Gå direkt till huvudinnehållet

Förmaksflimmer och förmaksfladder

Senast uppdaterad: Senast reviderad:


Definition:
Förmaksflimmer (FF) är en supraventrikulär arytmi som kännetecknas av okoordinerad förmaksaktivitet. Vid förmaksfladder finns en elektrisk återkopplingskrets och aktiviteten är jämnare.
Förekomst:
Vanligt tillstånd, särskilt efter 60 års ålder. Viktig riskfaktor för ischemisk stroke.
Symtom:
Palpitationer, dyspné, bröstsmärtor, trötthet och nedsatt kondition kan förekomma. Alla har inte symtom.
Kliniska fynd:
Takykardi som är helt oregelbunden (förmaksflimmer) eller regelbunden (förmaksfladder).
Diagnostik:
Typiska förändringar på EKG (avsaknad av p-vågor, oregelbunden rytm vid FF och regelbunden rytm vid förmaksfladder) bekräftar diagnosen.
Behandling:
Förebyggande av stroke, främst med antikoagulantia (A). Bättre symtomkontroll med frekvens-/rytmreglerande behandling (B). Behandling av komorditet och kardiovaskulära riskfaktorer (C). 
  1. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS) published online ahead of print, 2020 Aug 29. Eur Heart J. 2020;ehaa612. PMID:32860505. PubMed  
  2. Nattel S, Opie LH. Controversies in atrial fibrillation. Lancet 2006; 367: 262-72. PubMed  
  3. Holmqvist F, Borgquist R, Ljungström E. Kateterablation – mer än bara symtomlindring?. Läkartidningen 2019; 116: FALZ. www.lakartidningen.se  
  4. Fuster V, Rydén LE, Cannom DS, et al. Task force report. ACC/AHA/ESC guide-lines for the management of patients with atrial fibrillation. Europace 2006;8:651-745. PubMed  
  5. Friberg L, Rosenqvist M. Epidemiologi och riskkategorisering. Information från Läkemedelsverket 2017;28(1):33–37.
  6. Antikoagulantiabehandling vid förmaksflimmer - behandlingsrekommendation: Information från Läkemedelsverket 2017;28(1):12–31. lakemedelsverket.se  
  7. Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass Screening for Untreated Atrial Fibrillation: The STROKESTOP Study. Circulation. 2015;131(25):2176-2184. PMID:25910800. PubMed  
  8. Rosamond W, et al. Heart disease and stroke statistics - 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117: e25-e146.
  9. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18(11): 1609-78. pmid:27567465 PubMed  
  10. Kwok CS1, Anderson SG2, Myint PK3, et al.. Physical activity and incidence of atrial fibrillation: a systematic review and meta-analysis.. Int J Cardiol 2014. pmid:25443248 PubMed  
  11. Bilal Iqbal M, Taneja AK, Lip GYH, Flather M. Recent developments in atrial fibrillation. BMJ 2005; 330: 238-43. PubMed  
  12. Marcus GM, Modrow MF, Schmid CH, et al. Individualized Studies of Triggers of Paroxysmal Atrial Fibrillation The I-STOP-AFib Randomized Clinical Trial. JAMA Cardiol 2021. pmid:34775507 PubMed  
  13. Wynn GJ, Todd DM, Webber M, et al. The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification. Europace 2014;16:965–972. PMID:24534264. PubMed  
  14. Boriani G, Botto GL, Padeletti L, et al. Improving stroke risk stratification using the CHADS2 and CHADS2-VASc risk scores in paroxysmal atrial fibrillation patients by continous arrhythmia burden monitoring. Stroke 2011; 42: 1768-70. Stroke  
  15. US Preventive Services Task Force. Screening for Atrial Fibrillation US Preventive Services Task Force Recommendation Statement. JAMA 2022; 327: 360-367. pmid:35076659 PubMed  
  16. Socialstyrelsen (2017). Screening för förmaksflimmer i syfte att förebygga stroke - Rekommendation och bedömningsunderlag. (Hämtad 2017-06-15) www.socialstyrelsen.se  
  17. Engdahl J, Rosenqvist M. Screening för förmaksflimmer – uppdatering i väntan på evidens. Läkartidningen. 2021;118:20178. lakartidningen.se  
  18. Hobbs FD, Fitzmaurice DA, Mant J, et al. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess. 2005;9(40):iii-74. PMID:16202350. PubMed  
  19. Svendsen JH, Diederichsen SZ, Højberg S, et al. Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial. Lancet 2021. pmid:34469766 PubMed  
  20. Perez MV, Mahaffey KW, Hedlin H, et al. Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation. N Engl J Med. 2019;381(20):1909–1917. PMID: 31722151. PubMed  
  21. Halligan SC, Gersh BJ, Brown RD, et al. The natural history of lone atrial flutter. Ann Intern Med 2004; 140: 265-68. Annals of Internal Medicine  
  22. Christersson C. NOAK vid klaffsjukdom - bara i särskilda fall. Lakartidningen.se 2018-12-04. www.lakartidningen.se  
  23. Läkemedelsverket (2017). Användning av blodproppshämmande läkemedel vid förmaksflimmer. (Hämtad 2017-07-12)
  24. Lau WCY, Cheung CL, Man KKC, et al. Association Between Treatment With Apixaban, Dabigatran, Rivaroxaban, or Warfarin and Risk for Osteoporotic Fractures Among Patients With Atrial Fibrillation. Ann Intern Med. 2020;10.7326/M19-3671. PMID:32423351. PubMed  
  25. Lv M, Wu T, Jiang S, et al. Risk of Intracranial Hemorrhage Caused by Direct Oral Anticoagulants for Stroke Prevention in Patients With Atrial Fibrillation (from a Network Meta-Analysis of Randomized Controlled Trials). Am J Cardiol. 2021. PMID: 34756593 PubMed  
  26. Carnicelli AP, Hong H, Connolly SJ, et al. Direct Oral Anticoagulants versus Warfarin in Patients with Atrial Fibrillation: Patient-Level Network Meta-Analyses of Randomized Clinical Trials with Interaction Testing by Age and Sex. Circulation 2022. pmid:34985309 PubMed  
  27. Beijer G. Dabigatran bör sannolikt inte ges vid kroppsvikt över 120 kilo. Läkartidningen 32-33/2021. (Hämtad 2021-09-17). lakartidningen.se  
  28. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014;383: 955–962. PMID:24315724. PubMed  
  29. 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: 321-6. PubMed  
  30. Hernandez I, He M, Brooks MM, et al. Adherence to Anticoagulation and Risk of Stroke Among Medicare Beneficiaries Newly Diagnosed with Atrial Fibrillation. Am J Cardiovasc Drugs 2019. pmid:31523759 PubMed  
  31. Aguilar MI, Hart R. Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001927. doi: 10.1002/14651858.CD001927.pub2. DOI  
  32. Amgad M, Ghanshyam S, Pulkit C, MD1, et al. Assessment of Outcomes of Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation and Multiple Chronic Conditions A Comparative Effectiveness Analysis. JAMA Network Open 2018. doi:10.1001/jamanetworkopen.2018.2870 DOI  
  33. Janusinfo (Region Stockholm). Sköra äldre patienter med förmaksflimmer – när behandla med anti­koagulantia och hur? 2019-09-20 (Hämtad 2019-10-30). www.janusinfo.se  
  34. January CT, Wann LS, Calkins H, et al 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRA guideline for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2019. DOI: 10.1161/CIR.0000000000000665.
  35. Schaefer JK, Errickson J, Li Y, et al. Adverse Events Associated With the Addition of Aspirin to Direct Oral Anticoagulant Therapy Without a Clear Indication published online ahead of print, 2021 Apr 19. JAMA Intern Med. 2021;10.1001/jamainternmed.2021.1197. PMID:33871544. PubMed  
  36. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation published online ahead of print, 2020 Aug 29. N Engl J Med. PMID:32865375. PubMed  
  37. Juhlin T. NOAK lika säkert som warfarin vid elektiv elkonvertering. Lakartidningen.se 2018-12-04. www.lakartidningen.se  
  38. Socialstyrelsen. Nationella riktlinjer för hjärtsjukvård – Stöd för styrning och ledning. 2018 (Hämtad 2020-09-09). www.socialstyrelsen.se  
  39. Piccini JP, Fauchier L. Rhythm control in atrial fibrillation. Lancet. 2016 Aug 20;388(10046):829-40.PMID:27560278. PubMed  
  40. Van Gelder IC, Rienstra M, Crijns HJ, et al. Rate control in atrial fibrillation. Lancet. 2016 Aug 20;388(10046):818-28.PMID:27560277. PubMed  
  41. Nyong J, Amit G, Adler AJ, et al. Efficacy and safety of ablation for people with non-paroxysmal atrial fibrillation. Cochrane Database Syst Rev. 2016 Nov 22;11:CD012088.PMID:27871122. PubMed  
  42. Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation. A randomized controlled trial. JAMA 2010; 303: 333-40. PubMed  
  43. Turagam MK, Musikantow D, Whang W, et al. Assessment of Catheter Ablation or Antiarrhythmic Drugs for First-line Therapy of Atrial Fibrillation A Meta-analysis of Randomized Clinical Trials. JAMA Cardiol 2021. pmid:33909022 PubMed  
  44. Bahnson TD, Giczewska A, Mark DB, et al. Association Between Age and Outcomes of Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: Results From the CABANA Trial. Circulation. 2022; 145:796-804. PMID: 34933570 PubMed  
  45. Anselmino M, Matta M, D'Ascenzo F, et al. Catheter ablation of atrial fibrillation in patients with left ventricular systolic dysfunction: a systematic review and meta-analysis. Circ Arrhythm Electrophysiol. 2014 Dec;7(6):1011-8. doi: 10.1161/CIRCEP.114.001938. DOI  
  46. Packer DL, Mark DB, Robb RA, et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation The CABANA Randomized Clinical Trial. JAMA 2019; 321: 1261-74. pmid:30874766 PubMed  
  47. Mark DB, Anstrom KJ, Sheng S, et al. Effect of Catheter Ablation vs Medical Therapy on Quality of Life Among Patients With Atrial Fibrillation The CABANA Randomized Clinical Trial. JAMA 2019; 321: 1275-85. pmid:30874716 PubMed  
  48. Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhytmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA 2010; 303: 333-40. PMID:20103757. PubMed  
  49. Ganesan AN, Nandal S, Lüker J, et al. Catheter ablation of atrial fibrillation in patients with concomitant left ventricular impairment: a systematic review of efficacy and effect on ejection fraction. Heart Lung Circ. 2015 Mar;24(3):270-80. doi: 10.1016/j.hlc.2014.09.012 DOI  
  50. Chen S, Purerfellner H, Meyer C, et al. Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data. Eur Heart J. 2019. PMID: 31298266 PubMed  
  51. Di Biase L, Mohanty P, Mohanty S, et al. Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial. Circulation 2016; 133: 1637-44. pmid:27029350 PubMed  
  52. Oral H, Pappone C, Chugh A, et al. Circumferential pulmonary-vein ablation for chronic atrial fibrillation. N Engl J Med 2006; 354: 934-41. New England Journal of Medicine  
  53. Wood MA, Ellenbogen KA. Catheter ablation of chronic atrial fibrillation - the gap between promise and practice. N Engl J Med 2006; 354: 967-9. PubMed  
  54. Sundt TM, Gersh BJ. Making sense of the maze. Which patients with atrial fibrillation will benefit?. JAMA 2005; 294: 2357-9. PubMed  
  55. Anfinsen O-G. Ikke-farmakologisk behandling av atrieflimmer. Tidsskr Nor Lægeforen 2000; 120: 2884-9. Tidsskrift for Den norske legeforening  
  56. Guimarães HP, Lopes RD, de Barros E Silva PGM, et al. Rivaroxaban in Patients with Atrial Fibrillation and a Bioprosthetic Mitral Valve. N Engl J Med 2020. pmid:33196155 PubMed  
  57. Janusinfo. Antikoagulantiabehandling av patienter med cancersjukdom och förmaksflimmer. 2019-07-02 (hämtad 2019-07-09). www.janusinfo.se  
  58. Fernandes CJ, Morinaga LTK, Alves JL jr, et al. Cancer-associated thrombosis: the when, how and why. Eur Respir Rev 2019; 28(151): pii: 180119. pmid:30918022 PubMed  
  59. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Jul 9;74(1):104-132. Epub 2019 Jan 28. PMID: 30703431. PubMed  
  60. Camm AJ, Kirchhof P, Lip GYH, et al. Guidelines for the management of atrial fibrillation. The task force for the management of atrial fibrillation of the European Society of Cardiology. Eur Heart J 2010; 31: 2369-429. PubMed  
  61. Healey JS, Baranchuk A, Crystal E, et al. Prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: a meta-analysis. J Am Coll Cardiol 2005; 45: 1832-9. PubMed  
  62. Caldeira D, Martins C, Alves LB, et al. Caffeine does not increase the risk of atrial fibrillation: a systematic review and meta-analysis of observational studies. Heart. 2013 Oct;99(19):1383-9. PMID: 24009307 PubMed  
  63. Macchia A, Grancelli H, Varini S, et al. Omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: results of the FORWARD (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation) trial.. J Am Coll Cardiol 2013; 61: 463-8. doi:10.1016/j.jacc.2012.11.021 DOI  
  64. Darghosian L, Free M, Li J, et al. Effect of Omega-three polyunsaturated fatty acids on Inflammation, oxidative stress, and recurrence of atrial fibrillation. Am J Cardiol. 2014. PMID: 25465932 PubMed  
  65. Lip GYH, Kamath S. Acute atrial fibrillation. Clinical Evidence 2001; 6: 1-7. PubMed  
  66. Freedman B, Potpara TS, Lip GY. Stroke prevention in atrial fibrillation. Lancet. 2016 Aug 20;388(10046):806-17.PMID:27560276. PubMed  
  67. Ganesan AN, Chew DP, Hartshorne T, et al. The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur Heart J 2016; 37: 1591-602. pmid:26888184 PubMed  
  68. Kapłon-Cieślicka A, Budnik M, Gawałko M, et al. Atrial fibrillation type and renal dysfunction as important predictors of left atrial thrombus. Heart 2019. pmid:31040170. www.ncbi.nlm.nih.gov  
  69. Gomez-Outes A, Lagunar-Ruiz J, Terleira-Fernandez AI, et al. Causes of Death in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol. 2016; 68:2508-21.PMID: 27931607. PubMed  
  70. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 1991; 22: 983-8. PubMed  
  71. Benjamin EJ, Wolf PA, d'Agostino RB et al. Impact of atrial fibrillation on the risk of death. The Framingham Heart Study. Circulation 1998;98:946-52. Circulation  
  72. Rattanawong P, Upala S, Riangwiwat T, et al. Atrial fibrillation is associated with sudden cardiac death: a systematic review and meta-analysis. J Interv Card Electrophysiol. 2018;51(2):91-104. PMID:29332241. PubMed  
  73. Bardai A, Blom MT, van Hoeijen DA, van Deutekom HW, Brouwer HJ, Tan HL. Atrial fibrillation is an independent risk factor for ventricular fibrillation: a large-scale population-based case-control study. Circ Arrhythm Electrophysiol. 2014;7(6):1033-1039. PMID:25236735. PubMed  
  74. Van Gelder IC, Crijns HJ, Tieleman RG, Brugemann J, De Kam PJ, Gosselink AT, et al. Chronic atrial fibrillation: success of serial cardioversion therapy and safety of oral anticoagulation. Arch Intern Med 1996; 156: 2585-92. PubMed  
  75. Volgman AS, Soble JS, Neumann A, Mukhtar KN, Iftikhar F, Vallesteros A, et al. Effect of left atrial size on recurrence of atrial fibrillation after electrical cardioversion: atrial dimension versus volume. Am J Card Imaging 1996; 10: 261-5. PubMed  
  76. Miyasaka Y, Barnes ME, Bailey KR, et al. Mortality trends in patients diagnosed with first atrial fibrillation a 21-year community-based study. J Am Coll Cardiol 2007; 49: 986-92. PubMed  
  • Faris Al-Khalili, med dr och specialist, Stockholm Heart Center