房颤和室颤趣味科普（RACEII）

房颤和室颤趣味科普（RACEII）主要结论这篇发表于2010年新格兰医学杂志（NEJM）的经典文献如下： Normal heart beats at 60-100 bpm.In cases with AF HR is greater than 100 bpm and beats at an irregular rhythm.因此，新的指南（即2014年AHA/ACC/HRS指南）推荐：症状性房颤患者：严格控制心室率，静息时心室率＜80次/分（IIa，B）左室功能正常的无症状性房颤患者：宽松的心室率控制策略——静息时心室率＜110次/分（IIb，C）

原创 Alpha Jun 阿尔法医学英语 1周前

医学的进步是先辈们筚路蓝缕，一点一滴开拓出来，从青霉素到HPV疫苗，从肿瘤化疗到CART细胞治疗。而现代医学的基石是一个个里程碑式的临床试验 （landmark trial）。我们的教科书的根本也是基于这些landmark trials。让我们来一起阅读医学史上的经典。阅读，不仅仅是学习医学英语最好的方式，也能更好地理解现代医学的精髓。

RACE II——房颤的心率控制

旧指南指出房颤患者应当严格控制心室率：静息为60-80bpm，中等运动量为90-115bpm，以防止心衰，症状加重，住院等情况。然而，这并没有多少的循证医学证据。RACE II（Rate Control Efficacy in Permanent Atrial Fibrillation II）研究表明宽松的室率控制在心源性致残和致死方面并不劣于严格的室率控制。 RACE II研究中的共614名永久性房颤患者随机分组并分别进行宽松（静息心率<110bpm）或严格（静息心率<80bpm，中等程度运动时心率<110bpm）的室率控制。结果显示，对于没有严重症状的患者，心室率控制目标可适度放宽（静息时＜110bmp)，并不影响预后。

Normal heart beats at 60-100 bpm.In cases with AF HR is greater than 100 bpm and beats at an irregular rhythm.

因此，新的指南（即2014年AHA/ACC/HRS指南）推荐：

症状性房颤患者：严格控制心室率，静息时心室率＜80次/分（IIa，B）左室功能正常的无症状性房颤患者：宽松的心室率控制策略——静息时心室率＜110次/分（IIb，C）

这篇发表于2010年新格兰医学杂志（NEJM）的经典文献如下：

主要结论

Lenient rate-control was found to be non-inferior to strict rate-control in managing patients with atrial fibrillation.

Compared to strict rate-control lenient rate-control could be achieved with lower doses of medication and fewer medications.

试验结果

The study was conducted in 33 centres in the Netherlands and involved 614 patients.

Patients were eligible if they

had atrial fibrillation for up to 12 monthswere ≤80 years of agehad a mean resting heart rate >80 bpmand were using oral anticoagulation therapy

Included patients were randomized to the lenient control strategy or the strict control strategy.

Lenient ControlStrict Control

Target resting heart rate <110 bpmvsTarget resting HR <80 bpm <110 bpm during exercise

The primary outcome was a composite of death from cardiovascular causes hospitalization for heart failure stroke systemic embolism major bleeding and arrhythmic events (e.g. syncope sustained ventricular tachycardia cardiac arrest). Secondary outcomes included components of the primary outcome along with all-cause mortality symptoms and functional status.

As in the cases of AF without enough blood supply patients may suffer from syncope.

At the end of the follow-up period the resting heart rates were 85±14 and 76±14 in the lenient- and strict-control groups respectively (p<0.001).

It was found that lenient control was noninferior to strict control in preventing the primary outcome (HR 0.84; 90%CI 0.58-1.21). Moreover there was no significant difference in all-cause mortality (HR 0.91; 90%CI 0.52-1.59). There were no significant differences between the two groups in symptoms associated with atrial fibrillation including dyspnea fatigue and palpitations. Additionally there was no significant difference between the two groups in terms of heart failure functional status.

Lenient rate-control could be achieved with significantly lower doses of medications and significantly fewer medications than strict rate-control.

深度解析与批评

Atrial fibrillation is the most prevalent sustained cardiac arrhythmia. It is a condition characterized by tachycardia and irregular heart rate which often results due to disorganized electrical signaling in the atria. The condition is associated with an increased risk of stroke and anticoagulation is an important management consideration.

ECG of atrial fibrillation (top) and normal sinus rhythm (bottom). The purple arrow indicates a P wave which is lost in atrial fibrillation.

Previously rate-control and rhythm-control were both considered acceptable options for management. The AFFIRM and RACE trials demonstrated however that rate-control was not inferior and was also associated with fewer adverse events compared to rhythm-control. As a result rate-control is now often the first-line approach for treating atrial fibrillation along with appropriate anticoagulation.

Easy Jerry. No need to restrict your heart rate within 80bpm at rest.

In Summary there was no significant difference between the two strategies in the risk of death from cardiovascular causes hospitalization for heart failure stroke systemic embolism major bleeding and arrhythmic events (HR 0.84; 90%CI 0.58-1.21).

Key Word:lenient [ˈli:niənt]adj.宽松的non-inferior [ɪnˈfɪəriə(r)]adj.不劣于，不差于eligible [ˈelɪdʒəbl]adj. 合适的，可入组的arrhythmic [ə'rɪðmɪk]adj. 心律失常的syncope [ˈsɪŋkəpi]n. 晕厥respectively [rɪˈspektɪvli]adj. 分别的dyspnea [dɪs'pni:ə]adj. 气喘的，呼吸困难的-pnea suff. 呼吸

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