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(Circulation. 1996;93:1262-1277.)
© 1996 American Heart Association, Inc.
Articles |
Management of Patients With Atrial Fibrillation
A Statement for Healthcare Professionals From the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association
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Executive Summary |
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Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. Its incidence increases with age and the presence of structural heart disease. It is a major cause of stroke, especially in the elderly. Although the causes are diverse, hypertension is common. Most patients experience palpitations, but fatigue, dyspnea, and dizziness are not uncommon. Patients with an uncontrolled ventricular response during AF may occasionally develop a tachycardia-induced cardiomyopathy. There are three therapeutic goals to consider for patients with AF: rate control, maintenance of sinus rhythm, and prevention of thromboembolism. The risks and benefits of each treatment must be considered for each patient.
Restoration and Maintenance of Sinus Rhythm
Several drugs
effectively restore and maintain sinus rhythm
in patients with AF. To date few data are available to confirm
superiority of any particular drug over another for this purpose.
Agents such as digitalis, verapamil, diltiazem, and
ß-adrenergic blockers may be useful during AF to decrease the
ventricular response that occurs over the
atrioventricular (AV) node, but they rarely terminate
AF. Intravenous procainamide is the treatment of
choice for patients with Wolff-Parkinson-White syndrome who have a
preexcited ventricular response during AF, provided they
are hemodynamically stable. Patients who are unstable
(eg, those with hypotension or significant heart failure) may require
immediate cardioversion. Drugs selected for long-term oral therapy
should be given initially in low to moderate doses and titrated upward,
depending on effectiveness and side effects. Drug interactions with
warfarin and digoxin should be monitored. Proarrhythmia is
the most important risk associated with antiarrhythmic drug therapy.
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A. L. Klein, R. A. Grimm, R. D. Murray, C. Apperson-Hansen, R. W. Asinger, I. W. Black, R. Davidoff, R. Erbel, J. L. Halperin, D. A. Orsinelli, et al. Use of Transesophageal Echocardiography to Guide Cardioversion in Patients with Atrial Fibrillation N. Engl. J. Med., May 10, 2001; 344(19): 1411 - 1420. [Abstract] [Full Text] [PDF]
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C. Ozcan, A. Jahangir, P. A. Friedman, P. J. Patel, T. M. Munger, R. F. Rea, M. A. Lloyd, D. L. Packer, D. O. Hodge, D. L. Hayes, et al. Long-Term Survival after Ablation of the Atrioventricular Node and Implantation of a Permanent Pacemaker in Patients with Atrial Fibrillation N. Engl. J. Med., April 5, 2001; 344(14): 1043 - 1051. [Abstract] [Full Text] [PDF]
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M. Fukuchi, J. Watanabe, K. Kumagai, Y. Katori, S. Baba, K. Fukuda, T. Yagi, A. Iguchi, H. Yokoyama, M. Miura, et al. Increased von Willebrand factor in the endocardium as a local predisposing factor for thrombogenesis in overloaded human atrial appendage J. Am. Coll. Cardiol., April 1, 2001; 37(5): 1436 - 1442. [Abstract] [Full Text] [PDF]
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B. F. Gage, S. D. Fihn, and R. H. White Warfarin Therapy for an Octogenarian Who Has Atrial Fibrillation Ann Intern Med, March 20, 2001; 134(6): 465 - 474. [Abstract] [Full Text] [PDF]
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A. L. Klein, R. D. Murray, and R. A. Grimm Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation J. Am. Coll. Cardiol., March 1, 2001; 37(3): 691 - 704. [Abstract] [Full Text] [PDF]
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H. S. Friedman Serum Homocysteine and Stroke in Atrial Fibrillation Ann Intern Med, February 6, 2001; 134(3): 253 - 254. [Full Text] [PDF]
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K. L. Grady, K. Dracup, G. Kennedy, D. K. Moser, M. Piano, L. W. Stevenson, and J. B. Young Team Management of Patients With Heart Failure : A Statement for Healthcare Professionals From the Cardiovascular Nursing Council of the American Heart Association Circulation, November 7, 2000; 102(19): 2443 - 2456. [Full Text] [PDF]
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M. J. P. Raatikainen, T. E. Morey, P. Druzgala, P. Milner, M. D. Gonzalez, and D. M. Dennis Potent and Reversible Effects of ATI-2001 on Atrial and Atrioventricular Nodal Electrophysiological Properties in Guinea Pig Isolated Perfused Heart J. Pharmacol. Exp. Ther., November 1, 2000; 295(2): 779 - 785. [Abstract] [Full Text]
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G E Kochiadakis, N E Igoumenidis, M E Marketou, M D Kaleboubas, E N Simantirakis, and P E Vardas Low dose amiodarone and sotalol in the treatment of recurrent, symptomatic atrial fibrillation: a comparative, placebo controlled study Heart, September 1, 2000; 84(3): 251 - 257. [Abstract] [Full Text] [PDF]
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R. L. Page Beta-blockers for atrial fibrillation: must we consider asymptomatic arrhythmias? J. Am. Coll. Cardiol., July 1, 2000; 36(1): 147 - 150. [Full Text] [PDF]
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L.-P. Lai, J.-L. Lin, W.-P. Lien, Y.-Z. Tseng, and S. K. S. Huang Intravenous sotalol decreases transthoracic cardioversion energy requirement for chronic atrial fibrillation in humans: assessment of the electrophysiological effects by biatrial basket electrodes J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1434 - 1441. [Abstract] [Full Text] [PDF]
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S. Mittal, S. Ayati, K. M. Stein, D. Schwartzman, D. Cavlovich, P. J. Tchou, S. M. Markowitz, D. J. Slotwiner, M. A. Scheiner, and B. B. Lerman Transthoracic Cardioversion of Atrial Fibrillation : Comparison of Rectilinear Biphasic Versus Damped Sine Wave Monophasic Shocks Circulation, March 21, 2000; 101(11): 1282 - 1287. [Abstract] [Full Text] [PDF]
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M. A. Wood, C. Brown-Mahoney, G. N. Kay, and K. A. Ellenbogen Clinical Outcomes After Ablation and Pacing Therapy for Atrial Fibrillation : A Meta-Analysis Circulation, March 14, 2000; 101(10): 1138 - 1144. [Abstract] [Full Text] [PDF]
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H Nakazawa, D.A Lythall, J Noh, N Ishikawa, K Sugino, K Ito, and S.M.C Hardman Is there a place for the late cardioversion of atrial fibrillation?. A long-term follow-up study of patients with post-thyrotoxic atrial fibrillation Eur. Heart J., February 2, 2000; 21(4): 327 - 333. [Abstract] [PDF]
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A Capucci, G.Q Villani, D Aschieri, A Rosi, and M.F Piepoli Oral amiodarone increases the efficacy of direct-current cardioversion in restoration of sinus rhythm in patients with chronic atrial fibrillation Eur. Heart J., January 1, 2000; 21(1): 66 - 73. [Abstract] [PDF]
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S. H. Hohnloser, Y.-G. Li, B. Bender, and G. Gronefeld Review : Pharmacological Management of Atrial Fibrillation: An Update Journal of Cardiovascular Pharmacology and Therapeutics, January 1, 2000; 5(1): 11 - 16. [Abstract] [PDF]
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P. Schauerte, B. J. Scherlag, M. A. Scherlag, S. Goli, W. M. Jackman, and R. Lazzara Ventricular rate control during atrial fibrillation by cardiac parasympathetic nerve stimulation: a transvenous approach J. Am. Coll. Cardiol., December 1, 1999; 34(7): 2043 - 2050. [Abstract] [Full Text] [PDF]
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L Frost, G Engholm, H Moller, and S. Husted Decrease in mortality in patients with a hospital diagnosis of atrial fibrillation in Denmark during the period 1980-1993 Eur. Heart J., November 1, 1999; 20(21): 1592 - 1599. [Abstract] [PDF]
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M Gasparini, M Mantica, M Brignole, L Gianfranchi, C Menozzi, F Pizzetti, G Magenta, P Delise, A Proclemer, S Tognarin, et al. Thromboembolism after atrioventricular node ablation and pacing: long term follow up Heart, October 1, 1999; 82(4): 494 - 498. [Abstract] [Full Text] [PDF]
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W. G. Stevenson and L. W. Stevenson Atrial Fibrillation in Heart Failure N. Engl. J. Med., September 16, 1999; 341(12): 910 - 911. [Full Text]
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P. J. Zimetbaum and M. E. Josephson The Evolving Role of Ambulatory Arrhythmia Monitoring in General Clinical Practice Ann Intern Med, May 18, 1999; 130(10): 848 - 856. [Abstract] [Full Text] [PDF]
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M. A. Gatzoulis, M. A. Freeman, S. C. Siu, G. D. Webb, and L. Harris Atrial Arrhythmia after Surgical Closure of Atrial Septal Defects in Adults N. Engl. J. Med., March 18, 1999; 340(11): 839 - 846. [Abstract] [Full Text] [PDF]
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G. E. Kochiadakis, N. E. Igoumenidis, F. I. Parthenakis, G. I. Chlouverakis, and P. E. Vardas Amiodarone versus propafenone for conversion of chronic atrial fibrillation: results of a randomized, controlled study J. Am. Coll. Cardiol., March 15, 1999; 33(4): 966 - 971. [Abstract] [Full Text] [PDF]
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P. B. Sparks, S. Jayaprakash, H. G. Mond, J. K. Vohra, L. E. Grigg, and J. M. Kalman Left atrial mechanical function after brief duration atrial fibrillation J. Am. Coll. Cardiol., February 1, 1999; 33(2): 342 - 349. [Abstract] [Full Text] [PDF]
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N. S PETERS Atrial fibrillation: towards an understanding of initiation, perpetuation, and specific treatment Heart, December 1, 1998; 80(6): 533 - 534. [Full Text]
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R. S. Stafford, D. C. Robson, B. Misra, J. Ruskin, and D. E. Singer Rate Control and Sinus Rhythm Maintenance in Atrial Fibrillation: National Trends in Medication Use, 1980-1996 Arch Intern Med, October 26, 1998; 158(19): 2144 - 2148. [Abstract] [Full Text] [PDF]
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M. Brignole, C. Menozzi, L. Gianfranchi, G. Musso, R. Mureddu, N. Bottoni, and G. Lolli Assessment of Atrioventricular Junction Ablation and VVIR Pacemaker Versus Pharmacological Treatment in Patients With Heart Failure and Chronic Atrial Fibrillation : A Randomized, Controlled Study Circulation, September 8, 1998; 98(10): 953 - 960. [Abstract] [Full Text] [PDF]
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M. Haissaguerre, P. Jais, D. C. Shah, A. Takahashi, M. Hocini, G. Quiniou, S. Garrigue, A. Le Mouroux, P. Le Metayer, and J. Clementy Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins N. Engl. J. Med., September 3, 1998; 339(10): 659 - 666. [Abstract] [Full Text] [PDF]
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M. H. Eckman, R. H. Falk, and S. G. Pauker Cost-effectiveness of Therapies for Patients With Nonvalvular Atrial Fibrillation Arch Intern Med, August 10, 1998; 158(15): 1669 - 1677. [Abstract] [Full Text]
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A. L. Gullov, B. G. Koefoed, P. Petersen, T. S. Pedersen, E. D. Andersen, J. Godtfredsen, and G. Boysen Fixed Minidose Warfarin and Aspirin Alone and in Combination vs Adjusted-Dose Warfarin for Stroke Prevention in Atrial Fibrillation: Second Copenhagen Atrial Fibrillation, Aspirin, and Anticoagulation Study Arch Intern Med, July 27, 1998; 158(14): 1513 - 1521. [Abstract] [Full Text] [PDF]
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F. Gaita, R. Riccardi, L. Calo, M. Scaglione, L. Garberoglio, R. Antolini, M. Kirchner, F. Lamberti, and E. Richiardi Atrial Mapping and Radiofrequency Catheter Ablation in Patients With Idiopathic Atrial Fibrillation : Electrophysiological Findings and Ablation Results Circulation, June 2, 1998; 97(21): 2136 - 2145. [Abstract] [Full Text] [PDF]
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M BRIGNOLE Ablate and pace: a pragmatic approach to paroxysmal atrial fibrillation not controlled by antiarrhythmic drugs Heart, June 1, 1998; 79(6): 531 - 533. [Full Text]
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