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Guideline Update

How should we manage newly diagnosed

atrial fibrillation?
Keith B. Holten, MD
University of Cincinnati College of Medicine, Cincinnati, Ohio

■ What is the primary treatment goal diagnosed atrial fibrillation. The guideline does
of cardiac medication? not apply to postoperative patients, post-
myocardial infarction patients, those with class
■ What is the role of digoxin?
IV heart failure or valvular heart disease, or
■ When should medications be used to patients taking antiarrhythmic medications.
maintain sinus rhythm after cardioversion? The objective of this guideline is to recom-
mend pharmacologic management of newly
■ Should all patients be anticoagulated
diagnosed atrial fibrillation. The evidence cate-
with warfarin?
gory for this guideline is management.
■ What are the contraindications Outcomes considered are control of heart rate
to warfarin therapy? and stroke risk reduction. The committees used
the Guyatt method of grading recommenda-
tions,1 a qualitative approach to the literature.
These were revised to comply with the SORT

ecommendations for these management
issues are found in the guideline ■ GUIDELINE RELEVANCE
developed in a joint effort of the AND LIMITATIONS
American College of Physicians Clinical Efficacy Atrial fibrillation is common, affecting any-
Assessment Subcommittee and the American where from 1% of the American population at
Academy of Family Physicians Commission on age 60 to 8% at age 80. It is more common in
Clinical Policies and Research. It was funded by men than women. Even if patients are asympto-
both organizations and approved by their matic, they are at increased risk of stroke
Boards before publication. The target audience (1.9%–18% per year).
is internists and family physicians. A lengthy bibliography accompanies the
The target patients are adults with newly guideline. Tables of supporting evidence are
lacking, which makes it more difficult to ana-
Correspondence: Keith B. Holten, MD, Clinton Memorial lyze the final recommendations. The guideline
Hospital/University of Cincinnati Family Practice Residency,
825 W. Locust St., Wilmington, OH, 45177. E-mail: is weakened by the lack of a cost-effectiveness analysis.

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with the Agency for Healthcare Research and

Quality. There are 57 references.
PRACTICE RECOMMENDATIONS The guideline group reviewed the evidence
and made graded recommendations regarding
Grade A Recommendations rate control versus rhythm control, stroke pre-
• Prescribe long-term warfarin at therapeutic vention and anticoagulation, electrical conver-
levels unless stroke risk is low, as deter- sion versus pharmacologic conversion, the role
mined by risk factors: congestive heart fail- of transesophageal echocardiography in guiding
ure, hypertension, age 75 years older, dia- therapy, and maintenance therapy.
betes mellitus, or history of transient
ischemic event/cerebrovascular accident. ■ SOURCE FOR THIS GUIDELINE
Warfarin should not be prescribed if there
Snow V, Weiss KB, LeFevre M, et al. Management
are contraindications of thrombocytopenia,
of newly detected atrial fibrillation: A clinical
recent trauma, surgery, or alcoholism.
practice guideline from the American Academy
• Atenolol (Tenormin), metoprolol (Lopressor, of Family Physicians and the American College of
Toprol-XL), diltiazem, and verapamil are Physicians. Ann Intern Med 2003; 139:
optimal choices for rate control during exer-
cise and at rest. Digoxin (Lanoxin is a sec-
ond-line agent and is only effective at rest.

Grade B Recommendations ON ATRIAL FIBRILLATION

• Rate control with anticoagulation is the • ACC/AHA/ESC guidelines for the manage-
primary goal of treatment. Consider rhythm ment of patients with atrial fibrillation. A report
control according to a patient’s symptoms. of the American College of Cardiology/
• Cardioversion by electrical conversion American Heart Association Task Force on
and pharmacologic conversion are both Practice Guidelines and the European Society of
appropriate. Cardiology Committee for Practice Guidelines and
Policy Conferences (Committee to Develop
• For patients who elect cardioversion,
Guidelines for the Management of Patients with
options include 1) early antiocoagulation
and cardioversion (with transesophageal Atrial Fibrillation).
echocardiography confirming absence of This 2001 guideline is the work of an interna-
mural thrombus), or 2) delayed cardiover- tional panel. Algorithms are provided for pharma-
sion with pre- and post-anticoagulation. cologic management of patients with newly diag-
nosed atrial fibrillation, pharmacologic manage-
• Most patients who convert to sinus rhythm
ment of patients with recurrent paroxysmal atrial
do not need maintenance rhythm therapy.
When quality of life is threatened, the best fibrillation, antiarrythmic drug therapy to main-
agents are amiodarone (Cordarone), tain sinus rhythm in patients with recurrent
disopyramide (Norpace), propafenone paroxysmal or persistent atrial fibrillation, and
(Rythmol), and sotalol (Betapace). pharmacologic management of patients with
recurrent persistent or permanent atrial fibrilla-
tion. Recent evidence regarding rate control ver-
■ GUIDELINE DEVELOPMENT sus rhythm control was not available at publica-
AND EVIDENCE REVIEW tion of this guideline.
This guideline is based on background papers Sources: American College of Cardiology, American Heart
published by McNamara3 and the John Hopkins Association, European Society of Cardiology. ACC/AHA/ESC
guidelines for the management of patients with atrial fibrilla-
Evidence-Based Practice Center4 under contract tion. J Am Coll Cardiol 2001; 38:1266i–lxx. (580 references)

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Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guide- • Preventive health care, 2000 update. Use
lines for the management of patients with atrial fibrillation.
A report of the American College of Cardiology/ of ambulatory electrocardiography for the detec-
American Heart Association Task Force on Practice tion of paroxysmal atrial fibrillation in patients
Guidelines and the European Society of Cardiology. Eur Heart
J 2001; 22:1852–1923. (580 references) with stroke.
This guideline is from 2000 and found insuffi-
• Antithrombotic therapy in atrial fibrillation. cient evidence to recommend for or against ambu-
In: Sixth ACCP Consensus Conference on latory electrocardiography to detect atrial fibrilla-
Antithrombotic Therapy. tion for patients after stroke or TIA.
This is an excellent review of a grading Source: Bell C, Kapral M. Use of ambulatory electrocardiog-
scheme for stroke risk and choice of anti-throm- raphy for the detection of paroxysmal atrial fibrillation in
patients with stroke. Canadian Task Force on Preventive
botic agents. Health Care. Can J Neurol Sc. 2000; 27:25–31. (78 references)
Source: Albers GW, Dalen JE, Laupacis A, et al.
Antithrombotic therapy in atrial fibrillation. Chest 2001; REFERENCES
119(1 Suppl):194S–206S. (103 references)
1. Guyatt GH, Sackett DL, Sinclair JC, et al. User’s guide to the
medical literature:IX. A method for grading health care rec-
• Atrial fibrillation: drug treatment and ommendations. JAMA 1995; 274:1800.
electric cardioversion. 2. Ebell M, Siwek J, Weiss BD, et al. Strength of recommenda-
tion taxonomy (SORT): A patient-centered approach to grad-
This Finnish guideline makes recommenda- ing evidence in the medical literature. Am Fam Physician
tions regarding drug treatment, anticoagulation, 2004; 69:548–556.
3. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management
and cardioversion for patients with atrial fibrilla- of atrial fibrillation: review of the evidence for the role of
tion and atrial flutter. The recommendations are pharmacologic therapy, electrical cardioversion, and
echocardiography. Ann Int Med 2003;139:1018–1033.
not graded.
4. McNamara RL, Bass EB, Miller MR, et al. Evidence report
Source: Finnish Medical Society Duodecim. Atrial on the management of new onset atrial fibrillation. Agency
Fibrillation: Drug Treatment and Electric Cardioversion. for Healthcare Research and Quality publication no. AHRQ
Helsinki, Finland: Duodecim Medical Publications Ltd.; 01-E026. Rockville, MD: Agency for Healthcare Research
2002 Mar 4. Various pages. and Quality; January 2001.

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