Lee A. Green

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

Atrial fibrillation is the most common type of arrhythmia in adults. It is more common as patients age; the prevalence is 1% among those younger than age 60 years and increases to more than 8% in those older than age 80 years. When data are adjusted for age, men are affected more often than women. Cardiac conditions associated with the development of atrial fibrillation are hypertension, rheumatic mitral valve disease, coronary artery disease, and congestive heart failure. Noncardiac causes include hyperthyroidism, hypoxic pulmonary conditions, surgery, and alcohol intoxication. Patients with atrial fibrillation may have symptoms of hemodynamic compromise, such as irregular palpitations and lightheadedness, or more vague symptoms, such as malaise, but may be asymptomatic. Patients with atrial fibrillation are at increased risk for thromboembolic disease. The purpose of this guideline is to make recommendations on the pharmacologic management of newly detected atrial fibrillation in primary care. The target patient population is adult patients with first-detected atrial fibrillation, defined as the presence of symptoms or electrocardiographic evidence of atrial fibrillation. The American College of Cardiology/American Heart Association has recommended using first-detected atrial fibrillation regardless of whether it is symptomatic or self-limited, recognizing that there can be uncertainty about the duration of the episode and about previous undetected episodes (1). This guideline does not apply to patients with postoperative or postmyocardial 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. This guideline is based on the accompanying background paper by McNamara and colleagues (2) and on the evidence report Management of New-Onset Atrial Fibrillation (3), which was produced by the Johns Hopkins Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, Maryland. The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) created this guideline in collaboration. The Joint AAFP/ACP Panel reviewed the evidence and developed and graded the recommendations (Table 1). The guideline was then approved by both organizations. The guideline makes recommendations in the following areas: rate control versus rhythm control, stroke prevention and anticoagulation, electrical cardioversion versus pharmacologic cardioversion, the role of transesophageal echocardiography in guiding therapy, and maintenance therapy. Table 1. The Guyatt Approach to Grading Recommendations* Section 1: Rate Control versus Rhythm Control One of the fundamental questions in the management of atrial fibrillation is whether to attempt cardioversion. The answer to this question depends on whether rate control or rhythm control provides more effective protection from thromboembolic events, improved mortality, better relief of symptoms, or improved quality of life. Another significant clinical question is whether certain populations, such as women, patients with hypertension or congestive heart failure, or young people with structurally healthy hearts, have better outcomes with one or the other strategy. Four studies have compared rate control with rhythm control. The study samples have generally involved older patients (>65 years of age), and women and younger patients with healthy hearts and paroxysmal atrial fibrillation have not been well represented (5). The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial compared rhythm control versus rate control, and use of anticoagulation was recommended in both arms (6). More than 4000 patients who were at least 65 years of age or who had at least 1 risk factor for stroke or death, such as hypertension, diabetes, previous stroke, or poor ventricular function, were followed for a mean of 3.5 years. Slightly more than one third of the patients were enrolled after their first episode of atrial fibrillation, and more than 90% had had their qualifying episode within the previous 6 weeks. In more than two thirds of patients, the qualifying episode lasted at least 2 days. The average patient age was 70 years. Sixty-one percent of patients were men, and 89% were white. Seventy-one percent of patients had hypertension, 38% had coronary heart disease, 18% had previously had failure of antiarrhythmic therapy, and 12% had no apparent heart disease (lone atrial fibrillation). Patients were randomly assigned to rate or rhythm control, and their physicians chose the specific therapies (pharmacologic first, then nonpharmacologic if needed). Anticoagulation was continued indefinitely in the rate-control group and was encouraged in the rhythm-control group but could be stopped at the physicians discretion if sinus rhythm had been maintained for at least 4, and preferably 12, consecutive weeks with antiarrhythmic therapy. The prevalence of sinus rhythm in the rhythm-control group was 82%, 73%, and 63% at 1, 3, and 5 years, respectively. The prevalence of sinus rhythm in the rate-control group was 34.6% at 5 years. The primary end point in the AFFIRM trial, overall mortality, was not statistically significantly different between the groups. However, the rhythm-control strategy was associated with a higher risk for death than the rate-control strategy among older patients, those without congestive heart failure, and those with coronary disease. Rates of stroke also did not differ between groups; 70% of all strokes occurred in patients who had stopped receiving anticoagulation or who had subtherapeutic international normalized ratios (<2.0). More hospitalizations were reported in the rhythm-control group (P < 0.001). Another recent study, the RAte Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) study, randomly assigned patients to receive aggressive rhythm control or rate control (7). This was a smaller study, involving 522 patients (mean age, 68 years). Sixty-four percent of patients were men, 49% had hypertension, and 27% had coronary artery disease. All patients had persistent atrial fibrillation lasting less than 1 year and had had at least 1 previous electrical cardioversion (a maximum of 2 previous cardioversions was permitted for study inclusion). The primary end point was a composite of cardiovascular mortality, heart failure, thromboembolic complications, bleeding, pacemaker implantation, and severe side effects of antiarrhythmic drugs. Again, no difference was seen between groups in the primary composite end point. As in the AFFIRM study, most of the strokes occurred in patients whose anticoagulation had been halted or patients whose international normalized ratio was subtherapeutic (<2.0). In post hoc analysis, a benefit for rate control over rhythm control was seen in patients with hypertension and in women. Since this was a post hoc analysis, these results will need to be confirmed by further studies. Of note, despite an aggressive treatment protocol, at the end of follow-up only 39% of the patients in the rhythm-control group were in sinus rhythm. The Pharmacological Intervention in Atrial Fibrillation (PIAF) trial randomly assigned 252 patients 18 to 75 years of age with new-onset or permanent symptomatic atrial fibrillation (mean duration of atrial fibrillation, approximately 4 months) to rate control with diltiazem or aggressive conversion (many times if necessary) and maintenance therapy with amiodarone (8). The primary end point of the study was improvement in symptoms related to atrial fibrillation. After 1 year of follow-up, relief of symptoms was similar in both groups, as were quality-of-life measures. Walking distance was improved in the rhythm-control group, but hospital admissions were more frequent in this group. Although final results are not yet available, preliminary reports of the Strategies of Treatment of Atrial Fibrillation (STAF) trial have been presented (9). Patients were randomly assigned to receive anticoagulation for 3 weeks before conversion and for 4 weeks after attempted conversion, with antiarrhythmic therapy to maintain sinus rhythm, or to long-term anticoagulation and rate control. (Patients included in this study had at least 1 previous conversion attempt.) After more than 1.5 years of follow-up, no difference was seen between the groups in rates of the primary end points of death, stroke, transient ischemic attacks, cardiopulmonary resuscitation, or thromboembolism. Of interest, only 40% of patients in the rhythm-control group were still in sinus rhythm at 1 year, and all primary end points occurred in patients in atrial fibrillation, even in the rhythm-control group. This result has created speculation about whether fewer events would have occurred if anticoagulation had been continued indefinitely in the conversion group. It also suggests that despite aggressive rhythm management, a substantial number of patients cannot maintain sinus rhythm. In general, the trial samples were older and male and had risk factors for stroke, such as hypertension, congestive heart failure, and coronary disease. Certain subgroups of patients with atrial fibrillation, such as younger patients with healthy hearts or paroxysmal atrial fibrillation, were not well represented in the trials. Therefore, it is not certain whether these subgroups of patients may benefit from more aggressive rhythm control or rate control. 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

ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with peripheral artery disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Socie

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical Performance Measures for Peripheral Artery Disease)*,y