The Joint Panel of the American Aca...

The Joint Panel of the American Academy of Family Physicians (AAFP) and the American corporation of Physicians (ACP), in collaboration with the John Hopkins Evidence-Based Practice Center systematically reviewed the available evidence upon the management of newly exposeed atrial fibrillation and developed recommendations for adult patients with first-detected atrial fibrillation. The glutted report was published in the December 16 2003 issue of Annals of Internal Medicine.

The guideline attract favor tos pharmacologic management options for newly ascertained atrial fibrillation in adult patients, which is defined as the appearance of symptoms or electrocardiographic evidence of atrial fibrillation. This guideline does not apply to patients with postoperative or postmyocardial infarction atrial fibrillation, patients with class IV heart failure, patients already taking antiarrhythmic remedys or patients with valvular disease. The recommendations focus forward rate control versus rhythm sway stroke prevention and anticoagulation, electrical cardioversion versus pharmacologic cardioversion, the character of transesophageal echocardiography in guiding therapy, and maintenance therapy.

Rate govern vs. Rhythm Control

Rate manage with chronic anticoagulation is the commended strategy for the majority of patients with atrial fibrillation. harmonious flow control has not been shown to be superior to rate rule (with chronic anticoagulation) in reducing morbidity and mortality and may be worse in a certain number of patient subgroups compared with use of rate bridle Rhythm control is appropriate when based upon other special considerations, such as patient symptoms, exercise tolerance, and patient preference

Anticoagulation

Patients with atrial fibrillation should receive chronic anticoagulation with adjusted-dose warfarin, unles they are at soft risk of stroke or have a specific contraindication to the use of warfarin (i.e., thrombocytopenia, newly come trauma or surgery, alcoholism).

Aspirin may be useful for patients with atrial fibrillation and a grave risk of stroke, but the evidence is inconclusive. There is popularly insufficient evidence to support the use of low-molecular-weight heparin or other antiplatelet agents in the management of atrial fibrillation.

Efficacy of Different Agents for Rate Control

For patients with atrial fibrillation, the following unsalable articles are recommended for their demonstrated efficacy in rate govern during exercise and while at rest: atenolol, metoprolol, diltiazem, and verapamil (drug listed alphabetically on class). Digoxin is only effective for rate sway at rest and only should be used as a second-line agent for rate rule in atrial fibrillation.

Side validity profiles for all medications should be reviewed with patients and can provide guidance in the choice of agents for individual patients. Combinations of digoxin plus diltiazem, atenolol, or betaxolol also have been shown to be effective at quiet and with exercise. These combinations may be better reserv for situations when single-agent therapy has failed.

Acute Conversion

For patients who choose to undergo acute cardioversion to achieve sinus verse in atrial fibrillation, direct-current and pharmacologic conversion are appropriate options. While there are religious data to support both options, there are no data forward the efficacy of one [i]modus operandi[/i] over the other because no head-to-head trials have compared them. Long-term effectiveness in maintaining sinus rhyme is moderate to low for the one and the other methods. Adequate safety data are not available to make recommendations about the setting of cardioversion.

part of Echocardiography in the Acute Conversion of Atrial Fibrillation

Transesophageal echocardiography with prior shortterm anticoagulation followed from early acute cardioversion (in the absence of intracardiac thrombus) with postcardioversion anticoagulation versus delayed cardioversion with pre- and postanticoagulation are appropriate management strategies for patients who fix upon to undergo cardioversion. The choice between the sum of two units strategies should be based upon patient preference and clinical situation, including contraindications to transesophageal echocardiography or availability of this technology.

Maintenance Therapy

chiefly patients who convert to sinus metre from atrial fibrillation should not be placed upon maintenance therapy because the risks outweigh the benefits. In a cull group of patients whose quality of life is compromised on atrial fibrillation, the recommended pharmacologic agents for rhyme maintenance are amiodarone, disopyramide, propafenone, and sotalol (drug listed in alphabetical order). The choice of agent predominantly hangs on specific risk of side imports based on patient characteristics. All agents have more [i]or[/i] less potential for minor and serious side drifts suggesting the need for careful consideration of the relative risks and benefits of an aggressive approach to maintaining sinus number versus the alternate strategy of rate command and stroke prevention before beginning therapy.

COPYRIGHT 2004 American Academy of Family Physicians

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