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心房細動の再発予防のフローチャート

出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドライン.https://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p74、図18、心房細動の再発予防のフローチャート

心房細動の心電図所見

RR間隔が不規則なQRS波。基線が消失してf波を認める様子が、V1誘導ではっきりと確認できる。
出典
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1: 鈴木信也先生ご提供

通常型心房粗動の心電図所見

RR間隔が不規則なQRS波であるが、II・III・aVF誘導に鋸歯状波を認めており、通常型心房粗動である。
2:1~4:1房室伝導であるため、QRS波の出現が不規則となっている。
出典
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1: 鈴木信也先生ご提供

偽性心室頻拍の心電図所見

Wide QRS波であり、一見すると心室頻拍のようであるが、RR間隔が不規則。
WPW症候群患者に心房細動の発作が生じると、Kent束(副伝導路)経由の房室伝導のためにwide QRS波を呈し、一見心室頻拍のような心電図となる(偽性心室頻拍)。
出典
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1: 鈴木信也先生ご提供

心房静止の心電図所見

心房細動の終末像として心房が完全に停止する状態に至ることがあり、「心房静止」と呼んでいる。基線は完全に平坦となり、心房波(P波、鋸歯状波もしくはf波)はまったく認められない。QRS波はややwide QRS波を呈し、規則正しい徐脈となる(補充調律)。
出典
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1: 鈴木信也先生ご提供

塞栓症リスクスコア(CHADS2スコア)

各スコアでの実際の脳梗塞の発症率(図[ID0606])にて確認できる。2点以上を中等度以上のリスクと考え、抗凝固薬の適応となる。
 
原著:
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001 Jun 13;285(22):2864-70. PubMed PMID:11401607
出典
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1: Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.
著者: Gregory Y H Lip, Robby Nieuwlaat, Ron Pisters, Deirdre A Lane, Harry J G M Crijns
雑誌名: Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17.
Abstract/Text: BACKGROUND: Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism (TE) in patients with atrial fibrillation (AF) are largely derived from risk factors identified from trial cohorts. Thus, many potential risk factors have not been included.
METHODS: We refined the 2006 Birmingham/National Institute for Health and Clinical Excellence (NICE) stroke risk stratification schema into a risk factor-based approach by reclassifying and/or incorporating additional new risk factors where relevant. This schema was then compared with existing stroke risk stratification schema in a real-world cohort of patients with AF (n = 1,084) from the Euro Heart Survey for AF.
RESULTS: Risk categorization differed widely between the different schemes compared. Patients classified as high risk ranged from 10.2% with the Framingham schema to 75.7% with the Birmingham 2009 schema. The classic CHADS(2) (Congestive heart failure, Hypertension, Age > 75, Diabetes, prior Stroke/transient ischemic attack) schema categorized the largest proportion (61.9%) into the intermediate-risk strata, whereas the Birmingham 2009 schema classified 15.1% into this category. The Birmingham 2009 schema classified only 9.2% as low risk, whereas the Framingham scheme categorized 48.3% as low risk. Calculated C-statistics suggested modest predictive value of all schema for TE. The Birmingham 2009 schema fared marginally better (C-statistic, 0.606) than CHADS(2). However, those classified as low risk by the Birmingham 2009 and NICE schema were truly low risk with no TE events recorded, whereas TE events occurred in 1.4% of low-risk CHADS(2) subjects. When expressed as a scoring system, the Birmingham 2009 schema (CHA(2)DS(2)-VASc acronym) showed an increase in TE rate with increasing scores (P value for trend = .003).
CONCLUSIONS: Our novel, simple stroke risk stratification schema, based on a risk factor approach, provides some improvement in predictive value for TE over the CHADS(2) schema, with low event rates in low-risk subjects and the classification of only a small proportion of subjects into the intermediate-risk category. This schema could improve our approach to stroke risk stratification in patients with AF.
Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 S...

塞栓症リスクスコア(CHADS2スコア)と脳梗塞の発症率

参考文献:
Lip GY, et al: Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010 Feb;137(2):263-272. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17. PubMed PMID:19762550
出典
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1: Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
著者: B F Gage, A D Waterman, W Shannon, M Boechler, M W Rich, M J Radford
雑誌名: JAMA. 2001 Jun 13;285(22):2864-70.
Abstract/Text: CONTEXT: Patients who have atrial fibrillation (AF) have an increased risk of stroke, but their absolute rate of stroke depends on age and comorbid conditions.
OBJECTIVE: To assess the predictive value of classification schemes that estimate stroke risk in patients with AF.
DESIGN, SETTING, AND PATIENTS: Two existing classification schemes were combined into a new stroke-risk scheme, the CHADS( 2) index, and all 3 classification schemes were validated. The CHADS( 2) was formed by assigning 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and by assigning 2 points for history of stroke or transient ischemic attack. Data from peer review organizations representing 7 states were used to assemble a National Registry of AF (NRAF) consisting of 1733 Medicare beneficiaries aged 65 to 95 years who had nonrheumatic AF and were not prescribed warfarin at hospital discharge.
MAIN OUTCOME MEASURE: Hospitalization for ischemic stroke, determined by Medicare claims data.
RESULTS: During 2121 patient-years of follow-up, 94 patients were readmitted to the hospital for ischemic stroke (stroke rate, 4.4 per 100 patient-years). As indicated by a c statistic greater than 0.5, the 2 existing classification schemes predicted stroke better than chance: c of 0.68 (95% confidence interval [CI], 0.65-0.71) for the scheme developed by the Atrial Fibrillation Investigators (AFI) and c of 0.74 (95% CI, 0.71-0.76) for the Stroke Prevention in Atrial Fibrillation (SPAF) III scheme. However, with a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS( 2) index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS( 2) score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6.
CONCLUSION: The 2 existing classification schemes and especially a new stroke risk index, CHADS( 2), can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.
JAMA. 2001 Jun 13;285(22):2864-70.

塞栓症リスクスコア(CHA2DS2-VAScスコア)

各スコアでの実際の脳梗塞の発症率(図[ID0608])にて確認できる。CHADS2スコア2点に相当するのはCHA2DS2-VASc スコア4点である。低リスク群での評価に優れる。
出典
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1: Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.
著者: Gregory Y H Lip, Robby Nieuwlaat, Ron Pisters, Deirdre A Lane, Harry J G M Crijns
雑誌名: Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17.
Abstract/Text: BACKGROUND: Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism (TE) in patients with atrial fibrillation (AF) are largely derived from risk factors identified from trial cohorts. Thus, many potential risk factors have not been included.
METHODS: We refined the 2006 Birmingham/National Institute for Health and Clinical Excellence (NICE) stroke risk stratification schema into a risk factor-based approach by reclassifying and/or incorporating additional new risk factors where relevant. This schema was then compared with existing stroke risk stratification schema in a real-world cohort of patients with AF (n = 1,084) from the Euro Heart Survey for AF.
RESULTS: Risk categorization differed widely between the different schemes compared. Patients classified as high risk ranged from 10.2% with the Framingham schema to 75.7% with the Birmingham 2009 schema. The classic CHADS(2) (Congestive heart failure, Hypertension, Age > 75, Diabetes, prior Stroke/transient ischemic attack) schema categorized the largest proportion (61.9%) into the intermediate-risk strata, whereas the Birmingham 2009 schema classified 15.1% into this category. The Birmingham 2009 schema classified only 9.2% as low risk, whereas the Framingham scheme categorized 48.3% as low risk. Calculated C-statistics suggested modest predictive value of all schema for TE. The Birmingham 2009 schema fared marginally better (C-statistic, 0.606) than CHADS(2). However, those classified as low risk by the Birmingham 2009 and NICE schema were truly low risk with no TE events recorded, whereas TE events occurred in 1.4% of low-risk CHADS(2) subjects. When expressed as a scoring system, the Birmingham 2009 schema (CHA(2)DS(2)-VASc acronym) showed an increase in TE rate with increasing scores (P value for trend = .003).
CONCLUSIONS: Our novel, simple stroke risk stratification schema, based on a risk factor approach, provides some improvement in predictive value for TE over the CHADS(2) schema, with low event rates in low-risk subjects and the classification of only a small proportion of subjects into the intermediate-risk category. This schema could improve our approach to stroke risk stratification in patients with AF.
Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 S...

塞栓症リスクスコア(CHA2DS2-VAScスコア)と脳梗塞の発症率

出典
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1: Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort.
著者: Gregory Y H Lip, Lars Frison, Jonathan L Halperin, Deirdre A Lane
雑誌名: Stroke. 2010 Dec;41(12):2731-8. doi: 10.1161/STROKEAHA.110.590257. Epub 2010 Oct 21.
Abstract/Text: BACKGROUND AND PURPOSE: The risk of stroke in patients with atrial fibrillation (AF) is not homogeneous, and various clinical risk factors have informed the development of stroke risk stratification schemes (RSS). Among anticoagulated cohorts, the emphasis should be on the identification of patients who remain at high risk for stroke despite anticoagulation.
METHODS: We investigated predictors of thromboembolism (TE) risk in an anticoagulated AF clinical trial cohort (n = 7329 subjects) and tested the predictive value of contemporary RSS in this cohort: CHADS₂, Framingham, NICE 2006, American College of Cardiology/American Heart Association/European Society of Cardiology 2006, the 8th American College of Chest Physicians guidelines and the CHA₂DS₂-VASc schemes.
RESULTS: On multivariate analysis, significant predictors of TE were stroke/TIA (hazard ratio [HR], 2.24; P < 0.001), age 75 years or older (HR, 1.77; P = 0.0002), coronary artery disease (HR, 1.52; P = 0.0047), and smoking (HR, 2.10; P = 0.0005), whereas reported alcohol use (HR, 0.70; P = 0.02) was protective. Comparison of contemporary RSS demonstrated variable classification of AF patients into risk strata, although c-statistics for TE were broadly similar among the RSS tested and varied between 0.575 (NICE 2006) and 0.647 (CHA₂DS₂-VASc). CHA₂DS₂-VASc classified 94.2% as being at high risk, whereas most other RSS categorized two-thirds as being at high risk. Of the 184 TE events, 181 (98.4%) occurred in patients identified as being at high risk by the CHA₂DS₂-VASc schema. There was a stepwise increase in TE with increasing CHA₂DS₂-VASc score (P (trend) < 0.0001), which had the highest HR (3.75) among the tested schemes. The negative predictive value (ie, the percent categorized as "not high risk" actually being free from TE) for CHA₂DS₂-VASc was 99.5%.
CONCLUSIONS: Coronary artery disease and smoking are additional risk factors for TE in anticoagulated AF patients, whereas alcohol use appears protective. Of the contemporary stroke RSS, the CHA₂DS₂-VASc scheme correctly identified the greatest proportion of AF patients at high risk, despite the similar predictive ability of most RSS evidenced by the c-statistic.
Stroke. 2010 Dec;41(12):2731-8. doi: 10.1161/STROKEAHA.110.590257. Epu...

重大な出血リスクスコア(HAS BLEDスコア)

出典
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1: A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
著者: Ron Pisters, Deirdre A Lane, Robby Nieuwlaat, Cees B de Vos, Harry J G M Crijns, Gregory Y H Lip
雑誌名: Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010 Mar 18.
Abstract/Text: OBJECTIVE: Despite extensive use of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and the increased bleeding risk associated with such OAC use, no handy quantification tool for assessing this risk exists. We aimed to develop a practical risk score to estimate the 1-year risk for major bleeding (intracranial, hospitalization, hemoglobin decrease > 2 g/L, and/or transfusion) in a cohort of real-world patients with AF.
METHODS: Based on 3,978 patients in the Euro Heart Survey on AF with complete follow-up, all univariate bleeding risk factors in this cohort were used in a multivariate analysis along with historical bleeding risk factors. A new bleeding risk score termed HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) was calculated, incorporating risk factors from the derivation cohort.
RESULTS: Fifty-three (1.5%) major bleeds occurred during 1-year follow-up. The annual bleeding rate increased with increasing risk factors. The predictive accuracy in the overall population using significant risk factors in the derivation cohort (C statistic 0.72) was consistent when applied in several subgroups. Application of the new bleeding risk score (HAS-BLED) gave similar C statistics except where patients were receiving antiplatelet agents alone or no antithrombotic therapy, with C statistics of 0.91 and 0.85, respectively.
CONCLUSION: This simple, novel bleeding risk score (HAS-BLED) provides a practical tool to assess the individual bleeding risk of real-world patients with AF, potentially supporting clinical decision making regarding antithrombotic therapy in patients with AF.
Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010...

重大な出血リスクスコア(HAS BLEDスコア)と重大な出血発症率

出典
imgimg
1: A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
著者: Ron Pisters, Deirdre A Lane, Robby Nieuwlaat, Cees B de Vos, Harry J G M Crijns, Gregory Y H Lip
雑誌名: Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010 Mar 18.
Abstract/Text: OBJECTIVE: Despite extensive use of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and the increased bleeding risk associated with such OAC use, no handy quantification tool for assessing this risk exists. We aimed to develop a practical risk score to estimate the 1-year risk for major bleeding (intracranial, hospitalization, hemoglobin decrease > 2 g/L, and/or transfusion) in a cohort of real-world patients with AF.
METHODS: Based on 3,978 patients in the Euro Heart Survey on AF with complete follow-up, all univariate bleeding risk factors in this cohort were used in a multivariate analysis along with historical bleeding risk factors. A new bleeding risk score termed HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) was calculated, incorporating risk factors from the derivation cohort.
RESULTS: Fifty-three (1.5%) major bleeds occurred during 1-year follow-up. The annual bleeding rate increased with increasing risk factors. The predictive accuracy in the overall population using significant risk factors in the derivation cohort (C statistic 0.72) was consistent when applied in several subgroups. Application of the new bleeding risk score (HAS-BLED) gave similar C statistics except where patients were receiving antiplatelet agents alone or no antithrombotic therapy, with C statistics of 0.91 and 0.85, respectively.
CONCLUSION: This simple, novel bleeding risk score (HAS-BLED) provides a practical tool to assess the individual bleeding risk of real-world patients with AF, potentially supporting clinical decision making regarding antithrombotic therapy in patients with AF.
Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010...

虚血性心疾患合併心房細動に対する抗血栓療法の推奨期間

出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドラインhttps://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p61、図14、虚血性心疾患合併心房細動に対する抗血栓療法の推奨期間

除細動時の経口抗凝固療法の推奨期間

出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドラインhttps://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p56、図13、除細動時の経口抗凝固療法の推奨期間

心房細動患者の抗凝固療法における出血リスクからみた観血的手技の分類

出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドラインhttps://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p57、表39、心房細動患者の抗凝固療法における出血リスクからみた観血的手技の分類

心不全を伴うAFに対するカテーテルアブレーションの推奨とエビデンスレベル(2018年改訂版 表63)

出典
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1: 日本循環器学会/日本不整脈心電学会合同ガイドライン:2021年JCS/JHRSガイドラインフォーカスアップデート版 不整脈非薬物治療https://www.j-circ.or.jp/cms/wp-content/uploads/2021/03/JCS2021_Kurita_Nogami.pdf(2021年4月閲覧)班長:栗田隆志、野上昭彦、p23、表12、心不全を伴うAFに対するカテーテルアブレーションの推奨とエビデンスレベル(2018年改訂版 表63)

NVAFに対する左心耳閉鎖術の推奨とエビデンスレベル

出典
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1: 日本循環器学会/日本不整脈心電学会合同ガイドライン:2021年JCS/JHRSガイドラインフォーカスアップデート版 不整脈非薬物治療https://www.j-circ.or.jp/cms/wp-content/uploads/2021/03/JCS2021_Kurita_Nogami.pdf(2021年4月閲覧)班長:栗田隆志、野上昭彦、p28、表14、NVAFに対する左心耳閉鎖術の推奨とエビデンスレベル

心房細動のスクリーニングと診断に用いられる各デバイスの特徴

出典
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1: 日本循環器学会/日本不整脈心電学会合同ガイドライン:2022年改訂版不整脈の診断とリスク評価に関するガイドライン.https://www.j-circ.or.jp/cms/wp-content/uploads/2022/03/JCS2022_Takase.pdf(2022年3月閲覧)班長:髙瀬 凡平、p40、図11

DOAC投与中の出血発現時における中和薬の投与法と中和効果時間

出典
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1: 日本循環器学会/日本不整脈心電学会編:2024年JCS/JHRSガイドライン フォーカスアップデート版 不整脈治療https://www.j-circ.or.jp/cms/wp-content/uploads/2024/03/JCS2024_Iwasaki.pdf(2024年8月閲覧)

心不全をともなう心房細動に対するカテーテルアブレーションに関する推奨とエビデンスレベル

出典
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1: 日本循環器学会/日本不整脈心電学会:2024年JCS/JHRSガイドラインフォーカスアップデート版不整脈治療https://www.j-circ.or.jp/cms/wp-content/uploads/2024/03/JCS2024_Iwasaki.pdf(2024年8月閲覧)

HELT-E2S2スコア

Okumura K, et al. A Novel Risk Stratification System for Ischemic Stroke in Japanese Patients With Non-Valvular Atrial Fibrillation. Circ J [Internet]. Circ J; 2021;85(8):1254–1262. PMID: 33762526より改変
出典
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1: 日本循環器学会/日本不整脈心電学会:2024年JCS/JHRSガイドラインフォーカスアップデート版不整脈治療https://www.j-circ.or.jp/cms/wp-content/uploads/2024/03/JCS2024_Iwasaki.pdf(2024年8月閲覧)

待機的手術における抗凝固薬の術前の休薬時期と術後の再開時期

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1: 日本循環器学会:2020年JCSガイドライン フォーカスアップデート版 冠動脈疾患患者における抗血栓療法https://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Kimura_Nakamura.pdf(2024年8月閲覧)

24時間ホルター心電図所見:頻拍停⽌時に約10秒間の⼼停⽌所⾒を認める

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1: 著者提供

カテーテルアブレーション所見:クライオバルーンを用いたカテーテルアブレーション写真

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1: 著者提供

頻拍発作時心電図所見:頻脈性心房細動(135 bpm)の12誘導心電図

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1: 著者提供

頻脈性心房細動に対する心拍数調節療法療の治療方針

出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドライン.https://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p67、図16、頻脈性心房細動に対する心拍数調節療法療の治療方針

心房細動における抗凝固療法の推奨

CHADS2スコアについては下記のリンクを参照にする。
  1. 塞栓症リスクスコア(CHADS2スコア):[ID0605]
  1. 塞栓症リスクスコア(CHADS2スコア)と脳梗塞の発症率:[ID0606]
出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドライン.https://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p49、図12、心房細動における抗凝固療法の推奨

心房細動に対する除細動施行のフローチャート

出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドライン.https://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p69、図17、心房細動に対する除細動施行のフローチャート

心房細動の再発予防のフローチャート

出典
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1: 日本循環器学会/日本不整脈心電学会編:2020年改訂版 不整脈薬物治療ガイドライン.https://www.j-circ.or.jp/cms/wp-content/uploads/2020/04/JCS2020_Ono.pdf(2020年4月閲覧)班長:小野 克重、p74、図18、心房細動の再発予防のフローチャート

心房細動の心電図所見

RR間隔が不規則なQRS波。基線が消失してf波を認める様子が、V1誘導ではっきりと確認できる。
出典
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1: 鈴木信也先生ご提供