Beruflich Dokumente
Kultur Dokumente
The first step in the management of atrial fibrillation, despite the cause, is to control
the ventricular response.
Beta-adrenergic blocking agents are effective in controlling the ventricular rate and
are the drugs of choice[8] in the absence of decompensated congestive heart failure.
These agents also help alleviate the beta-receptor-mediated symptoms, such as anxiety
and tremulousness. The patient requires cardiac and noninvasive arterial pressure
monitoring because of the potential risks of hypotension, worsening of heart failure,
or bradycardia. Higher-than-usual doses of these agents are often required because of
increased plasma clearance in hyperthyroidism.[9] The use of beta-blockers should be
carefully considered in patients with mild heart failure because of the risk of
exacerbation.
Which beta-blocker?
Oral calcium channel blockers, such as diltiazem or verapamil, can be useful for longterm control of ventricular rate12 in patients in whom beta-adrenergic blockade is
contraindicated, but these agents may also have negative inotropic effects. Intravenous
calcium channel blockers may be considered in which beta-blockers are
contraindicated but should be used cautiously, as these may cause severe
hypotension[13] and a further reduction in systemic vascular resistance that is already
low in patients with thyrotoxicosis.
Digoxin
Digoxin may be considered for rate control in patients with heart failure in whom
beta-blockers or calcium channel blockers may not be suitable. However,
hyperthyroid atrial fibrillation is typically resistant to digoxin that is caused in part by
an increase in the renal clearance and apparent volume of its distribution[14] as well
References
1. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J
Med. 2001;344:501509. [PubMed]
2. Ostrander LD, Jr, Brandt RL, Kjelsberg MO, Epstein FH. Electrocardiographic
findings among the adult population of a total natural community, Tecumesh,
Michigan. Circulation.1965;31:888898. [PubMed]
3. Agner T, Almdal T, Thorsteinsson B, Agner E. A reevaluation of atrial fibrillation in
thyrotoxicosis. Dan Med Bull. 1984;31:157159. [PubMed]
4. Peterson P. Thromboembolic complications in atrial fibrillation. Stroke. 1990;21:4
13. [PubMed]
5. Sawin CT, Geller A, Wolf PA, et al. Low serum thyrotropin concentrations as a risk
factor for atrial fibrillation in older persons. N Engl J Med. 1994;331:1249
1252. [PubMed]
6. Forfar JC, Miller HC, Toft AD. Occult thyrotoxicosis: a reversible cause of
idiopathic atrial fibrillation. Am J Cardiol. 1979;44:912. [PubMed]
7. Krahn AD, Klein GJ, Kerr Cr, et al. How useful is thyroid function testing in
patients with recent-onset atrial fibrillation? Arch Intern Med. 1996;156:2221
2224. [PubMed]
8. Geffner DL, Hershman JM. Beta-adrenergic blockade for the treatment of
hyperthyroidism. Am J Med. 1992;93:6168. [PubMed]
9. Shenfield GM. Influence of thyroid dysfunction on drug pharmacokinetics. Clin
Pharmacokinet. 1981;6:275297. [PubMed]
10. Feely J, Peden N. Use of beta-adrenoceptor blocking drugs in
hyperthyroidism. Drugs. 1984;27:425446. [PubMed]
11. Isley WL, Dahl S, Gibbs H. Use of esmolol in managing a thyrotoxic patient
needing emergency surgery. Am J Med. 1990;89:122123. [PubMed]
12. Roti E, Montermini M, Roti S, et al. The effect of diltiazem, a calcium channelblocking drug, on cardiac rate and rhythm in hyperthyroid patients. Arch Intern
Med. 1988;148:19191921.[PubMed]
13. Klein I, Becker DV, Levey GS. Treatment of hyperthyroid disease. Ann Intern
Med. 1994;121:281288. [PubMed]
14. Morrow DH, Gaffney TE, Braunwald E. Studies on digitalis VIII. Effect of
autonomic innervation and of myocardial catecholamine stores upon the cardiac
action of ouabain. J Pharmacol Exp Ther. 1963;140:236245.
15. Newman CM, Price A, Davies DW, et al. Amiodarone and the thyroid: a practical
guide to the management of the thyroid dysfunction induced by amiodarone
therapy. Heart. 1998;79:121127. [PMC free article] [PubMed]
16. Paradis P, Lambert C, Rouleau J. Amiodarone antagonizes the effects of T3 at the
receptor level: an additional mechanism for its in vivo hypothyroid-like effects. Can J
Physiol Pharmacol.1991;69:865870. [PubMed]
17. Cauchie P, Decaux G, Unger J. Treatment of atrial fibrillation associated with
hyperthyroidism by amiodarone and methimazole. Int J Cardiol. 1988;19:123
124. [PubMed]
18. Unger J, Lambert M, Jonckheer MH, Denayer Ph. Amiodarone and the thyroid:
pharmacological, toxic and therapeutic effects. J Intern Med. 1993;233:435
443. [PubMed]
19. Bar Sela S, Ehrenfeld M, Eliakim M. Arterial embolism in thyrotoxicosis with
atrial fibrillation. Arch Intern Med. 1981;141:11911192. [PubMed]
20. Presti CF, Hart RG. Thyrotoxicosis, atrial fibrillation, and embolism,
revisited. Am Heart J. 1989;117:976977. [PubMed]
21. Petersen P, Hansen JM. Stroke in thyrotoxicosis with atrial
fibrillation. Stroke. 1988;18:1518. [PubMed]
22. The Stroke Prevention in Atrial Fibrillation. Predictors of thromboembolism in
atrial fibrillation I. Clinical features of patients at risk. Ann Intern Med. 1992;116:1
5. [PubMed]
23. The Stroke Prevention in Atrial Fibrillation. Predictors of thromboembolism in
atrial fibrillation II. Echocardiographic features of patients at risk. Ann Intern
Med. 1992;116:612. [PubMed]
24. Taylor FC, Cohen H, Ebrahim S. Systematic review of long term anticoagulation
or
antiplatelet
treatment
in
patients
with
non-rheumatic
atrial
fibrillation. BMJ. 2001;322:321326. [PMC free article] [PubMed]
25. Segal JB, McNamara RL, Miller MR, et al. Anticoagulants or antiplatelet therapy
for non-rheumatic atrial fibrillation and flutter. Cochrane Database Syst Rev. 2001;
(1):CD001938.[PubMed]
26. Cundiff DK. Anticoagulants for nonvalvular atrial fibrillation (NVAF) drug
review. Medscape
General
Medicine. 2003;5:4. Available
at: http://www.medscape.com/viewarticle/448817_1Access
December
16,
2004. [PubMed]
27. Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ.
Antithrombotic therapy in atrial fibrillation. Chest. 2001;126(suppl):429S
456S. [PubMed]
28. Nakazawa HK, Sakurai K, Hamada N, Momotani N, Ito K. Management of atrial
fibrillation in the post-thyrotoxic state. Am J Med. 1982;72:903906. [PubMed]
29. Chopra IJ, Huang TS, Hurd RE, Solomon DH. A study of cardiac effects of
thyroid hormones: evidence for amelioration of the effects of thyroxine by sodium
ipodate. J Endocrinol.1984;114:20392045. [PubMed]
30. Franklyn JA, Maisonneuve P, Sheppard MC, et al. Mortality after the treatment of
hyperthyroidism with radioactive iodine. N Engl J Med. 1998;338:712
718. [PubMed]
31. Osman F, Daykin J, Sheppard M, Franklyn J, Gammage M. Cardiac rhythm
abnormalities in thyrotoxicosis the explanation for excess vascular mortality. J
Endocrinol. 2000;164:321.