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Guideline Update
R E C O M M E N D AT I O N S F O R P R A C T I C E
How should we manage newly diagnosed
atrial fibrillation?
Keith B. Holten, MD
University of Cincinnati College of Medicine, Cincinnati, Ohio
■ What is the primary treatment goal
of cardiac medication?
■ What is the role of digoxin?
■ When should medications be used to
maintain sinus rhythm after cardioversion?
■ Should all patients be anticoagulated
with warfarin?
■ What are the contraindications
to warfarin therapy?
R
ecommendations for these management
issues are found in the guideline
developed in a joint effort of the
American College of Physicians Clinical Efficacy
Assessment Subcommittee and the American
Academy of Family Physicians Commission on
Clinical Policies and Research. It was funded by
both organizations and approved by their
Boards before publication. The target audience
is internists and family physicians.
The target patients are adults with newly
Correspondence: Keith B. Holten, MD, Clinton Memorial
Hospital/University of Cincinnati Family Practice Residency,
825 W. Locust St., Wilmington, OH, 45177. E-mail:
keholtenmd@cmhregional.com.
diagnosed atrial fibrillation. The guideline does
not apply to postoperative patients, post-
myocardial infarction patients, those with class
IV heart failure or valvular heart disease, or
patients taking antiarrhythmic medications.
The objective of this guideline is to recom-
mend pharmacologic management of newly
diagnosed atrial fibrillation. The evidence cate-
gory for this guideline is management.
Outcomes considered are control of heart rate
and stroke risk reduction. The committees used
the Guyatt method of grading recommenda-
tions,1 a qualitative approach to the literature.
These were revised to comply with the SORT
taxonomy.2
■ GUIDELINE RELEVANCE
AND LIMITATIONS
Atrial fibrillation is common, affecting any-
where from 1% of the American population at
age 60 to 8% at age 80. It is more common in
men than women. Even if patients are asympto-
matic, they are at increased risk of stroke
(1.9%–18% per year).
A lengthy bibliography accompanies the
guideline. Tables of supporting evidence are
lacking, which makes it more difficult to ana-
lyze the final recommendations. The guideline
is weakened by the lack of a cost-effectiveness
analysis.
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G U I D E L I N E U P D AT E
PRACTICE RECOMMENDATIONS
Grade A Recommendations
• Prescribe long-term warfarin at therapeutic
levels unless stroke risk is low, as deter-
mined by risk factors: congestive heart fail-
ure, hypertension, age 75 years older, dia-
betes mellitus, or history of transient
ischemic event/cerebrovascular accident.
Warfarin should not be prescribed if there
are contraindications of thrombocytopenia,
recent trauma, surgery, or alcoholism.
• Atenolol (Tenormin), metoprolol (Lopressor,
Toprol-XL), diltiazem, and verapamil are
optimal choices for rate control during exer-
cise and at rest. Digoxin (Lanoxin is a sec-
ond-line agent and is only effective at rest.
Grade B Recommendations
• Rate control with anticoagulation is the
primary goal of treatment. Consider rhythm
control according to a patient’s symptoms.
• Cardioversion by electrical conversion
and pharmacologic conversion are both
appropriate.
• For patients who elect cardioversion,
options include 1) early antiocoagulation
and cardioversion (with transesophageal
echocardiography confirming absence of
mural thrombus), or 2) delayed cardiover-
sion with pre- and post-anticoagulation.
• Most patients who convert to sinus rhythm
do not need maintenance rhythm therapy.
When quality of life is threatened, the best
agents are amiodarone (Cordarone),
disopyramide (Norpace), propafenone
(Rythmol), and sotalol (Betapace).
■ GUIDELINE DEVELOPMENT
AND EVIDENCE REVIEW
This guideline is based on background papers
published by McNamara3 and the John Hopkins
Evidence-Based Practice Center4 under contract
642 AUGUST 2004 / VOL 53, NO 8 · The Journal of Family Practice
with the Agency for Healthcare Research and
Quality. There are 57 references.
The guideline group reviewed the evidence
and made graded recommendations regarding
rate control versus rhythm control, stroke pre-
vention and anticoagulation, electrical conver-
sion versus pharmacologic conversion, the role
of transesophageal echocardiography in guiding
therapy, and maintenance therapy.
■ SOURCE FOR THIS GUIDELINE
Snow V, Weiss KB, LeFevre M, 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; 139:
1009–1017.
■ OTHER GUIDELINES
ON ATRIAL FIBRILLATION
• ACC/AHA/ESC guidelines for the manage-
ment of patients with atrial fibrillation. A report
of the American College of Cardiology/
American Heart Association Task Force on
Practice Guidelines and the European Society of
Cardiology Committee for Practice Guidelines and
Policy Conferences (Committee to Develop
Guidelines for the Management of Patients with
Atrial Fibrillation).
This 2001 guideline is the work of an interna-
tional panel. Algorithms are provided for pharma-
cologic management of patients with newly diag-
nosed atrial fibrillation, pharmacologic manage-
ment of patients with recurrent paroxysmal atrial
fibrillation, antiarrythmic drug therapy to main-
tain sinus rhythm in patients with recurrent
paroxysmal or persistent atrial fibrillation, and
pharmacologic management of patients with
recurrent persistent or permanent atrial fibrilla-
tion. Recent evidence regarding rate control ver-
sus rhythm control was not available at publica-
tion of this guideline.
Sources: American College of Cardiology, American Heart
Association, European Society of Cardiology. ACC/AHA/ESC
guidelines for the management of patients with atrial fibrilla-
tion. J Am Coll Cardiol 2001; 38:1266i–lxx. (580 references)
JFP_08.04_GU.final 7/20/04 1:47 PM Page 643
GUIDELINE BRIEFS
Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guide-
lines for the management of patients with atrial fibrillation.
A report of the American College of Cardiology/
American Heart Association Task Force on Practice
Guidelines and the European Society of Cardiology. Eur Heart
J 2001; 22:1852–1923. (580 references)
• Antithrombotic therapy in atrial fibrillation.
In: Sixth ACCP Consensus Conference on
Antithrombotic Therapy.
This is an excellent review of a grading
scheme for stroke risk and choice of anti-throm-
botic agents.
Source: Albers GW, Dalen JE, Laupacis A, et al.
Antithrombotic therapy in atrial fibrillation. Chest 2001;
119(1 Suppl):194S–206S. (103 references)
• Atrial fibrillation: drug treatment and
electric cardioversion.
This Finnish guideline makes recommenda-
tions regarding drug treatment, anticoagulation,
and cardioversion for patients with atrial fibrilla-
tion and atrial flutter. The recommendations are
not graded.
Source: Finnish Medical Society Duodecim. Atrial
Fibrillation: Drug Treatment and Electric Cardioversion.
Helsinki, Finland: Duodecim Medical Publications Ltd.;
2002 Mar 4. Various pages.
• Preventive health care, 2000 update. Use
of ambulatory electrocardiography for the detec-
tion of paroxysmal atrial fibrillation in patients
with stroke.
This guideline is from 2000 and found insuffi-
cient evidence to recommend for or against ambu-
latory electrocardiography to detect atrial fibrilla-
tion for patients after stroke or TIA.
Source: Bell C, Kapral M. Use of ambulatory electrocardiog-
raphy for the detection of paroxysmal atrial fibrillation in
patients with stroke. Canadian Task Force on Preventive
Health Care. Can J Neurol Sc. 2000; 27:25–31. (78 references)
REFERENCES
1. Guyatt GH, Sackett DL, Sinclair JC, et al. User’s guide to the
medical literature:IX. A method for grading health care rec-
ommendations. JAMA 1995; 274:1800.
2. Ebell M, Siwek J, Weiss BD, et al. Strength of recommenda-
tion taxonomy (SORT): A patient-centered approach to grad-
ing evidence in the medical literature. Am Fam Physician
2004; 69:548–556.
3. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management
of atrial fibrillation: review of the evidence for the role of
pharmacologic therapy, electrical cardioversion, and
echocardiography. Ann Int Med 2003;139:1018–1033.
4. McNamara RL, Bass EB, Miller MR, et al. Evidence report
on the management of new onset atrial fibrillation. Agency
for Healthcare Research and Quality publication no. AHRQ
01-E026. Rockville, MD: Agency for Healthcare Research
and Quality; January 2001.
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