A study of routine pulse checks or electrocardiograms during routine office visits, found that the annual rate of detection of atrial fibrillation in elderly patients improved from 1.04% to 1.63%. This implies that the sensitivity of the routine examination is 64% (1.04/1.63).
- Interpreted by software:
- Interpreted by a primary care physician:
- Interpreted by a primary care physician with software:
Risk of stroke
- CHADS2 (Congestive heart failure, Hypertension, Age ≥ 75 years, diabetes, previous stroke)
- Vascular disease, Age 65-74 years, Sex category (female=1)
- score 0 is low risk. 0.8% rate of embolism and thrombosis at one year
- score 1 is intermediate risk. 2.0% rate of embolism and thrombosis at one year
- score ≥ 2 is high risk. 1.7% rate of embolism and thrombosis at one year
Rate control versus rhythm control
- "Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation. ... Rhythm control is appropriate when based on other special considerations, such as patient symptoms, exercise tolerance, and patient preference."
Regarding target heart rate, a recent randomized controlled trial found that resting heart rate <110 beats per minute had similar outcomes to stricter control. Previously, the goal rate is "80 beats per minute during resting ... and of less than 110 beats per minute during a 6-minute walk test."
As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in randomized controlled trials. In addition, "the incidence of the components of the primary end point did not differ significantly according to whether the patient had sinus rhythm or atrial fibrillation at the end of follow-up." Whether the index episode was the initial or a recurrent episode did not effect results.
|Study||Patients||Intervention in rhythm control group||Results|
|Rhythm control group||Rate control group|
| Van Gelder
Regarding the choice of medication:
Shown effective in some randomized controlled trials
Shown not effective in some randomized controlled trials
- Episodic therapy
Episodic medical therapy has conflicting results with a positive uncontrolled before and after trial of flecainide and propafenone and a negative randomized controlled trial of episodic amiodarone versus continuous amiodarone.
Regarding artificial pacemakers, "dual-chamber minimal ventricular pacing, as compared with conventional dual-chamber pacing, ...reduces the risk of persistent atrial fibrillation in patients with sinus-node disease" according to a randomized controlled trial.
Dual site, overdrive pacing be effective.
Randomized controlled trial have found that using ablation to cause pulmonary-vein isolation was superior to medical therapy and to atrioventricular-node ablation. About two thirds of patients remain in sinus rhythm after 9 months.
Patients with a CHA2DS2-VASc of two or more may benefit from chronic anticoagulation according to a recent observational study and American clinical practice guidelines. European clinical practice guidelines recommend anticoagulants if the CHA2DS2-VASc is two or more.
|18,201 patients||Apixaban 5 mg twice daily||warfarin (target INR 2.0 to 3.0; time in therapeutic range 62%)||stroke or systemic embolism at 1.3 years||1.3% per year||1.6% per year||• hazard ratio for primary outcome 0.79|
• relative risk for death 0.89 (95% CI: 0.80 to 0.99; P=0.047)
| ROCKET AF
|14,264 patients|| Rivaroxaban 20 mg daily
(15 mg daily if creatinine clearance 30 to 49 ml per minute)
|warfarin (target INR 2.0 to 3.0; time in therapeutic range 55%)||stroke or systemic embolism at 1.6 years||2.1% per year||2.4% per year||• hazard ratio for primary outcome 0.79|
• relative risk for death 0.92 (95% CI: 0.82 to 1.03; P=0.15)
|18,113 patients||Dabigatran 150 mg twice daily||warfarin (target INR 2.0 to 3.0; time in therapeutic range 64%)||stroke or systemic embolism at 1.3 years||1.1% per year||1.5% per year||• relative risk for primary outcome 0.66|
• relative risk for death 0.88 (95% CI: 0.77 to 1.00; P=0.051)
• Not blinded
|Stroke or systemic embolism||Major bleeding||Mortality|
|Dabigatran 110 mg twice daily||1.53%||2.71%†||3.75%|
|Dabigatran 150 mg twice daily||1.11%†||3.11%||3.64%|
|† p < 0.05 as compared to warfarin group|
Anticoagulation can prevent recurrent stroke. Among patients with nonvalvular atrial fibrillation, anticoagulation can reduce stroke by 60% while antiplatelet agents can reduce stroke by 20%. . However, a recent meta-analysis suggests harm from anti-coagulation started early after an embolic stroke.
Anticoagulants is underused for atrial fibrillation. Both doctors and patients are reluctant to use anticoagulants. Patients may avoid warfarin even when they prefer the outcomes of warfarin.
| Copenhagen AFASAK study
|1007 patients||aspirin 75 mg daily||Warfarin||stroke, transient ischemic attack, or systemic embolism||6.0%||1.4%|
|1,330 patients||aspirin 325 mg daily||Warfarin||ischemic stroke and systemic embolism||3.6%||2.3%†|
| ACTIVE study
• All were taking aspirin, usually at 75 to 100 mg per day
•None were taking warfarin
|clopidogrel 75 mg daily||Placebo||stroke, myocardial infarction, systemic embolism, or death from vascular causes||6.8%‡||7.6%|
|† This was not a direct comparison as warfarin patients were younger and had to be eligible for warfarin.|
‡ However, combination therapy increased major bleeding from 1.3% to 2.0%.
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