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