Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

16 December 2003 | Volume 139 Issue 12 | Pages 1009-1017

The Joint Panel of the American Academy of Family Physicians and the American College of Physicians, in collaboration with the Johns Hopkins Evidence-based Practice Center, systematically reviewed the available evidence on the management of newly detected atrial fibrillation and developed recommendations for adult patients with first-detected atrial fibrillation. The recommendations do not apply to patients with postoperative or post–myocardial infarction atrial fibrillation, patients with class IV heart failure, patients already taking antiarrhythmic drugs, or patients with valvular disease. The target physician audience is internists and family physicians dedicated to primary care. The recommendations are as follows:

Recommendation 1: Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation. Rhythm control has not been shown to be superior to rate control (with chronic anticoagulation) in reducing morbidity and mortality and may be inferior in some patient subgroups to rate control. Rhythm control is appropriate when based on other special considerations, such as patient symptoms, exercise tolerance, and patient preference. Grade: 2A

Recommendation 2: Patients with atrial fibrillation should receive chronic anticoagulation with adjusted-dose warfarin, unless they are at low risk of stroke or have a specific contraindication to the use of warfarin (thrombocytopenia, recent trauma or surgery, alcoholism). Grade: 1A

Recommendation 3: For patients with atrial fibrillation, the following drugs are recommended for their demonstrated efficacy in rate control during exercise and while at rest: atenolol, metoprolol, diltiazem, and verapamil (drugs listed alphabetically by class). Digoxin is only effective for rate control at rest and therefore should only be used as a second-line agent for rate control in atrial fibrillation. Grade: 1B

Recommendation 4: For those patients who elect to undergo acute cardioversion to achieve sinus rhythm in atrial fibrillation, both direct-current cardioversion (Grade: 1C+) and pharmacological conversion (Grade: 2A) are appropriate options.

Recommendation 5: Both transesophageal echocardiography with short-term prior anticoagulation followed by early acute cardioversion (in the absence of intracardiac thrombus) with postcardioversion anticoagulation versus delayed cardioversion with pre- and postanticoagulation are appropriate management strategies for those patients who elect to undergo cardioversion. Grade: 2A

Recommendation 6: Most patients converted to sinus rhythm from atrial fibrillation should not be placed on rhythm maintenance therapy since the risks outweigh the benefits. In a selected group of patients whose quality of life is compromised by atrial fibrillation, the recommended pharmacologic agents for rhythm maintenance are amiodarone, disopyramide, propafenone, and sotalol (drugs listed in alphabetical order). The choice of agent predominantly depends on specific risk of side effects based on patient characteristics. Grade: 2A

Author and Article Information

From American College of Physicians, Philadelphia, Pennsylvania; Hines Veterans Affairs Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Missouri–Columbia, Columbia, Missouri; Yale University School of Medicine, New Haven, Connecticut; Johns Hopkins University, Baltimore, Maryland; University of Michigan, Ann Arbor, Michigan; University of Vermont College of Medicine, Burlington, Vermont; Veterans Affairs Palo Alto Health Care System, Palo Alto, and Stanford University, Stanford, California; University of Cincinnati, Cincinnati, Ohio; and Indiana University School of Medicine, Indianapolis, Indiana.

This manuscript was approved by the ACP Board of Regents on 31 March 2003 and by the AAFP Board of Directors on 29 April 2003.

Note: Clinical practice guidelines are "guides" only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn, or invalid, 5 years after publication, or once an update has been issued.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Grant Support: Financial support for the development of this guideline came exclusively from the AAFP and ACP operating budgets.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Vincenza Snow, MD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, vincenza{at}acponline.org.

Current Author Addresses: Drs. Snow and Mottur-Pilson: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Weiss: 676 North St. Clair Street, Suite 200, Chicago, IL 60611.

Dr. LeFevre: M223 Health Science Center, University of Missouri–Columbia, Columbia, MO 65211.

Dr. McNamara: Cardiovascular Section, Yale University, 333 Cedar Street, 315A FMP, P.O. Box 208017, New Haven, CT 06520-8017.

Dr. Bass: 1830 East Monument Street, Room 8068, Baltimore, MD 21287.

Dr. Green: Family Medicine, 1018 Fuller 708, University of Michigan, Ann Arbor, MI 48109.

Dr. Michl: P.O. Box 1431, Manchester Center, VT 05255.

Dr. Owens: Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.

Dr. Susman: HPB 141, P.O. Box 670582, University of Cincinnati, Cincinnati, OH 45267-0582.

Dr. Allen: Family Medicine, LO 254, Indiana University School of Medicine, Indianapolis, IN 46202.