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Brief Summary

GUIDELINE TITLE

Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians.

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

This is the current release of the guideline.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 16, 2007, Coumadin (Warfarin): Updates to the labeling for Coumadin to include pharmacogenomics information to explain that people's genetic makeup may influence how they respond to the drug.
  • October 6, 2006, Coumadin (warfarin sodium): Revisions to the labeling for Coumadin to include a new patient Medication Guide as well as a reorganization and highlighting of the current safety information to better inform providers and patients.

BRIEF SUMMARY CONTENT

 ** REGULATORY ALERT **
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

The grades of recommendations (1A, 1B, 1C+, 1C, 2A, 2B, 2C) are defined at the end of the "Major Recommendations" field.

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 is appropriate when based on other special considerations, such as patient symptoms, exercise tolerance, and patient preference. Grade: 2A

Recommendation 2: Patients with atrial fibrillation should receive chronic anticoagulation with adjusted-dose warfarin, unless they are at low risk of stroke or have a specific contraindication to the use of warfarin (thrombocytopenia, recent trauma or surgery, alcoholism). Grade: 1A

Recommendation 3: For patients with atrial fibrillation, the following drugs are recommended for their demonstrated efficacy in rate control during exercise and while at rest: atenolol, metoprolol, diltiazem, and verapamil (drugs listed alphabetically by class). Digoxin is only effective for rate control at rest and therefore should only be used as a second-line agent for rate control in atrial fibrillation. Grade: 1B

Recommendation 4: For those patients who elect to undergo acute cardioversion to achieve sinus rhythm in atrial fibrillation, both direct-current cardioversion (Grade: 1C+) and pharmacological conversion (Grade: 2A) are appropriate options.

Recommendation 5: Both transesophageal echocardiography with short-term prior anticoagulation followed by early acute cardioversion (in the absence of intracardiac thrombus) with postcardioversion anticoagulation versus delayed cardioversion with pre-and postanticoagulation are appropriate management strategies for those patients who elect to undergo cardioversion. Grade: 2A

Recommendation 6: Most patients converted to sinus rhythm from atrial fibrillation should not be placed on rhythm maintenance therapy since the risks outweigh the benefits. In a selected group of patients whose quality of life is compromised by atrial fibrillation, the recommended pharmacologic agents for rhythm maintenance are amiodarone, disopyramide, propafenone, and sotalol (drugs listed in alphabetical order). The choice of agent predominantly depends on specific risk of side effects based on patient characteristics. Grade: 2A

Definitions:

Grade of Recommendation

1A
Clarity of Risk-Benefit: Clear
Methodologic Strength of Supporting Evidence: Randomized trials without important limitations
Implications: Strong recommendation, can apply to most patients in most circumstances without reservation

1B
Clarity of Risk-Benefit: Clear
Methodologic Strength of Supporting Evidence: Randomized trials without important limitations (inconsistent results, nonfatal methodologic flaws)
Implications: Strong recommendation; likely to apply to most patients

1C+
Clarity of Risk-Benefit: Clear
Methodologic Strength of Supporting Evidence: No randomized trials for this specific patient or patient population, but results from randomized trial(s) including different patients can be unequivocally extrapolated to the patient under current consideration; or overwhelming evidence from observational studies is available
Implications: Strong recommendation; can apply to most patients in most circumstances

1C
Clarity of Risk-Benefit: Clear
Methodologic Strength of Supporting Evidence: Observational studies
Implications: Intermediate-strength recommendation; may change when stronger evidence is available

2A
Clarity of Risk-Benefit: Unclear
Methodologic Strength of Supporting Evidence: Randomized trials without important limitations
Implications: Intermediate-strength recommendation; best action may differ depending on circumstances or patients’ or societal values

2B
Clarity of Risk-Benefit: Unclear
Methodologic Strength of Supporting Evidence: Randomized trials without important limitations (inconsistent results, nonfatal methodologic flaws)
Implications: Weak recommendation; alternative approaches likely to be better for some patients under some circumstances

2C
Clarity of Risk-Benefit: Unclear
Methodologic Strength of Supporting Evidence: Observational studies
Implications: Very weak recommendation; other alternatives may be equally reasonable

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is identified in the "Major Recommendations" field.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2003 Dec 16

GUIDELINE DEVELOPER(S)

American Academy of Family Physicians - Medical Specialty Society
American College of Physicians - Medical Specialty Society

SOURCE(S) OF FUNDING

American College of Physicians and American Academy of Family Physicians

GUIDELINE COMMITTEE

Joint American College of Physicians (ACP)/American Academy of Family Physicians (AAFP) Panel on Atrial Fibrillation and ACP's Clinical Efficacy Assessment Subcommittee (CEAS) and AAFP Commission on Clinical Policies and Research

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Authors: Vincenza Snow, MD; Kevin B. Weiss, MD, MPH; Michael LeFevre, MD, MSPH; Robert McNamara, MD, MHS; Eric Bass, MD, MPH; Lee A. Green, MD, MPH; Keith Michl, MD; Douglas K. Owens, MD; Jeffrey Susman, MD; Deborah I. Allen, MD; and Christel Mottur-Pilson, PhD, the Joint AAFP/ACP Panel on Atrial Fibrillation

Clinical Efficacy Assessment Subcommittee Members: Kevin Weiss, MD, MPH (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Douglas K. Owens, MD; Katherine D. Sherif, MD

American Academy of Family Physicians Commission on Clinical Policies and Research Members: Martin C. Mahoney, MD, PhD (Chair); Larry S. Fields, MD; Richard D. Clover, MD; Deborah I. Allen, MD; Doug Campos-Outcalt, MD; Martin L. Kabongo, MD, PhD; Evelyn L. Lewis, MD, MA; Kevin C. Oeffinger, MD; Eric M. Wall, MD, MPH; Kevin A. Peterson, MD, MPH; Michael Rhea King, MD; Christine Albrecht; Herbert F. Young, MD, MA; and Bellinda K. Schoof.

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Consultancies: R.L. McNamara (Aventis, EU3)

Grants received: L.J. Tamariz (National Heart, Lung, and Blood Institute)

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available from the American College of Physicians (ACP) Web site:

Print copies: Available from the American College of Physicians (ACP), 190 N. Independence Mall West, Philadelphia PA 19106-1572.

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

The following is available:

  • 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 2003 Dec 16;139(12):I32.

Electronic copies: Available from the American College of Physicians (ACP) Web site:

Print copies: Available from the American College of Physicians (ACP), 190 N. Independence Mall West, Philadelphia PA 19106-1572.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC STATUS

This NGC summary was completed by ECRI on May 20, 2004. The information was verified by the guideline developer on June 4, 2004. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin).

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

DISCLAIMER

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