Atrial fibrillation

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Diagnosis

Routine office evaluation

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%.[1] This implies that the sensitivity of the routine examination is 64% (1.04/1.63).

Electrocardiogram

Regarding the accuracy of the electrocardiogram[2]:

Prognosis

Risk of stroke

The risk of stroke in a patient with atrial fibrillation can be predicted with the CHADS2 score.

Treatment

Clinical practice guidelines by the American College of Physicians and the American Academy of Family Physicians address treatment.[3][4]

Rate control versus rhythm control

Medications

"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."[3]
Randomized controlled trial of rhythm versus rate control
Study Patients Intervention in rhythm control group Sinus rhythm
in rhythm group		 Sinus rhythm
in control group		 Cardiovascular death
in rhythm group		 Cardiovascular death
in control group
Van Gelder[5]
2002
  • All had prior episode of atrial dysrythmia requiring electrical cardioversion..
  • All had current atrial dysrythmia for median of 32 days.
  • 50% has previous heart failure
 Cardioversion followed by sotalol for median of 2.3 years 39% 10% 6.8% 7%
AFFIRM[6]
2002
  • 65% had prior episode of atrial dysrythmia requiring electrical cardioversion..
  • All had current atrial dysrythmia with 69% lasting 2 or more days.
  • 23% has previous heart failure
 "antiarrhythmic drug used was chosen by the treating physician" for 5 years 63% 35% 23.8%
(overall mortality)		 21.3%
(overall mortality)
Roy[7]
2008
  • All had prior episode of atrial dysrythmia.
  • 55% to 60% with current atrial dysrythmia.
  • All with a history of heart failure and systolic dysfunction
 Amiodarone for median of 3 years 73% 30% 27% 25%

As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in randomized controlled trials.[5][7][6] 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."[5]

Episodic medical therapy has conflicting results with a positive uncontrolled before and after trial of flecainide and propafenone[8] and a negative randomized controlled trial of episodic amiodarone versus continuous amiodarone.[9]

Ablation

Pulmonary-vein isolation

Randomized controlled trials have found that using ablation to cause pulmonary-vein isolation was superior to medical therapy[10][11] and to atrioventricular-node ablation[12].

Anticoagulation

"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). "[3]

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%. [13]. However, a recent meta-analysis suggests harm from anti-coagulation started early after an embolic stroke.[14]

References

  1. ↑ Fitzmaurice DA, Hobbs FD, Jowett S, et al (2007). "Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial". DOI:10.1136/bmj.39280.660567.55. PMID 17673732. Research Blogging.
  2. ↑ Mant J, Fitzmaurice DA, Hobbs FD, et al (2007). "Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial". DOI:10.1136/bmj.39227.551713.AE. PMID 17604299. Research Blogging.
  3. ↑ 3.0 3.1 3.2 Snow V, Weiss KB, LeFevre M, et al (December 2003). "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. 139 (12): 1009–17. PMID 14678921. [e]
  4. ↑ McNamara RL, Tamariz LJ, Segal JB, Bass EB (December 2003). "Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography". Ann. Intern. Med. 139 (12): 1018–33. PMID 14678922. [e]
  5. ↑ 5.0 5.1 5.2 Van Gelder IC, Hagens VE, Bosker HA, et al (December 2002). "A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation". N. Engl. J. Med. 347 (23): 1834–40. DOI:10.1056/NEJMoa021375. PMID 12466507. Research Blogging.
  6. ↑ 6.0 6.1 Wyse DG, Waldo AL, DiMarco JP, et al (December 2002). "A comparison of rate control and rhythm control in patients with atrial fibrillation". N. Engl. J. Med. 347 (23): 1825–33. DOI:10.1056/NEJMoa021328. PMID 12466506. Research Blogging.
  7. ↑ 7.0 7.1 Roy D, Talajic M, Nattel S, et al (June 2008). "Rhythm control versus rate control for atrial fibrillation and heart failure". N. Engl. J. Med. 358 (25): 2667–77. DOI:10.1056/NEJMoa0708789. PMID 18565859. Research Blogging.
  8. ↑ Alboni P, Botto GL, Baldi N, et al (December 2004). "Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach". The New England journal of medicine 351 (23): 2384–91. DOI:10.1056/NEJMoa041233. PMID 15575054. Research Blogging.
  9. ↑ Ahmed, Sheba; Michiel Rienstra, Harry J. G. M. Crijns, Thera P. Links, Ans C. P. Wiesfeld, Hans L. Hillege, Hans A. Bosker, Dirk J. A. Lok, Dirk J. Van Veldhuisen, Isabelle C. Van Gelder, for the CONVERT Investigators (2008-10-15). "Continuous vs Episodic Prophylactic Treatment With Amiodarone for the Prevention of Atrial Fibrillation: A Randomized Trial". JAMA 300 (15): 1784-1792. DOI:10.1001/jama.300.15.1784. Retrieved on 2008-10-15. Research Blogging.
  10. ↑ Wazni OM, Marrouche NF, Martin DO, et al (June 2005). "Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial". JAMA 293 (21): 2634–40. DOI:10.1001/jama.293.21.2634. PMID 15928285. Research Blogging.
  11. ↑ Oral H, Pappone C, Chugh A, et al (March 2006). "Circumferential pulmonary-vein ablation for chronic atrial fibrillation". N. Engl. J. Med. 354 (9): 934–41. DOI:10.1056/NEJMoa050955. PMID 16510747. Research Blogging.
  12. ↑ Khan MN, Jaïs P, Cummings J, et al (October 2008). "Pulmonary-vein isolation for atrial fibrillation in patients with heart failure". N. Engl. J. Med. 359 (17): 1778–85. DOI:10.1056/NEJMoa0708234. PMID 18946063. Research Blogging.
  13. ↑ Hart RG, Pearce LA, Aguilar MI (2007). "Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation". Ann. Intern. Med. 146 (12): 857-67. PMID 17577005. [e]
  14. ↑ Paciaroni M, Agnelli G, Micheli S, Caso V (2007). "Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials". Stroke 38 (2): 423-30. DOI:10.1161/01.STR.0000254600.92975.1f. PMID 17204681. Research Blogging. ACP JC synopsis
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