International Circulation: For atrial fibrillation and other rhythm abnormalities， which is best and in what cases:  CRT， drugs or ablation?
　　《国际循环》：对心房颤动和其他节律异常，CRT、药物或消融哪种是最好的以及在什么情况下？
　　Dr Packer: Atrial fibrillation affects about 10% of patients who are over the age of 75 or 80. It affects the upper chambers and is mainly a quality of life issue but it is a huge problem for stroke risk particularly if someone has high blood pressure or diabetes and even if they have sleep apnea. In atrial fibrillation usually the left atrium is the most important. For this condition， treatment with drugs is usually the best first step. The problem is that it usually doesn’t work for very long. The problem is also typically that it only controls the rhythm in about 30% of cases. In the remaining 70% of cases， if they are highly symptomatic， another therapy needs to be applied. That is where catheter ablation for atrial fibrillation fits in. In my presentation at this meeting， I talked about drug therapy versus ablation for that particular patient population. The Guidelines right now typically say drugs first， ablation second. But the European Guidelines and the Canadian Guidelines were changed for only for patients who have paroxysmal atrial fibrillation that comes and goes. It hasn’t changed for persistent; it hasn’t changed for long-standing conditions. Another disease problem would be ventricular tachycardia where the abnormal rhythm comes from the lower chambers. It can show up as single extra beats occurring recurrently or two or three in a row or more prolonged in duration. Most of the time， the problem with those will be dependent upon what the underlying disease is. If a person has no other underlying disease then they just have an abnormal heartbeat. Those patients usually have a quality of life issue， not a quantity of life issue. Either drugs or ablation can work very well to improve quality of life in these cases that don’t have any underlying disease. If patients have a lot of underlying disease (they have had a heart attack or have heart failure)， then they can get a lot of ventricular tachycardia. Those patients are at a much higher risk of dying from the condition. Those patients have to be treated more aggressively. Most of the patients who have underlying heart disease or have a low ejection fraction or heart failure are best treated by a defibrillator. In some locations such as the United States and Europe， there are a lot of defibrillators being used. In India， China and Japan， defibrillators are used less often and there are a variety of different reasons for that. The bottom line is that for those patients with the underlying disease， it is not just a matter of quality of life; it is a matter of quantity of life. The studies have not been done to compare ablation versus the defibrillator， so we don’t know which one is best. We do know that defibrillators in the setting of underlying disease tend to be better than drug therapy which we know from a variety of different studies. The third rhythm anomaly is heart failure. Heart failure is usually an issue where the pump muscles just don’t work. Normally about 60% of the blood is pumped out of the heart but in the setting of underlying disease that is going to be somewhere in the order of 10%， 20%， depending on what the underlying disease is. If it is below 30% then we worry about the risk of sudden death (from the SCUD-HFT trial that looked at the utility of defibrillators in those patients). CRT has more to do with the heart failure itself. Studies that I have examined do show mortality benefit just from improving the pumping action. If you have Class I， II or III heart failure， then the defibrillator component will decrease arrhythmic death. It is also true that in many studies like SCUD-HFT that have looked at Class III， there wasn’t much benefit for arrhythmic death in Class III failure. If you are going to be treating Class III and Class IV and getting mortality benefit， it is more from treatment of the pump. That is where CRT comes in. If you are in Class I and II， sudden death risk is high and benefit from a device is high. The RAFT trial looking at CRT suggested that even in Class II or lower Class III， there will be a mortality benefit. So that is a compartmentalization of treatment for arrhythmic conditions.
　　Dr Packer：心房颤动影响着大约10%的年龄大于75岁或80岁的患者。它影响上腔，且主要是一个生活质量的问题，但对卒中风险而言它是一个巨大的问题，尤其是如果某人有高血压或糖尿病，甚至是他们有睡眠呼吸暂停时。在心房颤动中，左心房通常是最重要的。对于这种情况，用药物治疗通常是最好的第一步。问题是，它通常不能很长时间的发挥作用。还有一个典型的问题是，它仅能在约30%的病例中控制心律。在其余70%的病例中，如果他们症状明显则需要应用另一种治疗。这就是心房颤动导管消融所适合之处。我在这次会议上的演讲中谈及了对特定患者人群药物治疗与消融的比较。 指南现在通常说药物第一，消融第二。但欧洲指南和加拿大指南作出了改变仅针对患有来去匆匆的阵发性心房颤动的患者。对持续性心房颤动则并无改动；对长期疾病无改动。另一种疾病问题是室性心动过速，其异常节律来自下腔。它可以显示为周期性发生的单个额外搏动或一连串2个或3个或持续时间更长。多数情况下，这些问题将取决于基础疾病是什么。如果一个人没有其他基础疾病，那么他们只是异常的心跳。这些患者通常有生活质量的问题，而不是生活数量的问题。在这些没有任何基础疾病的情况下，无论是药物或消融都可以很好地发挥作用来提高生活质量。如果患者有很多基础疾病（他们有过心脏病发作或有心力衰竭），那么他们可能有很多种室性心动过速。这些患者死于这种疾病的风险要高得多。必须更积极地治疗这些患者。有基础心脏病或射血分数低或有心力衰竭的患者中大多数最好是接受除颤器治疗。在一些地区，如美国和欧洲，应用了很多除颤器。在印度、中国和日本，除颤器使用较少，对此有各种不同的原因。底线是，对那些有基础疾病的患者，它不只是生活质量的问题，还是生活数量的问题。比较消融与除颤器的研究尚未完成，所以我们不知道哪种最好。我们确切知道的是，在有基础疾病的情况下，除颤器往往优于药物治疗，这是我们从各种不同的研究中所了解到的。第三种节律异常是心力衰竭。心力衰竭通常是心脏泵肌肉不工作的问题。正常情况下，约60％的血液从心脏中泵出，但在基础疾病的情况下，将会是约10％、20％，取决于基础疾病是什么。如果是低于30％，那么我们担心猝死风险（来自观察除颤器在这些患者中的效用德SCUD-HFT试验）。CRT自身与心力衰竭有着更为密切的关系。我所审查过的研究的确显示了仅源自改善泵功能的死亡率受益。如果你有I级、II级或III级心力衰竭，那么除颤器组件将减少心律失常死亡。还可以肯定的是，在许多像SCUD-HFT一样观察III级心力衰竭的研究中，在III级心力衰竭中对心律失常死亡并无多少益处。如果你要治疗III级和IV级心力衰竭并要获得死亡率益处，这对泵功能治疗而言所求过多。这正是CRT的用武之地。如果患者时处于I级和II级，则猝死风险高，且从装置中获得的益处高。观察CRT的RAFT试验提示，即使是在II级或更低的III级心力衰竭中也将会有死亡率受益。因此这是心律失常疾病治疗的区分。
 

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