutyczny nowych doustnych antykoagulantów – leków mających zastąpić stosowane do tej pory preparaty (antagonistów witaminy K) w zapobieganiu powikłaniom zatorowym FA. Jednocześnie wciąż żywa jest debata naukowa nad leczeniem samego migotania. W poniższym artykule przedstawimy wyniki analizy[1], która dotyczyła właśnie jednej ze strategii terapeutycznych stosowanych u pacjentów z FA – przywracania rytmu zatokowego. Kardiowersja (DC), zarówno elektryczna jak i farmakologicza, jest bardzo często zabiegiem skutecznym, przynajmniej w krótkiej perspektywie. Znacznie większym problemem jest utrzymanie rytmu zatokowego na okres wielu miesięcy, optymalnie lat. W celu maksymalizacji szans na trwały efekt DC stosowane są leki antyarytmiczne. To właśnie efektom ich działania, wpływowi na pozostanie chorego „w zatoce” oraz wywoływanym przez nie działaniom niepożądanym poświęcono analizę, której wyniki opiszemy w poniższym tekście.

Autorzy omawianego opracowania wzięli pod uwagę badania w pełni randomizowane  z co najmniej półrocznym okresem obserwacji, w których porównywano działanie leku antyarytmicznego w porównaniu z placebo po udanym przywróceniu rytmu zatokowego. Odpowiednich publikacji poszukiwano w bazach Cochrane, MEDLINE (od 1950r.) oraz EMBSE (od 1966r.), ostatecznie włączając do analizy 56 badań, w których obserwowano łącznie ponad 20 tysięcy pacjentów.  Do pierwszorzędowych punktów końcowych opisujących skuteczność terapii zaliczono: ryzyko zgonu chorego i powikłań zatorowych (w tym udarów), za punkt drugorzędowy uznano nawrót FA. Bezpieczeństwo terapii analizowano biorąc pod uwagę częstość zaprzestawania leczenia z różnych przyczyn (zgon, nasilenie arytmii, poszerzenie zesp. QRS, wydłużenie odstępu QT). Po przeliczeniu zebranych danych wyniki przedstawiały się następująco: ilość zgonów w sposób istotny statystycznie zwiększał sotalol, natomiast podobny niekorzystny trend (bez istotności statystycznej) wykazano w przypadku chinidyny, dizopyramidu, azymilidu. W przypadku pozostałych preparatów nie obserwowano wpływu na ryzyko śmierci chorego. Wszystkie badane leki, z wyjątkiem amiodaronu, dronedaronu i propafenonu, wykazywały efekt proarytmiczny. Chorzy leczeni amiodaronem istotnie rzadziej rezygnowali z leczenia (p=0,006) i mieli mniejszą ilość arytmii (p=0,0007), gdy porównano ich dane z danymi chorych przyjmujących pozostałe leki klasy I. Porównanie amiodaronu do placebo nie wypadło jednak równie pomyślnie – pacjenci leczeni tym lekiem antyarytmicznym częściej rezygnowali z leczenia. Wszystkie preparaty zaliczane do klas IA, IC, III, a także metoprolol, w sposób istotny statystycznie redukowały ryzyko nawrotu FA. Podobnego efektu nie rejestrowano w przypadku leków z klasy IB. Łączna częstość nawrotów FA u chorych nieleczonych (grupa kontrolna) wyniosła 69-84%, podczas gdy leki antyarytmiczne pozwalały na zmniejszenie tego odsetka do poziomu 43-67%. Porównując amiodaron bezpośrednio z poszczególnymi grupami leków wykazano jego wyższość pod względem częstości nawrotów FA – vs. leki klasy I (iloraz szans (OR) 0,36; p<0,00001), vs. dronedaron (OR=0,45; p<0,00001) oraz vs. sotalol 0,43; p<0,00001).

Podsumowując przedstawione wyniki należy zauważyć, że spośród stosowanych leków antyarytmicznych u chorych po kardiowersji elektrycznej migotania przedsionków najskuteczniejszą substancją jest amiodaron. Po drugiej stronie klasyfikacji uplasował się sotalol, który co prawda także ma udokumentowany wpływ na zmniejszenie częstości nawrotów FA, jednak jako jedyny spośród badanych leków w sposób istotny statystycznie zwiększa śmiertelność.

1. Lafuente-Lafuente C et al., Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev. 2012 May 16;5:CD005049



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i s choledochojejunostomy k o l e d o k o j i j u N O St o m e choledochotomy k o l e d o K O T o m e DIGESTIVE SYSTEM TERM PRONUNCIATION MEANING cholelithiasis k o l e l i TH I a s i s colon K O l o n colonic k o L O N i k colonoscopy k o l o n O Sk o p e colostomy k o L O St o m e common bile duct K O M o n b i l d u kt defecation d e f e K A sh u n deglutition d e glooT I SH u n dentibuccal d e nt i B U K a l dentin D E Nt i n digestion d i J E STy u n duodenal d u o D E n a l or d u O D e n a l duodenum d u o D E n u m or d u O D e n u m elimination e l i m i N A sh u n emulsication e m u ls i f i K A sh u n enamel e N A M e l endodontist e nd o D O Nt i st enterocolitis e nt e r o k o L I t i s enteroenterostomy e nt e r o e nt e r O St o m e enzyme E Nz i m esophageal e s o f a J E a l esophagus e S O F a g u s fatty acids F A Tt e A s i dz facial F A sh u l feces F E s e z gallbladder GAWLbl a d e r gastrointestinal tract g a str o i nT E St i n a l tr a ct gastrojejunostomy g a str o j e j u N O St o m e gastrostomy g a sTR O St o m e gingivitis j i nj i V I t i s gluconeogenesis glook o n e o J E N e s i s DIGESTIVE SYSTEM TERM PRONUNCIATION MEANING glucose GLOOk o s glycogen GL I k o j e n glycogenolysis gl i k o j e N O L i s i s hepatoma h e p a T O m a hepatomegaly h e p a t o M E G a l E hydrochloric acid h i dr o KL O R i k A s i d hyperbilirubinemia h i p e rb i l i roob i N E m e a hyperglycemia h i p e rgl i S E m e a hypoglossal h i p o GL O s a l ileitis i l e I t i s ileocecal sphincter i l e o S E k a l SF I NKt e r ileostomy i l e O St o m e ileum I L e u m incisor i nS I z o r insulin I Ns u l i n jejunum j e JOOn u m labial L A b e a l laparoscopy l a p a R O Sk o p e lipase L I p a s lithogenesis l i th o J E N e s i s liver L I v e r lower esophageal sphincter L O W e r e s o f a J E a l SF I NKt e r mastication m a st i K A sh u n mesentery M E S e nt e r e molar teeth M O l a r t e th oral O R a l orthodontist o rth o D O Nt i st palate P A L a t palatopharyngoplasty p a l a t o f a R I NGg o pl a st e palatoplasty P A L a t o pl a st e pancreas P A Nkr e a s pancreatitis p a nkr e a T I t i s papillae p a P I L e DIGESTIVE SYSTEM TERM PRONUNCIATION MEANING parenteral p a R E Nt e r a l parotid gland p a R O T i d gl a nd perianal p e r e A n a l periodontist p e r e o D O Nt i st peritonitis p e r i t o N I t i s peristalsis p e r i ST A Ls i s pharyngeal f a r a nJ E a l or f a R I Nj e a l pharynx F A R i nks portal vein P O Rt a l v a n postprandial p o stPR A Nd e a l premolar teeth pr e M O l a r t e th proctologist pr o kT O L o j i st protease PR O t e a se pulp p u lp pyloric sphincter p i L O R i k SF I NKt e r pyloroplasty p i L O R o pl a st e pylorus p i L O R u s rectocele R E Kt o s e l rectum R E Kt u m rugae ROOg e saliva s a L I v a salivary glands S A L i v a r e gl a ndz sialadenitis s i a l a d e N I t i s sialolith s i A L o l i th sigmoid colon S I Gmoyd K O l o n sigmoidoscopy s i gmoyd O Sk o p e sphincter SF I NKt e r steatorrhea st e a t o R E a stomach STOMak stomatitis st o m a T I t i s sublingual s u bL I NGw a l submandibular s u bm a nD I B u l a r DIGESTIVE SYSTEM TERM PRONUNCIATION MEANING triglycerides tr i GL I s e r i dz uvula U v u l a uvulectomy u v u L E Kt o m e villi V I L i Pathologic Terminology TERM PRONUNCIATION MEANING achalasia a k a hL A z e a anal stula A n a l F I St u l a anorexia a n o R E Ks e a aphthous stomatitis A Fth u s st o m a T I t i s ascites a S I t e z borborygmus b o rb o R I Gm u s cholelithiasis k o l e l i TH I a s i s cirrhosis s i rR O s i s colonic polyps k o L O N i k p o l i ps colorectal cancer k o l o R E Kt a l K A Ns e r constipation c o nst i P A sh u n Crohn disease kr o n d i Z E Z dental caries D E Nt a l K A R e z diarrhea d i a hR E a diverticula d i v e rT I K u l a diverticulitis d i v e rt i k u L I t i s diverticulosis d i v e rt i k u L O s i s dysentery D I S e nt e r e dysphagia d i sPH A j e a eructation e r u kT A sh u n esophageal cancer e s o f a J E a l K a Ns e r esophageal varices e s o f a J E a l V A R i s e z etiology e t e O L o j e atus FL A t u s DIGESTIVE SYSTEM TERM PRONUNCIATION MEANING gastric cancer G A Str i k K A Ns e r gastroesophageal reux disease g a str o e s o f a J E a l R E u x d i Z E Z hematochezia h e m a t o K E z e a hemorrhoids H E M o roydz herpetic stomatitis h e rP E T i k st o m a T I t i s hiatal hernia h i A t a l H E Rn e a icterus I Kt e r u s idiopathic i d e o P A TH i k ileus I L e u s inammatory bowel disease i nFL A m a t o r e B O W e l d i Z E Z inguinal hernia I NGw i n a l H E Rn e a intussusception i nt u ss u sS E Psh u n irritable bowel syndrome I R i t a bl B O W e l S I Ndr o m jaundice J A WNd i s lipoma l i P O m a melena M E L e n a or m e L E n a nausea N A Wz e a oral leukoplakia O R a l l u k o PL A k e a pancreatic cancer p a nkr e A t i c K A Ns e r pancreatitis p a nkr e a T I t i s peptic ulcer P E Pt i c U Ls e r periodontal disease p e r e o D O Nt a l d i Z E Z pyorrhea p i o rR E a ulcerative colitis U Ls e r a t i v k o L I t i s viral hepatitis V I r a l h e p a T I t i s volvulus V O Lv u l u s Note The Review Sheet for this chapter is combined with the Review Sheet for Chapter on [url=http://banzell.com]cheap kamagra jelly india 219[/url] Cardiomegaly b.QuiCk Hit INR is a way of reporting the PT in a standardized fashion.This accounts for of cases of nephrotic syndrome in adults and is more com mon in blacks.Swan and Dr.Brugger et al. 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I a s i s colon K O l o n colonic k o L O N i k colonoscopy k o l o n O Sk o p e colostomy k o L O St o m e common bile duct K O M o n b i l d u kt defecation d e f e K A sh u n deglutition d e glooT I SH u n dentibuccal d e nt i B U K a l dentin D E Nt i n digestion d i J E STy u n duodenal d u o D E n a l or d u O D e n a l duodenum d u o D E n u m or d u O D e n u m elimination e l i m i N A sh u n emulsication e m u ls i f i K A sh u n enamel e N A M e l endodontist e nd o D O Nt i st enterocolitis e nt e r o k o L I t i s enteroenterostomy e nt e r o e nt e r O St o m e enzyme E Nz i m esophageal e s o f a J E a l esophagus e S O F a g u s fatty acids F A Tt e A s i dz facial F A sh u l feces F E s e z gallbladder GAWLbl a d e r gastrointestinal tract g a str o i nT E St i n a l tr a ct gastrojejunostomy g a str o j e j u N O St o m e gastrostomy g a sTR O St o m e gingivitis j i nj i V I t i s gluconeogenesis glook o n e o J E N e s i s DIGESTIVE SYSTEM TERM PRONUNCIATION MEANING glucose GLOOk o s glycogen GL I k o j e n glycogenolysis gl i k o j e N O L i s i s hepatoma h e p a T O m a hepatomegaly h e p a t o M E G a l E hydrochloric acid h i dr o KL O R i k A s i d hyperbilirubinemia h i p e rb i l i roob i N E m e a hyperglycemia h i p e rgl i S E m e a hypoglossal h i p o GL O s a l ileitis i l e I t i s ileocecal sphincter i l e o S E k a l SF I NKt e r ileostomy i l e O St o m e ileum I L e u m incisor i nS I z o r insulin I Ns u l i n jejunum j e JOOn u m labial L A b e a l laparoscopy l a p a R O Sk o p e lipase L I p a s lithogenesis l i th o J E N e s i s liver L I v e r lower esophageal sphincter L O W e r e s o f a J E a l SF I NKt e r mastication m a st i K A sh u n mesentery M E S e nt e r e molar teeth M O l a r t e th oral O R a l orthodontist o rth o D O Nt i st palate P A L a t palatopharyngoplasty p a l a t o f a R I NGg o pl a st e palatoplasty P A L a t o pl a st e pancreas P A Nkr e a s pancreatitis p a nkr e a T I t i s papillae p a P I L e DIGESTIVE SYSTEM TERM PRONUNCIATION MEANING parenteral p a R E Nt e r a l parotid gland p a R O T i d gl a nd perianal p e r e A n a l periodontist p e r e o D O Nt i st peritonitis p e r i t o N I t i s peristalsis p e r i ST A Ls i s pharyngeal f a r a nJ E a l or f a R I Nj e a l pharynx F A R i nks portal vein P O Rt a l v a n postprandial p o stPR A Nd e a l premolar teeth pr e M O l a r t e th proctologist pr o kT O L o j i st protease PR O t e a se pulp p u lp pyloric sphincter p i L O R i k SF I NKt e r pyloroplasty p i L O R o pl a st e pylorus p i L O R u s rectocele R E Kt o s e l rectum R E Kt u m rugae ROOg e saliva s a L I v a salivary glands S A L i v a r e gl a ndz sialadenitis s i a l a d e N I t i s sialolith s i A L o l i th sigmoid colon S I Gmoyd K O l o n sigmoidoscopy s i gmoyd O Sk o p e sphincter SF I NKt e r steatorrhea st e a t o R E a stomach STOMak stomatitis st o m a T I t i s sublingual s u bL I NGw a l submandibular s u bm a nD I B u l a r DIGESTIVE 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