The Joint Panel of the American Academy of Family Physicians and the American College of Physicians, in collaboration with the Johns Hopkins Evidence-based Practice Center, systematically reviewed the available evidence on the management of newly detected
atrial fibrillation and developed recommendations for adult patients with first-detected
atrial fibrillation. The recommendations do not apply to patients with postoperative or post-
myocardial infarction atrial fibrillation, patients with class IV
heart failure, patients already taking
antiarrhythmic drugs, or patients with valvular disease. The target physician audience is internists and family physicians dedicated to primary care. The recommendations are as follows: 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.