Atrial fibrillation: Difference between revisions
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imported>Robert Badgett |
imported>Robert Badgett |
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===Rate control versus rhythm control=== | ===Rate control versus rhythm control=== | ||
"Rate control with chronic [[anticoagulant|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."<ref name="pmid14678921">{{cite journal |author=Snow V, Weiss KB, LeFevre M, ''et al'' |title=Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians |journal=Ann. Intern. Med. |volume=139 |issue=12 |pages=1009–17 |year=2003 |month=December |pmid=14678921 |doi= |url=http://www.annals.org/cgi/content/full/139/12/1009 |issn=}}</ref> | :"Rate control with chronic [[anticoagulant|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."<ref name="pmid14678921">{{cite journal |author=Snow V, Weiss KB, LeFevre M, ''et al'' |title=Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians |journal=Ann. Intern. Med. |volume=139 |issue=12 |pages=1009–17 |year=2003 |month=December |pmid=14678921 |doi= |url=http://www.annals.org/cgi/content/full/139/12/1009 |issn=}}</ref> | ||
As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in two [[randomized controlled trial]]s of patients without<ref name="pmid12466507">{{cite journal |author=Van Gelder IC, Hagens VE, Bosker HA, ''et al'' |title=A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation |journal=N. Engl. J. Med. |volume=347 |issue=23 |pages=1834–40 |year=2002 |month=December |pmid=12466507 |doi=10.1056/NEJMoa021375 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12466507&promo=ONFLNS19 |issn=}}</ref> and with<ref name="pmid18565859">{{cite journal |author=Roy D, Talajic M, Nattel S, ''et al'' |title=Rhythm control versus rate control for atrial fibrillation and heart failure |journal=N. Engl. J. Med. |volume=358 |issue=25 |pages=2667–77 |year=2008 |month=June |pmid=18565859 |doi=10.1056/NEJMoa0708789 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18565859 |issn=}}</ref> [[heart failure]]. | As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in two [[randomized controlled trial]]s of patients without<ref name="pmid12466507">{{cite journal |author=Van Gelder IC, Hagens VE, Bosker HA, ''et al'' |title=A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation |journal=N. Engl. J. Med. |volume=347 |issue=23 |pages=1834–40 |year=2002 |month=December |pmid=12466507 |doi=10.1056/NEJMoa021375 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12466507&promo=ONFLNS19 |issn=}}</ref> and with<ref name="pmid18565859">{{cite journal |author=Roy D, Talajic M, Nattel S, ''et al'' |title=Rhythm control versus rate control for atrial fibrillation and heart failure |journal=N. Engl. J. Med. |volume=358 |issue=25 |pages=2667–77 |year=2008 |month=June |pmid=18565859 |doi=10.1056/NEJMoa0708789 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18565859 |issn=}}</ref> [[heart failure]]. | ||
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===Anticoagulation=== | ===Anticoagulation=== | ||
:"Patients with atrial fibrillation should receive chronic [[anticoagulant|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). "<ref name="pmid14678921">{{cite journal |author=Snow V, Weiss KB, LeFevre M, ''et al'' |title=Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians |journal=Ann. Intern. Med. |volume=139 |issue=12 |pages=1009–17 |year=2003 |month=December |pmid=14678921 |doi= |url=http://www.annals.org/cgi/content/full/139/12/1009 |issn=}}</ref> | |||
[[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%. <ref name="pmid17577005">{{cite journal |author=Hart RG, Pearce LA, Aguilar MI |title=Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation |journal=Ann. Intern. Med. |volume=146 |issue=12 |pages=857-67 |year=2007 |pmid=17577005 |doi=}}</ref>. However, a recent [[meta-analysis]] suggests harm from anti-coagulation started early after an embolic stroke.<ref name="pmid17204681"> {{cite journal |author=Paciaroni M, Agnelli G, Micheli S, Caso V |title=Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials |journal=Stroke |volume=38 |issue=2 |pages=423-30 | year=2007 |pmid=17204681 |doi=10.1161/01.STR.0000254600.92975.1f }} [http://www.acpjc.org/Content/147/1/issue/ACPJC-2007-147-1-017.htm ACP JC synopsis ]</ref> | [[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%. <ref name="pmid17577005">{{cite journal |author=Hart RG, Pearce LA, Aguilar MI |title=Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation |journal=Ann. Intern. Med. |volume=146 |issue=12 |pages=857-67 |year=2007 |pmid=17577005 |doi=}}</ref>. However, a recent [[meta-analysis]] suggests harm from anti-coagulation started early after an embolic stroke.<ref name="pmid17204681"> {{cite journal |author=Paciaroni M, Agnelli G, Micheli S, Caso V |title=Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials |journal=Stroke |volume=38 |issue=2 |pages=423-30 | year=2007 |pmid=17204681 |doi=10.1161/01.STR.0000254600.92975.1f }} [http://www.acpjc.org/Content/147/1/issue/ACPJC-2007-147-1-017.htm ACP JC synopsis ]</ref> | ||
==References== | ==References== | ||
<references/> | <references/> | ||
Revision as of 14:21, 11 December 2008
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]:
- Interpreted by software:
- sensitivity = 83%
- specificity = 99%
- Interpreted by a primary care physician:
- sensitivity = 80%
- specificity = 92%
- Interpreted by a primary care physician with software:
- sensitivity = 92%
- specificity = 91%
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
- "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]
As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in two randomized controlled trials of patients without[5] and with[6] heart failure.
Episodic medical therapy has conflicting results with a positive uncontrolled before and after trial of flecainide and propafenone[7] and a negative randomized controlled trial of episodic amiodarone versus continuous amiodarone.[8]
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%. [9]. However, a recent meta-analysis suggests harm from anti-coagulation started early after an embolic stroke.[10]
References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 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]
- ↑ 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]
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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]
- ↑ 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