1. Home>
2. Specialties>
3. Cardiology>
4. Clinical Practice Guideline Watch

Guidelines for Managing Patients with Atrial Fibrillation

Sponsoring Organizations: the American College of Cardiology, the American Heart Association, and the European Society of Cardiology (with the North American Society of Pacing and Electrophysiology)

Background and Purpose: Atrial fibrillation (AF) is the most common sustained arrhythmia (0.4 percent of the general population), and it is becoming even more prevalent. Significant morbidity and mortality result from the increased stroke risk associated with AF and from AF's hemodynamic effects. These guidelines were developed to help clinicians make decisions about AF management in a variety of clinical situations. For each presentation of AF, the authors provide therapeutic algorithms that emphasize AF type (i.e., recurrent, paroxysmal, persistent, permanent) and prevention of thromboembolism. Throughout the guidelines, atrial flutter, an arrhythmia that can occur with AF, is distinguished from AF but is not addressed comprehensively on its own.

Key Points:

1. Precipitating or reversible causes of AF (e.g., thyrotoxicosis) should be treated before initiating antiarrhythmic therapy.

2. Antiarrhythmic therapy is indicated for patients with disabling or otherwise troublesome symptoms in AF. The selection of an antiarrhythmic agent should be based primarily on safety. Considerations for specific drugs are catalogued in the guidelines.

3. Pharmacologic therapy should be avoided in patients with advanced sinus node or atrioventricular node dysfunction, unless a pacemaker has been implanted.

4. A strategy of ventricular rate control generally is used in asymptomatic or minimally symptomatic patients and in patients for whom AF control with antiarrhythmic therapy has failed. When using this strategy, rate should be measured both at rest and during exercise and should be controlled within the physiologic range, usually with beta-blockers or calcium-channel blockers.

5. Digitalis should not be used as the sole agent to control rapid ventricular response to AF in patients with paroxysmal AF.

6. Antithrombotic therapy with warfarin or aspirin should be administered to all patients with AF, except to those with lone AF who are younger than 60 and have no structural heart disease.

7. Chronic oral anticoagulant therapy (target INR, 2 to 3) should be used for patients with high stroke risk, unless contraindicated. Established risk factors are prior stroke or transient ischemic attack, history of hypertension, congestive heart failure, advanced age (continuous by decade), diabetes, and coronary artery disease. The majority of evidence supports using a lower target INR (range, 1.6 to 2.5) for primary prevention of stroke in patients older than 75.

8. Anticoagulant therapy should be administered for at least 3 weeks before and after cardioversion (INR, 2 to 3) in patients with AF lasting >48 hours or of unknown duration. Screening for the presence of a thrombus using transesophageal echocardiography is an alternative for routine preanticoagulation in candidates for cardioversion of AF.

9. Patients undergoing cardiac surgery should be treated with an oral beta-blocker to prevent postoperative AF, unless contraindicated.

Comment: These comprehensive guidelines are a welcome addition to the literature because they provide clinicians with a distilled set of recommendations for managing AF in a wide range of clinical situations. Particular attention was paid to the very important and easily overlooked issue of anticoagulation of AF patients. These guidelines are available free of charge on the Web at http://www.acc.org/clinical/guidelines/atrial_fib/pdfs/AFguid eline8_30.pdf

— H Calkins

Published in Journal Watch Cardiology October 26, 2001

Citation(s):

Fuster V et al. ACC/AHA/ESC Guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation). J Am Coll Cardiol 2001 Oct 38 1266-1266.

• Original article (Subscription may be required)