20 / 10 / 16
关于“近期发生心房颤动患者的早期或延迟复律”一文讨论部分的医学翻译摘要学习情况，记录于此。
Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation
讨论
Discussion
在近期发生有症状心房颤动的急诊患者中，在初次就诊后4周时恢复窦性心律方面，观察等待策略不劣于早期复律。延迟复律组患者常自发转复为窦性心律，从而减少了对立即药物复律或电复律的需求。
Among patients who presented to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see strategy was noninferior to early cardioversion in obtaining sinus rhythm at 4 weeks after the index visit. Spontaneous conversion frequently occurred in patients in the delayed-cardioversion group and reduced the need for immediate pharmacologic or electrical cardioversion.
笔记：
近期发生心房颤动患者的急诊治疗方法有很大差异。早期药物复律或电复律是常见做法1-3 。然而，根据需要在症状出现后48小时内进行延迟复律的观察等待策略对患者有几个优势。首先，有可能避免复律（及其潜在并发症）。其次，有可能缩短初次就诊时在急诊花费的时间。第三，有可能观察到心房颤动自发转复为窦性心律，从而减少错误分类为持续性心房颤动的情况19 。这一因素可能对未来的心律控制策略产生影响，人们认为阵发性心房颤动患者的心律控制策略比持续性心房颤动患者要简单20,21 。第四，患者有可能感受到心律失常自行终止，这可能会拓宽他们对可选治疗方案的认识。
The approaches to treating patients with recent-onset atrial fibrillation in the emergency department vary greatly. Early pharmacologic or electrical cardioversion is common practice.1-3 However, the wait-and-see strategy, with delayed cardioversion if needed within 48 hours after symptom onset, has several advantages for patients. First, cardioversion (along with its potential complications) may be avoided. Second, the time spent in the emergency department during the initial presentation may be reduced. Third, spontaneous conversions of atrial fibrillation may be observed, leading to fewer misclassifications of persistent atrial fibrillation.19 This factor may bear consequences for future rhythm-control strategies, which are considered to be less complex in patients with paroxysmal atrial fibrillation than in those with persistent atrial fibrillation.20,21 Fourth, patients may have the experience that their arrhythmia terminated by itself, which may broaden their insight into treatment options.
笔记：
在我们的试验中，我们发现早期复律与观察等待疗法相比缩短了至恢复窦性心律的时间，但并未增加最终实现窦性心律的患者数量。缩短恢复时间的一个潜在优势是可以更早地消除症状，预防心力衰竭、晕厥、心脏或脑缺血事件，防止发展为持续性心房颤动。然而，观察等待策略也产生了类似的临床效果，包括几乎所有患者的症状都得到控制，并出现持久的窦性心律，无发展为持续性心房颤动的表现。此外，延迟复律组患者的生活质量得以保持。采用延迟复律时，患者心房颤动的持续时间较长，这可能增加卒中风险22 ，但按照指南及时启动抗凝治疗1,2,12 预期会降低卒中风险。
In our trial, we found that early cardioversion shortened the time until conversion but did not increase the number of patients who eventually reached sinus rhythm, as compared with the wait-and-see approach. A potential advantage of shortening the time until conversion would be earlier elimination of symptoms and prevention of heart failure, syncope, cardiac or cerebral ischemic events, or progression to persistent atrial fibrillation. However, the wait-and-see strategy yielded similar clinical effects, including symptom control and durable sinus rhythm without signs of progression to persistent atrial fibrillation in almost all the patients. Furthermore, the patients’ quality of life was maintained in the delayedcardioversion group. Delayed cardioversion with longer time spent in atrial fibrillation could promote stroke,22 but timely, guideline-based initiation of anticoagulation1,2,12 is expected to reduce the risk of stroke.
笔记：
我们的数据提示，观察等待疗法（包括根据需要第二次到急诊就诊）不一定比早期复律更费时。这一观察结果可能是由于镇静或输入药物之前的检查、电复律前为了达到充分空腹状态而等待的时间，或者复律后必须进行的观察。非计划的早期复律在通常过于拥挤的急诊科内对其治疗组织工作提出了挑战。药物复律需要心脏科医师提供抗心律失常药物静脉给药方面的专门技术。电复律需要镇静，这涉及麻醉医师的专门技术。这些情况可能会阻碍复律的迅速执行，特别是由于临床稳定患者的复律通常并不视为紧急操作。相比之下，不论是否恢复窦性心律，几乎所有的延迟复律组患者在接受心率控制药物治疗后都可以离院回家。
Our data suggest that the wait-and-see approach, including a second emergency department visit as needed, is not necessarily more time consuming than early cardioversion. This finding may be due to workup for sedation or drug infusion, waiting time for a sufficient fasting state before electrical cardioversion, or obligatory observation after cardioversion. An unplanned early cardioversion challenges the organization of care in generally overcrowded emergency departments. Pharmacologic cardioversion requires specific expertise in the administration of intravenous antiarrhythmic drugs by the treating cardiologist. Electrical cardioversion requires sedation, involving the expertise of an anesthesiologist. These circumstances may hamper prompt execution of cardioversion, especially since cardioversion in a clinically stable patient is usually not considered to be an emergency procedure. In contrast, almost all the patients in the delayed-cardioversion group could be discharged home after the administration of ratecontrol medication, regardless of conversion to sinus rhythm.
笔记：
对于到急诊就诊的急性心房颤动患者，不论采用哪种复律策略，都必须采取适当措施管理卒中风险，这一点再怎么强调都不为过23 。在我们的试验中，我们规定所有高危患者均启动或继续接受适当的抗凝治疗。尽管如此仍有2例患者出现了脑栓塞：1例患者在初次就诊时启动达比加群治疗，在达比加群治疗期间，患者于自发恢复窦性心律后5日发生了脑栓塞（CHA2DS2-VASc量表评分为2分），另外1例患者在初次就诊启动利伐沙班治疗，在利伐沙班治疗期间，患者于早期电复律后10日发生了脑栓塞（CHA2DS2-VASc量表评分为3分）（补充附录表S6）。积极复律被认为是卒中的一个重要诱因，即使对于近期发生心房颤动的患者24,25 ，自发恢复也与卒中相关26,27 。在这方面，需要指出的是，在急诊科，对近期心房颤动患者心率和心律控制的关注有可能转移医师的注意力，导致其未关注到卒中风险评估和抗血栓治疗启动，尤其是对于接受复律的患者28,29 。此外，对于不知晓心房颤动持续时间的患者，除非患者正在接受充分的长期抗凝治疗，或者在经食管超声心动图排除心房内血栓后正在接受短期抗凝治疗，否则不应接受本试验评价的两种策略中的任何一种治疗30 。
It cannot be stressed enough that it is mandatory to manage stroke risk appropriately in patients presenting to the emergency department with acute atrial fibrillation, independent of cardioversion strategy.23 In our trial, we stipulated initiation or continuation of appropriate anticoagulation for all high-risk patients. Nevertheless, two patients had a cerebral embolism: one occurred 5 days after spontaneous conversion while the patient was receiving dabigatran initiated at the index visit (score of 2 on the CHA2DS2-VASc scale), and the other occurred 10 days after early electrical cardioversion while the patient was receiving rivaroxaban initiated at the index visit (score of 3 on the CHA2DS2-VASc scale) (Table S6 in the Supplementary Appendix). Active cardioversion is considered an important trigger for stroke even in patients with recent-onset atrial fibrillation, 24,25 but spontaneous conversion is also associated with stroke.26,27 In this respect, it is important to note that the focus on rate and rhythm control in recent-onset atrial fibrillation may shift physicians’ attention away from assessing stroke risk and initiation of antithrombotic treatment in the emergency department, especially in patients undergoing cardioversion.28,29 In addition, patients in whom the duration of atrial fibrillation is not known should not be subjected to either of the two strategies that were evaluated in this trial unless they are receiving adequate anticoagulation on a long-term basis or short-term anticoagulation after the exclusion of intraatrial thrombus on transesophageal echocardiography.30
笔记：
应指出我们试验的几个局限性。首先，虽然两组的心血管并发症均不常见，但本试验的统计学功效不足以评估安全性。其次，由于采用间断性监测，因此随机分组后4周内报告的心房颤动复发率无疑会低估真实复发率。尽管如此，4周30%的复发率说明了近期发生的心房颤动的复发特性。我们发现复发率无显著组间差异，提示心房颤动的复发概率不受急性心房颤动期间所采用的治疗方法的影响。
Several limitations of our trial should be mentioned. First, the trial was not powered to assess safety, although cardiovascular complications were infrequent in the two groups. Second, the reported incidence of recurrent atrial fibrillation within 4 weeks after randomization was no doubt an underestimation of the true recurrence rate since we used intermittent monitoring. Even so, the 4-week incidence of 30% illustrates the recurrent nature of recent-onset atrial fibrillation. Our finding that there was no significant between-group difference in recurrence rates suggests that the probability of recurrence of atrial fibrillation was not affected by management approach during the acute event.
笔记：
总之，在近期发生有症状心房颤动的急诊患者中，在4周时恢复窦性心律方面，观察等待疗法不劣于早期复律。
In conclusion, among patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving sinus rhythm at 4 weeks.
笔记：