Atrial fibrillation: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
=== | ===Prevalence=== | ||
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%.<ref name="pmid17673732">{{cite journal |author=Fitzmaurice DA, Hobbs FD, Jowett S, ''et al'' |title=Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial |journal= |volume= |issue= |pages= |year=2007 |pmid=17673732 |doi=10.1136/bmj.39280.660567.55}}</ref> This implies that the [[sensitivity (tests)|sensitivity]] of the routine examination is 64% (1.04/1.63). | 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%.<ref name="pmid17673732">{{cite journal |author=Fitzmaurice DA, Hobbs FD, Jowett S, ''et al'' |title=Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial |journal= |volume= |issue= |pages= |year=2007 |pmid=17673732 |doi=10.1136/bmj.39280.660567.55}}</ref> This implies that the [[sensitivity (tests)|sensitivity]] of the routine examination is 64% (1.04/1.63). | ||
Routine cardiac monitoring for seven days after [[ischemic stroke]] detected atrial fibrillation in 40% of patients.<ref name="pmid23899913">{{cite journal| author=Higgins P, MacFarlane PW, Dawson J, McInnes GT, Langhorne P, Lees KR| title=Noninvasive cardiac event monitoring to detect atrial fibrillation after ischemic stroke: a randomized, controlled trial. | journal=Stroke | year= 2013 | volume= 44 | issue= 9 | pages= 2525-31 | pmid=23899913 | doi=10.1161/STROKEAHA.113.001927 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23899913 }} </ref> | |||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
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==Prognosis== | ==Prognosis== | ||
===Risk of stroke=== | ===Risk of stroke=== | ||
The risk of [[stroke]] in a patient with atrial fibrillation can be predicted with the [[CHADS2]] score. | The risk of [[stroke]] in a patient with atrial fibrillation can be predicted with the [[CHADS2]] score and perhaps better with the CHA<sub>2</sub>DS<sub>2</sub>-VASc score.<ref>Lopes RD, Crowley MJ, Shah BR, et al . Stroke Prevention in Atrial Fibrillation. Comparative | ||
Effectiveness Review No. 123. AHRQ Publication No. 13-EHC113-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2013. www.effectivehealthcare.ahrq.gov/ reports/final.cfm.</ref><ref name="pmid21282258">{{cite journal| author=Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J et al.| title=Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. | journal=BMJ | year= 2011 | volume= 342 | issue= | pages= d124 | pmid=21282258 | doi=10.1136/bmj.d124 | pmc=PMC3031123 | url= }} </ref> CHA<sub>2</sub>DS<sub>2</sub>-VASc is: | |||
* CHADS2 (Congestive [[heart failure]], [[Hypertension]], Age ≥ 75 years, diabetes, previous [[stroke]]) | |||
* Vascular disease, Age 65-74 years, Sex category (female=1) | |||
Interpretation is: | |||
* 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 | |||
==Treatment== | ==Treatment== | ||
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:"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> | ||
Regarding target [[heart rate]], a recent [[randomized controlled trial]] found that resting heart rate <110 beats per minute had similar outcomes to stricter control.<ref name="pmid20231232">{{cite journal| author=Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JG, Alings AM et al.| title=Lenient versus strict rate control in patients with atrial fibrillation. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 15 | pages= 1363-73 | pmid=20231232 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20231232 | doi=10.1056/NEJMoa1001337 }} </ref> 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."<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> | |||
As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in [[randomized controlled trial]]s.<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><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><ref name="pmid12466506">{{cite journal |author=Wyse DG, Waldo AL, DiMarco JP, ''et al'' |title=A comparison of rate control and rhythm control in patients with atrial fibrillation |journal=N. Engl. J. Med. |volume=347 |issue=23 |pages=1825–33 |year=2002 |month=December |pmid=12466506 |doi=10.1056/NEJMoa021328 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12466506&promo=ONFLNS19 |issn=}}</ref> 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."<ref name="pmid12466507"/> Whether the index episode was the initial or a recurrent episode did not effect results.<ref name="pmid12466506"/> | As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in [[randomized controlled trial]]s.<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><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><ref name="pmid12466506">{{cite journal |author=Wyse DG, Waldo AL, DiMarco JP, ''et al'' |title=A comparison of rate control and rhythm control in patients with atrial fibrillation |journal=N. Engl. J. Med. |volume=347 |issue=23 |pages=1825–33 |year=2002 |month=December |pmid=12466506 |doi=10.1056/NEJMoa021328 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12466506&promo=ONFLNS19 |issn=}}</ref> 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."<ref name="pmid12466507"/> Whether the index episode was the initial or a recurrent episode did not effect results.<ref name="pmid12466506"/> | ||
{| class="wikitable" align="right" | {| class="wikitable" align="right" | ||
|+ Randomized controlled trial of rhythm versus rate control | |+ [[Randomized controlled trial]]s of rhythm versus rate control.<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><ref name="pmid12466506">{{cite journal |author=Wyse DG, Waldo AL, DiMarco JP, ''et al'' |title=A comparison of rate control and rhythm control in patients with atrial fibrillation |journal=N. Engl. J. Med. |volume=347 |issue=23 |pages=1825–33 |year=2002 |month=December |pmid=12466506 |doi=10.1056/NEJMoa021328 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12466506&promo=ONFLNS19 |issn=}}</ref><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> | ||
! Study!! Patients!! Intervention in rhythm control group!! | ! rowspan="2"|Study!! rowspan="2"|Patients!! rowspan="2"|Intervention in rhythm control group!! colspan="2"| Results | ||
|- | |||
! Rhythm control group!! Rate control group | |||
|- | |- | ||
| Van Gelder<ref name="pmid12466507"/><br/>2002|| | | Van Gelder<ref name="pmid12466507"/><br/>2002|| | ||
* All had prior episode of atrial dysrythmia requiring electrical cardioversion | * All had prior episode of atrial dysrythmia requiring electrical cardioversion. | ||
* All had current atrial dysrythmia for median of 32 days. | * All had current atrial dysrythmia for median of 32 days. | ||
* 50% has previous heart failure | * 50% has previous [[heart failure]]. | ||
|| Cardioversion followed by sotalol | || | ||
* Cardioversion followed by sotalol | |||
* 86% to 99% received [[anticoagulation]]. | |||
* 2.3 years. | |||
| | |||
* Sinus rhythm: 39% | |||
* Cardiovascular death: 6.8% | |||
* Thromboembolism: 5.5% | |||
|| | |||
* Sinus rhythm: 10% | |||
* Cardiovascular death: 7% | |||
* Thromboembolism: 7.9% | |||
|- | |- | ||
| AFFIRM<ref name="pmid12466506"/><br/>2002|| | | AFFIRM<ref name="pmid12466506"/><br/>2002|| | ||
* 65% had prior episode of atrial dysrythmia. | * 65% had prior episode of atrial dysrythmia. | ||
* All had current atrial dysrythmia with 69% lasting 2 or more days. | * All had current atrial dysrythmia with 69% lasting 2 or more days. | ||
* 23% has previous heart failure | * 23% has previous [[heart failure]]. | ||
|| "antiarrhythmic drug used was chosen by the treating physician" | || | ||
* "antiarrhythmic drug used was chosen by the treating physician" | |||
* 70% received [[anticoagulation]]. | |||
* 5 years. | |||
| | |||
* Sinus rhythm: 63% | |||
* Any death: 23.8% | |||
* Ischemic [[stroke]]: 5.5% | |||
|| | |||
* Sinus rhythm: 35% | |||
* Any death: 21.3% | |||
* Ischemic [[stroke]]: 7.1% | |||
|- | |- | ||
| Roy<ref name="pmid18565859"/><br/>2008 || | | Roy<ref name="pmid18565859"/><br/>2008 || | ||
* All had prior episode of atrial dysrythmia. | * All had prior episode of atrial dysrythmia. | ||
* 55% to 60% with current atrial dysrythmia. | * 55% to 60% with current atrial dysrythmia. | ||
* All with a history of heart failure and systolic dysfunction | * All with a history of [[heart failure]] and systolic dysfunction. | ||
|| Amiodarone | || | ||
* Amiodarone | |||
* 90% received [[anticoagulation]]. | |||
* 3 years. | |||
| | |||
* Sinus rhythm: 73% | |||
* Cardiovascular death: 27% | |||
* Any [[stroke]]: 3% | |||
|| | |||
* Sinus rhythm: 30% | |||
* Cardiovascular death: 25% | |||
* Any [[stroke]]: 4% | |||
|} | |} | ||
Regarding the choice of medication:<br/> | |||
Shown effective in some [[randomized controlled trial]]s | |||
* [[Amiodarone]]<ref name="pmid12843685">{{cite journal| author=Manios EG, Mavrakis HE, Kanoupakis EM, Kallergis EM, Dermitzaki DN, Kambouraki DC et al.| title=Effects of amiodarone and diltiazem on persistent atrial fibrillation conversion and recurrence rates: a randomized controlled study. | journal=Cardiovasc Drugs Ther | year= 2003 | volume= 17 | issue= 1 | pages= 31-9 | pmid=12843685 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12843685 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> | |||
* [[Metoprolol]]<ref name="pmid10898425">{{cite journal| author=Kühlkamp V, Schirdewan A, Stangl K, Homberg M, Ploch M, Beck OA| title=Use of metoprolol CR/XL to maintain sinus rhythm after conversion from persistent atrial fibrillation: a randomized, double-blind, placebo-controlled study. | journal=J Am Coll Cardiol | year= 2000 | volume= 36 | issue= 1 | pages= 139-46 | pmid=10898425 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10898425 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid17329409">{{cite journal| author=Nergårdh AK, Rosenqvist M, Nordlander R, Frick M| title=Maintenance of sinus rhythm with metoprolol CR initiated before cardioversion and repeated cardioversion of atrial fibrillation: a randomized double-blind placebo-controlled study. | journal=Eur Heart J | year= 2007 | volume= 28 | issue= 11 | pages= 1351-7 | pmid=17329409 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17329409 | doi=10.1093/eurheartj/ehl544 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> | |||
Shown ''not'' effective in some [[randomized controlled trial]]s | |||
* [[Diltiazem]]<ref name="pmid12843685">{{cite journal| author=Manios EG, Mavrakis HE, Kanoupakis EM, Kallergis EM, Dermitzaki DN, Kambouraki DC et al.| title=Effects of amiodarone and diltiazem on persistent atrial fibrillation conversion and recurrence rates: a randomized controlled study. | journal=Cardiovasc Drugs Ther | year= 2003 | volume= 17 | issue= 1 | pages= 31-9 | pmid=12843685 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12843685 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> | |||
;Episodic therapy | ;Episodic therapy | ||
Episodic medical therapy has conflicting results with a positive uncontrolled before and after trial of flecainide and propafenone<ref name="pmid15575054">{{cite journal |author=Alboni P, Botto GL, Baldi N, ''et al'' |title=Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach |journal=The New England journal of medicine |volume=351 |issue=23 |pages=2384–91 |year=2004 |month=December |pmid=15575054 |doi=10.1056/NEJMoa041233 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=15575054&promo=ONFLNS19 |issn=}}</ref> and a negative randomized controlled trial of episodic amiodarone versus continuous amiodarone.<ref>{{Cite journal | doi = 10.1001/jama.300.15.1784 | volume = 300 | issue = 15 | Episodic medical therapy has conflicting results with a positive uncontrolled before and after trial of flecainide and propafenone<ref name="pmid15575054">{{cite journal |author=Alboni P, Botto GL, Baldi N, ''et al'' |title=Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach |journal=The New England journal of medicine |volume=351 |issue=23 |pages=2384–91 |year=2004 |month=December |pmid=15575054 |doi=10.1056/NEJMoa041233 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=15575054&promo=ONFLNS19 |issn=}}</ref> and a negative randomized controlled trial of episodic amiodarone versus continuous amiodarone.<ref>{{Cite journal | doi = 10.1001/jama.300.15.1784 | volume = 300 | issue = 15 | ||
| pages = 1784-1792 | last = Ahmed | first = Sheba | coauthors = 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 | title = Continuous vs Episodic Prophylactic Treatment With Amiodarone for the Prevention of Atrial Fibrillation: A Randomized Trial | journal = JAMA | accessdate = 2008-10-15 | date = 2008-10-15 | url = http://jama.ama-assn.org/cgi/content/abstract/300/15/1784 }}</ref> | | pages = 1784-1792 | last = Ahmed | first = Sheba | coauthors = 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 | title = Continuous vs Episodic Prophylactic Treatment With Amiodarone for the Prevention of Atrial Fibrillation: A Randomized Trial | journal = JAMA | accessdate = 2008-10-15 | date = 2008-10-15 | url = http://jama.ama-assn.org/cgi/content/abstract/300/15/1784 }}</ref> | ||
====Artificial pacemakers==== | |||
Regarding [[artificial pacemaker]]s, "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]].<ref name="pmid17804844">{{cite journal |author=Sweeney MO, Bank AJ, Nsah E, ''et al'' |title=Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease |journal=N. Engl. J. Med. |volume=357 |issue=10 |pages=1000–8 |year=2007 |month=September |pmid=17804844 |doi=10.1056/NEJMoa071880 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17804844&promo=ONFLNS19 |issn=}}</ref> | |||
Dual site, overdrive pacing be effective.<ref name="pmid12354441">{{cite journal |author=Saksena S, Prakash A, Ziegler P, ''et al'' |title=Improved suppression of recurrent atrial fibrillation with dual-site right atrial pacing and antiarrhythmic drug therapy |journal=J. Am. Coll. Cardiol. |volume=40 |issue=6 |pages=1140–50; discussion 1151–2 |year=2002 |month=September |pmid=12354441 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109702020685 |issn=}}</ref> | |||
====Ablation==== | ====Ablation==== | ||
====Pulmonary-vein isolation==== | ====Pulmonary-vein isolation==== | ||
[[Randomized controlled trial]] have found that using ablation to cause pulmonary-vein isolation was superior to medical therapy<ref name="pmid15928285">{{cite journal |author=Wazni OM, Marrouche NF, Martin DO, ''et al'' |title=Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial |journal=JAMA |volume=293 |issue=21 |pages=2634–40 |year=2005 |month=June |pmid=15928285 |doi=10.1001/jama.293.21.2634 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15928285 |issn=}}</ref><ref name="pmid16510747">{{cite journal |author=Oral H, Pappone C, Chugh A, ''et al'' |title=Circumferential pulmonary-vein ablation for chronic atrial fibrillation |journal=N. Engl. J. Med. |volume=354 |issue=9 |pages=934–41 |year=2006 |month=March |pmid=16510747 |doi=10.1056/NEJMoa050955 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16510747&promo=ONFLNS19 |issn=}}</ref> and to atrioventricular-node ablation<ref name="pmid18946063">{{cite journal |author=Khan MN, Jaïs P, Cummings J, ''et al'' |title=Pulmonary-vein isolation for atrial fibrillation in patients with heart failure |journal=N. Engl. J. Med. |volume=359 |issue=17 |pages=1778–85 |year=2008 |month=October |pmid=18946063 |doi=10.1056/NEJMoa0708234 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18946063&promo=ONFLNS19 |issn=}}</ref>. | [[Randomized controlled trial]] have found that using ablation to cause pulmonary-vein isolation was superior to medical therapy<ref name="pmid20103757">{{cite journal| author=Wilber DJ, Pappone C, Neuzil P, De Paola A, Marchlinski F, Natale A et al.| title=Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. | journal=JAMA | year= 2010 | volume= 303 | issue= 4 | pages= 333-40 | pmid=20103757 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&[email protected]&retmode=ref&cmd=prlinks&id=20103757 | doi=10.1001/jama.2009.2029 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid15928285">{{cite journal |author=Wazni OM, Marrouche NF, Martin DO, ''et al'' |title=Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial |journal=JAMA |volume=293 |issue=21 |pages=2634–40 |year=2005 |month=June |pmid=15928285 |doi=10.1001/jama.293.21.2634 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15928285 |issn=}}</ref><ref name="pmid16510747">{{cite journal |author=Oral H, Pappone C, Chugh A, ''et al'' |title=Circumferential pulmonary-vein ablation for chronic atrial fibrillation |journal=N. Engl. J. Med. |volume=354 |issue=9 |pages=934–41 |year=2006 |month=March |pmid=16510747 |doi=10.1056/NEJMoa050955 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16510747&promo=ONFLNS19 |issn=}}</ref> and to atrioventricular-node ablation<ref name="pmid18946063">{{cite journal |author=Khan MN, Jaïs P, Cummings J, ''et al'' |title=Pulmonary-vein isolation for atrial fibrillation in patients with heart failure |journal=N. Engl. J. Med. |volume=359 |issue=17 |pages=1778–85 |year=2008 |month=October |pmid=18946063 |doi=10.1056/NEJMoa0708234 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18946063&promo=ONFLNS19 |issn=}}</ref>. About two thirds of patients remain in sinus rhythm after 9 months.<ref name="pmid20103757">{{cite journal| author=Wilber DJ, Pappone C, Neuzil P, De Paola A, Marchlinski F, Natale A et al.| title=Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. | journal=JAMA | year= 2010 | volume= 303 | issue= 4 | pages= 333-40 | pmid=20103757 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&[email protected]&retmode=ref&cmd=prlinks&id=20103757 | doi=10.1001/jama.2009.2029 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> | |||
===Anticoagulation=== | ===Anticoagulation=== | ||
:" | Patients with a CHA<sub>2</sub>DS<sub>2</sub>-VASc of two or more may benefit from chronic [[anticoagulation]] according to a recent observational study<ref name="pmid25614418">{{cite journal| author=Friberg L, Skeppholm M, Terént A| title=Benefit of Anticoagulation Unlikely in Patients With Atrial Fibrillation and a CHA2DS2-VASc Score of 1. | journal=J Am Coll Cardiol | year= 2015 | volume= 65 | issue= 3 | pages= 225-32 | pmid=25614418 | doi=10.1016/j.jacc.2014.10.052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25614418 }} </ref> and American [[clinical practice guideline]]s<ref name="pmid24682348">{{cite journal| author=January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC et al.| title=2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. | journal=Circulation | year= 2014 | volume= 130 | issue= 23 | pages= 2071-104 | pmid=24682348 | doi=10.1161/CIR.0000000000000040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24682348 }} </ref>. European [[clinical practice guideline]]s recommend [[anticoagulant]]s if the CHA<sub>2</sub>DS<sub>2</sub>-VASc is two or more.<ref name="pmid22923145">{{cite journal| author=Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH et al.| title=2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. | journal=Europace | year= 2012 | volume= 14 | issue= 10 | pages= 1385-413 | pmid=22923145 | doi=10.1093/europace/eus305 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22923145 }} </ref> | ||
{| class="wikitable" | |||
|+ [[Randomized controlled trial]]s of new [[anticoagulant]]s compared to [[warfarin]] for [[atrial fibrillation]].<ref name="pmid21870978">{{cite journal| author=Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M et al.| title=Apixaban versus warfarin in patients with atrial fibrillation. | journal=N Engl J Med | year= 2011 | volume= 365 | issue= 11 | pages= 981-92 | pmid=21870978 | doi=10.1056/NEJMoa1107039 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21870978 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22250164 Review in: Ann Intern Med. 2012 Jan 17;156(2):JC1-2, JC1-3] </ref> <ref name="pmid21830957">{{cite journal| author=Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W et al.| title=Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. | journal=N Engl J Med | year= 2011 | volume= | issue= | pages= | pmid=21830957 | doi=10.1056/NEJMoa1009638 | pmc= | url= }} </ref> <ref name="pmid19717844">{{cite journal| author=Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A et al.| title=Dabigatran versus Warfarin in Patients with Atrial Fibrillation. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 12 | pages= 1139-1151 | pmid=19717844 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19717844 | doi=10.1056/NEJMoa0905561 }} </ref> | |||
! rowspan="2"|Trial!!rowspan="2"| Patients!!rowspan="2"| Intervention!!rowspan="2"|Comparison !!rowspan="2"|Outcome!!colspan="2"|Results !! rowspan="2"|Comments | |||
|- | |||
! Intervention!!Control | |||
|- | |||
| ARISTOTLE<ref name="pmid21870978"/><br/>2011|| 18,201 patients|| [[Apixaban]] 5 mg twice daily ||[[warfarin]] (target [[International Normalized Ratio|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<br/>• relative risk for death 0.89 (95% [[confidence interval|CI]]: 0.80 to 0.99; P=0.047) | |||
|- | |||
| ROCKET AF<ref name="pmid21830957"/><br/>2011|| 14,264 patients|| [[Rivaroxaban]] 20 mg daily<br/>(15 mg daily if [[creatinine clearance]] 30 to 49 ml per minute) ||[[warfarin]] (target [[International Normalized Ratio|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<br/>• relative risk for death 0.92 (95% [[confidence interval|CI]]: 0.82 to 1.03; P=0.15) | |||
|- | |||
| RE-LY<ref name="pmid19717844"/><br/>2009|| 18,113 patients|| [[Dabigatran]] 150 mg twice daily ||[[warfarin]] (target [[International Normalized Ratio|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<br/>• relative risk for death 0.88 (95% [[confidence interval|CI]]: 0.77 to 1.00; P=0.051)<br/>• Not blinded | |||
|} | |||
{| class="wikitable" align="right" | |||
|+ [[Dabigatran]] versus [[warfarin]] for [[atrial fibrillation]]<ref name="pmid19717844"></ref> | |||
! rowspan="2"|Intervention!! colspan="3"|Outcomes | |||
|- | |||
! [[Stroke]] or systemic [[embolism]]!!Major bleeding !!Mortality | |||
|- | |||
| Dabigatran 110 mg twice daily||align="center"| 1.53% ||align="center"|2.71%<sup>†</sup>||3.75% | |||
|- | |||
| Dabigatran 150 mg twice daily||align="center"|1.11%<sup>†</sup>||align="center"|3.11%||3.64% | |||
|- | |||
| Warfarin ||align="center"|1.69%||align="center"|3.36%|| 4.13% | |||
|- | |||
|colspan="4"|† 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%. <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> | |||
[[Anticoagulant]]s is underused for atrial fibrillation.<ref name="pmid18373138">{{cite journal| author=Wess ML, Schauer DP, Johnston JA, Moomaw CJ, Brewer DE, Cook EF et al.| title=Application of a decision support tool for anticoagulation in patients with non-valvular atrial fibrillation. | journal=J Gen Intern Med | year= 2008 | volume= 23 | issue= 4 | pages= 411-7 | pmid=18373138 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&[email protected]&retmode=ref&cmd=prlinks&id=18373138 | doi=10.1007/s11606-007-0477-9 | pmc=PMC2359511 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> Both doctors<ref name="pmid10610643">{{cite journal| author=Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE| title=Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. | journal=Ann Intern Med | year= 1999 | volume= 131 | issue= 12 | pages= 927-34 | pmid=10610643 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&[email protected]&retmode=ref&cmd=prlinks&id=10610643 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> and patients<ref name="pmid10818030">{{cite journal| author=Protheroe J, Fahey T, Montgomery AA, Peters TJ| title=The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis. | journal=BMJ | year= 2000 | volume= 320 | issue= 7246 | pages= 1380-4 | pmid=10818030 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&[email protected]&retmode=ref&cmd=prlinks&id=10818030 | pmc=PMC27382 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> are reluctant to use anticoagulants. Patients may avoid [[warfarin]] even when they prefer the outcomes of warfarin.<ref name="pmid17515584">{{cite journal| author=Holbrook A, Labiris R, Goldsmith CH, Ota K, Harb S, Sebaldt RJ| title=Influence of decision aids on patient preferences for anticoagulant therapy: a randomized trial. | journal=CMAJ | year= 2007 | volume= 176 | issue= 11 | pages= 1583-7 | pmid=17515584 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&[email protected]&retmode=ref&cmd=prlinks&id=17515584 | doi=10.1503/cmaj.060837 | pmc=PMC1867833 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> | |||
In 2009, [[dabigatran]], a [[direct thrombin inhibitor]]s, was compared to [[warfarin]] in the RE-LY [[randomized controlled trial]].<ref name="pmid19717844"></ref> | |||
====Antiplatelet therapy==== | |||
{| class="wikitable" | |||
|+ [[Randomized controlled trial]]s of antiplatelet therapy for atrial fibrillation<ref name="pmid2563096">{{cite journal| author=Petersen P, Boysen G, Godtfredsen J, Andersen ED, Andersen B| title=Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study. | journal=Lancet | year= 1989 | volume= 1 | issue= 8631 | pages= 175-9 | pmid=2563096 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2563096 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid1860198">{{cite journal| author=| title=Stroke Prevention in Atrial Fibrillation Study. Final results. | journal=Circulation | year= 1991 | volume= 84 | issue= 2 | pages= 527-39 | pmid=1860198 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1860198 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid19336502">{{cite journal |author=Connolly SJ, Pogue J, Hart RG, ''et al.'' |title=Effect of clopidogrel added to aspirin in patients with atrial fibrillation |journal=N. Engl. J. Med. |volume=360 |issue=20 |pages=2066–78 |year=2009 |month=May |pmid=19336502 |doi=10.1056/NEJMoa0901301 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19336502&promo=ONFLNS19 |issn=}}</ref> | |||
! rowspan="2"|Trial!!rowspan="2"| Patients!!rowspan="2"| Intervention!!rowspan="2"| Comparison !!rowspan="2"|Outcome!!colspan="2"|Results | |||
|- | |||
! Intervention!!Control | |||
|- | |||
| Copenhagen AFASAK study<ref name="pmid2563096"/><br/>1989|| 1007 patients|| aspirin 75 mg daily||Warfarin|| [[stroke]], [[transient ischemic attack]], or systemic [[embolism]] || 6.0%|| 1.4% | |||
|- | |||
| SPAF<ref name="pmid1860198"/><br/>1991 || 1,330 patients|| aspirin 325 mg daily||Warfarin|| ischemic [[stroke]] and systemic [[embolism]] || 3.6%|| 2.3%<sup>†</sup> | |||
|- | |||
| ACTIVE study<ref name="pmid19336502"/><br/>2009||7554 patients:<br/>• All were taking aspirin, usually at 75 to 100 mg per day<br/>•None were taking [[warfarin]]||clopidogrel 75 mg daily||Placebo||[[stroke]], [[myocardial infarction]], systemic embolism, or death from vascular causes|| 6.8%<sup>‡</sup>|| 7.6% | |||
|- | |||
| colspan="7"|† This was not a direct comparison as warfarin patients were younger and had to be eligible for warfarin.<br/>‡ However, combination therapy increased major bleeding from 1.3% to 2.0%. | |||
|} | |||
If [[warfarin]] is contraindicated, the combination of [[clopidogrel]] and [[aspirin]] can help, especially in reducing stroke, but increases the risk of major hemorrhage.<ref name="pmid19336502">{{cite journal |author=Connolly SJ, Pogue J, Hart RG, ''et al.'' |title=Effect of clopidogrel added to aspirin in patients with atrial fibrillation |journal=N. Engl. J. Med. |volume=360 |issue=20 |pages=2066–78 |year=2009 |month=May |pmid=19336502 |doi=10.1056/NEJMoa0901301 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=19336502&promo=ONFLNS19 |issn=}}</ref> | |||
[[ | ==Screening== | ||
Screening may increase detection according to a [[systematic review]] by the [[Cochrane Collaboration]].<ref name="pmid23633374">{{cite journal| author=Moran PS, Flattery MJ, Teljeur C, Ryan M, Smith SM| title=Effectiveness of systematic screening for the detection of atrial fibrillation. | journal=Cochrane Database Syst Rev | year= 2013 | volume= 4 | issue= | pages= CD009586 | pmid=23633374 | doi=10.1002/14651858.CD009586.pub2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633374 }} </ref> | |||
==References== | ==References== | ||
{{reflist|2}}[[Category:Suggestion Bot Tag]] | |||
Latest revision as of 11:00, 14 July 2024
Diagnosis
Prevalence
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).
Routine cardiac monitoring for seven days after ischemic stroke detected atrial fibrillation in 40% of patients.[2]
Electrocardiogram
Regarding the accuracy of the electrocardiogram[3]:
- 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 and perhaps better with the CHA2DS2-VASc score.[4][5] CHA2DS2-VASc is:
- CHADS2 (Congestive heart failure, Hypertension, Age ≥ 75 years, diabetes, previous stroke)
- Vascular disease, Age 65-74 years, Sex category (female=1)
Interpretation is:
- 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
Treatment
Clinical practice guidelines by the American College of Physicians and the American Academy of Family Physicians address treatment.[6][7]
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."[6]
Regarding target heart rate, a recent randomized controlled trial found that resting heart rate <110 beats per minute had similar outcomes to stricter control.[8] 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."[9]
As compared to rate control, rhythm control was associated with slight, although statistically insignificant, increase in adverse outcomes in randomized controlled trials.[10][9][11] 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."[10] Whether the index episode was the initial or a recurrent episode did not effect results.[11]
| Study | Patients | Intervention in rhythm control group | Results | |
|---|---|---|---|---|
| Rhythm control group | Rate control group | |||
| Van Gelder[10] 2002 |
|
|
|
|
| AFFIRM[11] 2002 |
|
|
|
|
| Roy[9] 2008 |
|
|
|
|
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[15] and a negative randomized controlled trial of episodic amiodarone versus continuous amiodarone.[16]
Artificial pacemakers
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.[17]
Dual site, overdrive pacing be effective.[18]
Ablation
Pulmonary-vein isolation
Randomized controlled trial have found that using ablation to cause pulmonary-vein isolation was superior to medical therapy[19][20][21] and to atrioventricular-node ablation[22]. About two thirds of patients remain in sinus rhythm after 9 months.[19]
Anticoagulation
Patients with a CHA2DS2-VASc of two or more may benefit from chronic anticoagulation according to a recent observational study[23] and American clinical practice guidelines[24]. European clinical practice guidelines recommend anticoagulants if the CHA2DS2-VASc is two or more.[25]
| Trial | Patients | Intervention | Comparison | Outcome | Results | Comments | |
|---|---|---|---|---|---|---|---|
| Intervention | Control | ||||||
| ARISTOTLE[26] 2011 |
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[27] 2011 |
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) |
| RE-LY[28] 2009 |
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 |
| Intervention | Outcomes | ||
|---|---|---|---|
| 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% |
| Warfarin | 1.69% | 3.36% | 4.13% |
| † 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%. [29]. However, a recent meta-analysis suggests harm from anti-coagulation started early after an embolic stroke.[30]
Anticoagulants is underused for atrial fibrillation.[31] Both doctors[32] and patients[33] are reluctant to use anticoagulants. Patients may avoid warfarin even when they prefer the outcomes of warfarin.[34]
In 2009, dabigatran, a direct thrombin inhibitors, was compared to warfarin in the RE-LY randomized controlled trial.[28]
Antiplatelet therapy
| Trial | Patients | Intervention | Comparison | Outcome | Results | |
|---|---|---|---|---|---|---|
| Intervention | Control | |||||
| Copenhagen AFASAK study[35] 1989 |
1007 patients | aspirin 75 mg daily | Warfarin | stroke, transient ischemic attack, or systemic embolism | 6.0% | 1.4% |
| SPAF[36] 1991 |
1,330 patients | aspirin 325 mg daily | Warfarin | ischemic stroke and systemic embolism | 3.6% | 2.3%† |
| ACTIVE study[37] 2009 |
7554 patients: • 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%. | ||||||
If warfarin is contraindicated, the combination of clopidogrel and aspirin can help, especially in reducing stroke, but increases the risk of major hemorrhage.[37]
Screening
Screening may increase detection according to a systematic review by the Cochrane Collaboration.[38]
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.
- ↑ Higgins P, MacFarlane PW, Dawson J, McInnes GT, Langhorne P, Lees KR (2013). "Noninvasive cardiac event monitoring to detect atrial fibrillation after ischemic stroke: a randomized, controlled trial.". Stroke 44 (9): 2525-31. DOI:10.1161/STROKEAHA.113.001927. PMID 23899913. 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.
- ↑ Lopes RD, Crowley MJ, Shah BR, et al . Stroke Prevention in Atrial Fibrillation. Comparative Effectiveness Review No. 123. AHRQ Publication No. 13-EHC113-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2013. www.effectivehealthcare.ahrq.gov/ reports/final.cfm.
- ↑ Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J et al. (2011). "Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study.". BMJ 342: d124. DOI:10.1136/bmj.d124. PMID 21282258. PMC PMC3031123. Research Blogging.
- ↑ 6.0 6.1 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, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JG, Alings AM et al. (2010). "Lenient versus strict rate control in patients with atrial fibrillation.". N Engl J Med 362 (15): 1363-73. DOI:10.1056/NEJMoa1001337. PMID 20231232. Research Blogging.
- ↑ 9.0 9.1 9.2 9.3 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.
- ↑ 10.0 10.1 10.2 10.3 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.
- ↑ 11.0 11.1 11.2 11.3 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.
- ↑ 12.0 12.1 Manios EG, Mavrakis HE, Kanoupakis EM, Kallergis EM, Dermitzaki DN, Kambouraki DC et al. (2003). "Effects of amiodarone and diltiazem on persistent atrial fibrillation conversion and recurrence rates: a randomized controlled study.". Cardiovasc Drugs Ther 17 (1): 31-9. PMID 12843685.
- ↑ Kühlkamp V, Schirdewan A, Stangl K, Homberg M, Ploch M, Beck OA (2000). "Use of metoprolol CR/XL to maintain sinus rhythm after conversion from persistent atrial fibrillation: a randomized, double-blind, placebo-controlled study.". J Am Coll Cardiol 36 (1): 139-46. PMID 10898425.
- ↑ Nergårdh AK, Rosenqvist M, Nordlander R, Frick M (2007). "Maintenance of sinus rhythm with metoprolol CR initiated before cardioversion and repeated cardioversion of atrial fibrillation: a randomized double-blind placebo-controlled study.". Eur Heart J 28 (11): 1351-7. DOI:10.1093/eurheartj/ehl544. PMID 17329409. 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.
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- ↑ Sweeney MO, Bank AJ, Nsah E, et al (September 2007). "Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease". N. Engl. J. Med. 357 (10): 1000–8. DOI:10.1056/NEJMoa071880. PMID 17804844. Research Blogging.
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- ↑ 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.
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- ↑ 37.0 37.1 37.2 Connolly SJ, Pogue J, Hart RG, et al. (May 2009). "Effect of clopidogrel added to aspirin in patients with atrial fibrillation". N. Engl. J. Med. 360 (20): 2066–78. DOI:10.1056/NEJMoa0901301. PMID 19336502. Research Blogging.
- ↑ Moran PS, Flattery MJ, Teljeur C, Ryan M, Smith SM (2013). "Effectiveness of systematic screening for the detection of atrial fibrillation.". Cochrane Database Syst Rev 4: CD009586. DOI:10.1002/14651858.CD009586.pub2. PMID 23633374. Research Blogging.