 |
 |
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.
SUMMARIES FOR PATIENTS
Management of Newly Detected Atrial Fibrillation: Recommendations from the American College of Physicians and the American Academy of Family Physicians
16 December 2003 | Volume 139 Issue 12 | Page I-32
Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians.
The summary below is from the full reports titled "Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians" and "Management of Atrial Fibrillation: Review of the Evidence for the Role of Pharmacologic Therapy, Electrical Cardioversion, and Echocardiography." They are in the 16 December 2003 issue of Annals of Internal Medicine (volume 139, pages 1009-1017 and pages 1018-1033). The first report was written by V. Snow, K.B. Weiss, M. LeFevre, R. McNamara, E. Bass, L.A. Green, K. Michl, D.K. Owens, J. Susman, D.I. Allen, and C. Mottur-Pilson, the Joint AAFP/ACP Panel on Atrial Fibrillation; the second report was written by R.L. McNamara, L.J. Tamariz, J.B. Segal, and E.B. Bass.
Who developed these guidelines?
The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) developed these recommendations.
What is the problem and what is known about it so far?
Atrial fibrillation is a common abnormal heart rhythm. In atrial fibrillation, the upper heart chambers (atria) contract rapidly. Only some of the atrial beats pass to the lower heart chambers (ventricles). The heartbeat becomes irregular, leading to inefficient pumping of blood. Sometimes the cause of atrial fibrillation is unknown, but it is often due to underlying heart conditions, high blood pressure, overactive thyroid, or too much alcohol. Some people with atrial fibrillation have no symptoms, while others have a fluttering sensation in the chest, lightheadedness, shortness of breath, or chest pain. A dangerous complication of atrial fibrillation is stroke. Stroke occurs because blood clots form in the atria and travel to the brain. Blood thinners (anticoagulation) can prevent stroke in atrial fibrillation. Other treatments include medications to slow the heartbeat (rate control) or to convert it to normal rhythm (cardioversion). Doctors can use medications (medical cardioversion) or electricity (electrical cardioversion) to change atrial fibrillation to normal rhythm.
How did the ACP and the AAFP develop these recommendations?
The authors reviewed studies about atrial fibrillation to identify the benefits of blood thinners to prevent stroke, of slowing heart rate versus converting to normal rhythm, and of using medications versus electricity to convert to normal rhythm. They also examined the role of testing and anticoagulation before cardioversion. In addition, they reviewed the use of medications to maintain normal rhythm after cardioversion.
What did the authors find?
Studies showed that medications to slow the heartbeat (rate control) and thin the blood (anticoagulation) are the best treatment for most patients with atrial fibrillation. Studies did not show that rhythm control was better than rate control in reducing complications and death. The medications that worked best for rate control during both exercise and rest included atenolol, metoprolol, diltiazem, and verapamil. Digoxin only controls rate at rest. Studies showed that the side effects of medications to keep patients in normal rhythm may be greater than their benefits.
What do the ACP and AAFP suggest that patients and doctors do?
For most patients with atrial fibrillation, slowing heart rate with atenolol, metoprolol, diltiazem, or verapamil is the most appropriate treatment. Patients with atrial fibrillation should receive blood thinners to prevent stroke unless they have a condition that would make anticoagulation dangerous (such as alcoholism with frequent falls). Patients who choose conversion to normal heart rhythm instead of rate control because of symptoms can select electrical or medical cardioversion. For patients who choose cardioversion, outcomes are similar whether patients have immediate cardioversion following a special test (transesophageal echocardiogram) to make sure no blood clots exist or if they delay cardioversion until blood thinners take effect. Most patients should not take medications to maintain normal rhythm after cardioversion.
What are the cautions related to these recommendations?
These recommendations are intended to help patients and their physicians make decisions. They may not apply to all patients in all circumstances.
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  N. K Choudhry, B. Zagorski, J. Avorn, R. Levin, K. Sykora, A. Laupacis, and M. Mamdani Comparison of the Impact of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management Trial on Prescribing Patterns: A Time-Series Analysis Ann. Pharmacother., November 1, 2008; 42(11): 1563 - 1572. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N.A. M. Estes III, J. L. Halperin, H. Calkins, M. D. Ezekowitz, P. Gitman, A. S. Go, R. L. McNamara, J. V. Messer, J. L. Ritchie, S. J.W. Romeo, et al. ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation) Developed in Collaboration With the Heart Rhythm Society J. Am. Coll. Cardiol., February 26, 2008; 51(8): 865 - 884. [Full Text] [PDF]
|
|
|
|
 |
|
 N. A. M. Estes III, J. L. Halperin, H. Calkins, M. D. Ezekowitz, P. Gitman, A. S. Go, R. L. McNamara, J. V. Messer, J. L. Ritchie, S. J.W. Romeo, et al. ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation) Circulation, February 26, 2008; 117(8): 1101 - 1120. [Full Text] [PDF]
|
|
|
|
 |
|
 A. K Jaffer Warfarin reduced major stroke more than aspirin in elderly patients with atrial fibrillation in primary care. Evid. Based Med., December 1, 2007; 12(6): 172 - 172. [Full Text] [PDF]
|
|
|
|
 |
|
 E. A. Nutescu ASHP Therapeutic Position Statement on Antithrombotic Therapy in Chronic Atrial Fibrillation Am. J. Health Syst. Pharm., November 1, 2007; 64(21): 2281 - 2291. [Full Text] [PDF]
|
|
|
|
|
|
S. B. Rowan, D. N. Bailey, C. E. Bublitz, and R. J. Anderson Trends in Anticoagulation for Atrial Fibrillation in the U.S.: An Analysis of the National Ambulatory Medical Care Survey Database J. Am. Coll. Cardiol., April 10, 2007; 49(14): 1561 - 1565. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G Y H Lip and M Rudolf The new NICE guideline on atrial fibrillation management Heart, January 1, 2007; 93(1): 23 - 23. [Full Text] [PDF]
|
|
|
|
|
|
E. S Lang ED use of magnesium sulphate improved rate control in atrial fibrillation with rapid ventricular response Evid. Based Med., October 1, 2005; 10(5): 139 - 139. [Full Text] [PDF]
|
|
|
|
 |
|
 L. G. Futterman and L. Lemberg Atrial Fibrillation Am. J. Crit. Care., September 1, 2005; 14(5): 438 - 440. [Full Text] [PDF]
|
|
|
|
 |
|
 M. O'Donnell, G. Agnelli, and J. I. Weitz Emerging therapies for stroke prevention in atrial fibrillation Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C19 - C27. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Emmerich, J.-Y. Le Heuzey, P. M.W. Bath, and S. J. Connolly Indication for antithrombotic therapy for atrial fibrillation: reconciling the guidelines with clinical practice Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C28 - C33. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. L. Page Newly Diagnosed Atrial Fibrillation N. Engl. J. Med., December 2, 2004; 351(23): 2408 - 2416. [Full Text] [PDF]
|
|
|
|
 |
|
 T. D. Bahnson and A. O. Grant To Be or Not To Be in Normal Sinus Rhythm: What Do We Really Know? Ann Intern Med, November 2, 2004; 141(9): 727 - 729. [Full Text] [PDF]
|
|
|
|
|
|
K. K Anthony and V. F Mauro Rate Versus Rhythm Control in Atrial Fibrillation Ann. Pharmacother., May 1, 2004; 38(5): 839 - 844. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Guidelines: Management of Newly Detected Atrial Fibrillation Journal Watch Cardiology, February 13, 2004; 2004(213): 3 - 3. [Full Text]
|
|
|
|
 |
|
 Management of Patients with Newly Detected Atrial Fibrillation Journal Watch (General), January 27, 2004; 2004(127): 1 - 1. [Full Text]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Article
