1. 정상 동율동 유지 2. 심박수의 조정 3. 혈전증의 예방 치료 목표

정상 동율동심방세동

정상동율동 ECG

심방세동 ECG

심방세동의 분류 발작성 심방세동 : patient has had 2 or more epis odes ( recurrent AF ) and the arrhythmia termina tes spontaneously. 지속성 심방세동 : recurrent AF with sustained arr hythmia 영구형 심방세동 : long-standing AF ( e.g. greater than 1 year) in which cardioversion had not been indicated or attempted.

75 세 이상에서 35% 이상 발견됨 stroke 환자의 20% 가 심방세동을 동반 발작성 심방세동, 지속성 심방세동, 심방 조동간 stroke risk 는 동일하다.

Mechanisms of Stroke in Atrial Fibrillation Cardioembolic sources, almost exclusively represented by left atri al appendage thrombi, account for 90% of embolic events. JACC, 2015,

심방세동 : 어떤 환자에서 뇌졸중이 흔히 합병되나 ? 2010 New Guideline CHA 2 DS 2 -VASc criteria Score Congestive heart failure/ left ventricular dysfunction 1 Hypertension1 Age  75 years 2 Diabetes mellitus1 Stroke/transient ischaemic attack/TE 2 Vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) 1 Age 65–74 years1 Sex category (i.e. female gender)1

새로운 기준에 의한 뇌졸중 발생예측율 점수연간 발생예측율 00% 11.3% 22.2% 33.2% 44.0% 56.7% 69.8% 79.6% 86.7% 915.2%

10 The 2014 AHA/ACCF/HRS guidelines CHA 2 DS 2 -VASc scoreRecommended therapy 0 Either Aspirin 75–325 mg daily or no antithrombotic therapy Preferred choice is no antithrombotic therapy 1 Either OAC* or Aspirin 75–325 mg daily Preferred choice is OAC 22 OAC * *OAC, such as a VKA, adjusted to an intensity range of INR 2.0–3.0 (target 2.5). New OAC drugs, which may be viable alternatives to a VKA, may ultimately be considered (e.g. dabigatran etexilate).

증상 없는 심방세동의 빈도는 ??

Occult atrial fibrillation (AF) timeline Joseph Walker Keach et al. Heart 2015

At least a third of patients with AF are asymptomatic. Only a fifth of symptomatic AF patients will have symptoms temporally related to their AF episodes Hindricks G, et al. Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence. Circulation 2005;112:307–13. Quirino G, et al. Diagnosis of paroxysmal atrial fibrillation in patients with implanted pacemakers: relationship to symptoms and other variables. Pacing Clin Electrophysiol 2009;32:91–8. Silberbauer J, et al. Electrophysiological characteristics associated with symptoms in pacemaker patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2009;26:31–40.

어느 정도 오래 지속되어야 심방세동이 혈전 색전증을 일으킬수 있을까요 ??

Circ Arrhythm Electrophysiol Volume 2(5): October 1, 2009 Glotzer T et al. Circ Arrhythm Electrophysiol 2009;2:

New Eng J Med 2012 무증상 심방세동과 stroke risk

어떤 환자군이 무증상 심방세동의 빈도가 높 을까요 ??

 Cryptogenic stroke population  Intracardiac device population  Elderly population Current guidelines recommend opportunistic pulse palpation in patients 65 years and older followed by ECG screening if the pulse is abnormal ESC guideline: 2012 focused update

Case Review

Case 1 76-year-old man Diagnosed with complete AV block and DDD implantation (2 yrs ago) 3-yr history of treated hypertension and 10 yr diabetes Patient had been on antithrombotic therapy (Aspirin 100mg) No clinical AF Visited EMS for altered mental status

ECG before DDD implantation

24hr Holter Wenckebach block 2:1 AV block Complete AV block DDD implantation

ECG after DDD implantation

Chest PAEchocardiography DDD implantation 1. Enlarged LA(=44.5mm) 2. Normal LV systolic function No RWMA 3. Diastolic function : not determinated 4. Valve : thickened AV and MV

Brain CT

Pacemaker interrogation Mode switch episode 75 for 6 months Longest episode 16min 14secs AF/AT burden <1%

Case 1 Summary no clinical AF AT/AF burden – low CHA2DS2-VASc score – 4 points  Disabling stroke, dysarthria Currently Rehab for 1 yr