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Management of Patients with Newly Detected Atrial Fibrillation

A new guideline from the ACP and AAFP recommends rate control and anticoagulation regimens for AF patients.

A joint panel from the American College of Physicians and the American Academy of Family Physicians has published a clinical practice guideline based on a systematic review of the evidence on pharmacologic management of newly detected atrial fibrillation. The guideline does not address postoperative or post-myocardial infarction atrial fibrillation (AF), nor does it address patients with NYHA class IV heart failure or valvular heart disease or those on antiarrhythmic drugs.

Recommendations:

• Rate control (vs. rhythm control) with atenolol, metoprolol, diltiazem, or verapamil is the preferred strategy unless particular considerations exist, such as patient preference or reduced exercise tolerance with rate control. Digoxin should be used as a second-line agent, because it only controls rate at rest.
  
• For patients who elect to undergo cardioversion to achieve sinus rhythm, either direct current or pharmacologic cardioversion is appropriate. Both of the following anticoagulation strategies are acceptable: short-term anticoagulation and transesophageal echocardiography to exclude intracardiac thrombus, followed by early cardioversion; or delayed cardioversion preceded by 3 weeks of anticoagulation. With either strategy, patients should receive at least several weeks of postcardioversion anticoagulation. Most patients who achieve sinus rhythm should not be treated with rhythm-maintenance drugs.
  
• Most patients with AF should receive ongoing adjusted-dose warfarin.
  

Comment: These recommendations are supported by literature review. For example, randomized trial results do not show greater improvements in morbidity or mortality rates for rhythm control than for rate control. Randomized trial findings also demonstrate the efficacy of warfarin (and aspirin, for patients at low risk) for stroke prevention. No increased efficacy of antiarrhythmic drugs was noted in clinical trials when such drugs were given before cardioversion, whereas they were efficacious when given to maintain sinus rhythm; however, cardiac and (for amiodarone) noncardiac side effects balanced these benefits.

By making it clear that there often is more than one way to appropriately manage patients with atrial fibrillation, these guidelines help us to reach reasonable decisions for individual patients. At the time of publication, the full text of the guideline was available free of charge.

— Richard Saitz, MD, MPH, FASAM, FACP

Published in Journal Watch General Medicine January 27, 2004

Citation(s):

Snow V et al. Management of newly detected atrial fibrillation: A clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003 Dec 16; 139:1009-17.

• Original article (Subscription may be required)
• Medline abstract (Free)

McNamara RL et al. Management of atrial fibrillation: Review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med 2003 Dec 16; 139:1018-33.

• Original article (Subscription may be required)
• Medline abstract (Free)