Management of Atrial Fibrillation: Review of the Evidence for the Role of Pharmacologic Therapy, Electrical Cardioversion, and Echocardiography

  1. Robert L. McNamara, MD, MHS;
  2. Leonardo J. Tamariz, MD, MPH;
  3. Jodi B. Segal, MD, MPH; and
  4. Eric B. Bass, MD, MPH
  1. From Yale University School of Medicine, New Haven, Connecticut, and Johns Hopkins University, Baltimore, Maryland.

    Abstract

    Purpose: This review summarizes the available evidence regarding the efficacy of medications used for ventricular rate control, stroke prevention, acute conversion, and maintenance of sinus rhythm, as well as the efficacy of electrical cardioversion and the use of echocardiography in patients with atrial fibrillation.

    Data Sources: The Cochrane Collaboration's database of controlled clinical trials and MEDLINE.

    Study Selection: Primarily randomized, controlled trials of medications.

    Data Extraction: Paired reviewers obtained data on efficacy and safety. Strength of evidence was assessed.

    Data Synthesis: Recent clinical trial results showed that most patients with atrial fibrillation have similar outcomes with strategies for controlling ventricular rate compared with strategies for restoring sinus rhythm. For efficacy of primary stroke prevention, compared with placebo, evidence was strong for warfarin and suggestive for aspirin. The evidence for an increased risk for major bleeding was suggestive for warfarin and inconclusive for aspirin. For ventricular rate control, verapamil, diltiazem, atenolol, and metoprolol were qualitatively superior to digoxin and placebo, particularly during exercise. For efficacy of acute conversion, compared with placebo, evidence was strong for ibutilide, flecainide, dofetilide, propafenone, amiodarone, and quinidine. For efficacy of maintenance of sinus rhythm after conversion from atrial fibrillation, evidence was strong for amiodarone, propafenone, disopyramide, and sotalol. Echocardiography was found to be useful in estimating risk for thromboembolism and potentially useful in estimating likelihood of successful cardioversion and maintenance.

    Conclusions: For several key questions in the pharmacologic management of atrial fibrillation, strong evidence exists to support 1 or more treatment options.

    Article and Author Information

    • Disclaimer: The authors are responsible for the content of this article, including any 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.

    • Acknowledgments: The authors thank Karen Robinson and Drs. Marlene Miller, Steve Goodman, and Neil Powe for their valuable contribution to the Evidence-based Report on the Management of Atrial Fibrillation.

    • Grant Support: Portions of this background paper were drawn from a review conducted by the Johns Hopkins Evidence-based Practice Center through Contract No. 290-97-0006 from the Agency for Healthcare Research and Quality, Rockville, MD. Dr. Tamariz was supported by a training grant in behavioral research in heart and vascular diseases from the National Heart, Lung, and Blood Institute (T32HL07180).

    • Potential Financial Conflicts of Interest:Consultancies: R.L. McNamara (Aventis, EU3); Grants received: L.J. Tamariz (National Heart, Lung, and Blood Institute).

    • Requests for Single Reprints: Robert L. McNamara, MD, MHS, Cardiovascular Section, Yale University, 333 Cedar Street, 316 FMP, P.O. Box 208017, New Haven, CT 06520-8017; e-mail, robert.mcnamara{at}yale.edu.

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

    • Dr. Tamariz: 2024 East Monument Street, Room 2-516, Baltimore, MD 21205.

    • Dr. Segal: 720 Rutland Avenue, Ross #1025, Baltimore, MD 21205.

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

    Summary for Patients

    • Summaries for Patients:Management of Newly Detected Atrial Fibrillation: Recommendations from the American College of Physicians and the American Academy of Family Physicians Ann Intern Med December 16, 2003 139:I-32
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    1. Ann Intern Med December 16, 2003 vol. 139 no. 12 1018-1033
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