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Guidelines: Management of Newly Detected Atrial Fibrillation
Sponsoring Organizations: American Academy of Family Physicians, American College of Physicians, Johns Hopkins Evidence-Based Practice Center
Background and Purpose: Atrial fibrillation (AF) is the most common sustained arrhythmia. These guidelines, based on a systematic review of existing evidence, address the pharmacologic management of newly detected AF in primary care. The recommendations do not apply to patients with postoperative or post-MI AF, class IV heart failure, existing antiarrhythmic-drug therapy, or valvular disease.
Key Points:
1. The majority of patients with newly detected AF should be managed with pharmacologic rate control (rather than rhythm control) plus ongoing anticoagulation therapy. (The expense and risk of antiarrhythmic drugs give rate control a slight advantage, despite equivalent efficacy.) Rhythm control is appropriate for specific subgroups, including patients with severe symptoms and those with a preference for this strategy.
2. Recommended drugs for rate control are atenolol, metoprolol, diltiazem, and verapamil. Because digoxin is effective for rate control only at rest, it should be considered second-line therapy.
3. Unless contraindicated, adjusted-dose warfarin should be used for ongoing anticoagulation therapy in AF patients with stroke risk factors.
4. If a patient elects to undergo acute cardioversion to sinus rhythm, direct-current and pharmacologic options are each appropriate. The most effective drugs are ibutilide, flecainide, dofetilide, propafenone, and amiodarone. Two anticoagulation strategies are appropriate for preventing thromboembolism: (a) 3 to 4 weeks of anticoagulation before and after cardioversion; and (b) early cardioversion guided by transesophageal echocardiography plus 3 weeks of anticoagulation after cardioversion.
5. Most patients who undergo cardioversion should not receive long-term antiarrhythmic maintenance therapy. However, such therapy is indicated in some patients, based on symptoms and patient preference. The most effective maintenance drugs are amiodarone, disopyramide, propafenone, and sotalol.
Comment: The most important messages from these guidelines are that, for most patients, systemic anticoagulation therapy is vital, rate control and rhythm control are equivalent in terms of efficacy, and the risks of antiarrhythmic maintenance therapy outweigh the benefits. Although these guidelines were written for a primary care audience, they are generally consistent with the 2001 AF guidelines from the American College of Cardiology and American Heart Association (Journal Watch Cardiology Oct 26 2001). However, the 2 sets of guidelines do have some differences, for example, regarding specific pharmacologic agents to use with rate- and rhythm-control strategies. Also, the AAFP/ACP guidelines do not include a discussion of emerging data on catheter and surgical ablation techniques for AF. Once ablation techniques are enhanced, we will need new randomized trials to compare rate and rhythm control.
— Hugh Calkins, MD
Published in Journal Watch Cardiology February 13, 2004
Citation(s):
Snow V et al. for the Joint AAFP/ACP Panel on Atrial Fibrillation. Management of newly detected atrial fibrillation: A clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003 Dec 16; 139:1009-17.
- Original article (Subscription may be required)
- Medline abstract (Free)
McNamara RL et al. Management of atrial fibrillation: Review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med 2003 Dec 16; 139:1018-33.
- Original article (Subscription may be required)
- Medline abstract (Free)