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## Complete Summary

#### GUIDELINE TITLE

Management of newly detected atrial fibrillation: a clinical practice
guideline from the American Academy of Family Physicians and the
American College of Physicians.

#### BIBLIOGRAPHIC SOURCE(S)

Snow V, Weiss KB, LeFevre M, McNamara R, Bass E, Green LA, Michl K,
Owens DK, Susman J, Allen DI, Mottur-Pilson C. 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 2003 Dec 16;139(12):1009-17. \[57
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14678921)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [August 16, 2007, Coumadin
    (Warfarin)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Warfarin):
    Updates to the labeling for Coumadin to include pharmacogenomics
    information to explain that people\'s genetic makeup may influence
    how they respond to the drug.

-   [October 6, 2006, Coumadin (warfarin
    sodium)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Coumadin):
    Revisions to the labeling for Coumadin to include a new patient
    Medication Guide as well as a reorganization and highlighting of the
    current safety information to better inform providers and patients.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Atrial fibrillation

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To make recommendations on the pharmacologic management of newly
detected atrial fibrillation in primary care.

#### TARGET POPULATION

Adult patients with first-detected atrial fibrillation

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Rate control with chronic anticoagulation (adjusted-dose warfarin)

2.  Rhythm control (based on patient symptoms, exercise tolerance, and
    patient preference)

3.  Pharmacotherapy

    -   Beta-blockers (atenolol, metoprolol)

    -   Nondihydropyridine calcium-channel blockers (diltiazem,
        verapamil)

    -   Digoxin (rate control at rest)

4.  Cardioversion

    -   Direct current

    -   Pharmacological (ibutilide, flecainide, dofetilide, propafenone,
        amiodarone quinidine, procainamide, and sotalol)

5.  Transesophageal echocardiography

    -   Early acute cardioversion (prior anticoagulation with
        postcardioversion anticoagulation)

    -   Delayed cardioversion (pre- and postanticoagulation)

6.  Pharmacologic agents for rhythm maintenance

    -   Amiodarone

    -   Disopyramide

    -   Propafenone

    -   Sotalol

    -   Flecainide

    -   Quinidine

    -   Azimilide

7.  Anticoagulation with adjusted dose warfarin

Other antiplatelet agents considered but not specifically recommended
include low dose warfarin, aspirin, and low molecular weight heparin.

#### MAJOR OUTCOMES CONSIDERED

-   Mortality

-   Quality of life

-   Symptom relief

-   Heart rate

-   Rate of ischemic stroke

-   Risk of thromboembolic disease

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Joint American Academy of Family Physicians (AAFP)/American College
of Physicians (ACP) Panel focused its searches for relevant evidence on
the strongest study design: randomized, controlled trials (RCTs). For
the previous systematic review, the Panel identified controlled trials
in the CENTRAL database produced by the Cochrane Collaboration\'s
international efforts, searched MEDLINE from 1966 to 1998 for citations
tagged as \"randomized controlled trial\" or \"controlled clinical
trial,\" searched the PubMed \"Related Articles\" feature, reviewed hand
searches submitted to the Baltimore Cochrane Center, scanned the
reference lists in relevant publications, and scanned the table of
contents of relevant journals. For the current review, the Panel also
searched MEDLINE from May 1998 through September 2001 (using the same
search terms as in the original review plus terms to identify
meta-analyses and decision analyses). For topics without sufficient
RCTs, the Panel used observational data, consensus statements, review
articles, and decision analyses obtained from their search of MEDLINE
from 1966 through September 2001. Although September 2001 was used as a
cutoff for the systematic searching of the literature in order to
generate a report for the American College of Physicians (ACP)/American
Academy of Family Physicians (AAFP) Guideline group, the Panel included
selected studies published after September 2001 on the basis of input
from the group.

Studies were eligible for review if they were randomized trials of adult
patients that addressed the management of nonpostoperative atrial
fibrillation. In the previous systematic review, 521 citations were
identified and 179 articles were eligible for detailed review. The
updated search yielded 29 additional articles that met the Panel\'s
inclusion criteria.

#### NUMBER OF SOURCE DOCUMENTS

208

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Statistical Analysis**

For the quantitative analysis, the Joint American Academy of Family
Physicians (AAFP)/American College of Physicians (ACP) Panel stratified
data to obtain an effect measure for each drug. Stata, version 7.0
(Stata Corp., College Station, Texas) was used to calculate the odds
ratio (OR) of success of the drug compared with placebo. Respective 95%
confidence intervals (CIs) and *P* values were also calculated. The
Joint Panel used ORs because they provided less heterogeneity of study
results than relative risk ratio. Estimates of the relative rates of the
outcomes of interest were pooled using standard methods for combining
the OR for the outcomes of conversion to sinus rhythm, maintenance of
sinus rhythm, stroke, peripheral embolism, major bleeding, minor
bleeding, and death. Studies were weighted on the basis of the precision
of the estimate within each study. When no heterogeneity was found,
meta-analyses used the fixed-effects model (Mantel--Haenszel method for
pooling). When heterogeneity was found, the random-effects model was
used (DerSimonian and Laird method of pooling). An OR was considered
significantly different from 1 if the *P* value was less than 0.05.
Statistical strength of evidence was categorized as strong (*P*
[\<]{.underline}0.01), moderate (0.01 \<*P* [\<]{.underline}0.05),
suggestive (0.05 \<*P* [\<]{.underline}0.2), or inconclusive (*P*
\>0.2).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The Guyatt Approach to Grading Recommendations was used.

**Grade of Recommendation**

**1A**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations\
*Implications*: Strong recommendation, can apply to most patients in
most circumstances without reservation

**1B**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations (inconsistent results, nonfatal
methodologic flaws)\
*Implications*: Strong recommendation; likely to apply to most patients

**1C+**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: No randomized trials for
this specific patient or patient population, but results from randomized
trial(s) including different patients can be unequivocally extrapolated
to the patient under current consideration; or overwhelming evidence
from observational studies is available\
*Implications*: Strong recommendation; can apply to most patients in
most circumstances

**1C**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: Observational studies\
*Implications*: Intermediate-strength recommendation; may change when
stronger evidence is available

**2A**\
*Clarity of Risk-Benefit*: Unclear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations\
*Implications*: Intermediate-strength recommendation; best action may
differ depending on circumstances or patients´ or societal values

**2B**\
*Clarity of Risk-Benefit*: Unclear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations (inconsistent results, nonfatal
methodologic flaws)\
*Implications*: Weak recommendation; alternative approaches likely to be
better for some patients under some circumstances

**2C**\
*Clarity of Risk-Benefit*: Unclear\
*Methodologic Strength of Supporting Evidence*: Observational studies\
*Implications*: Very weak recommendation; other alternatives may be
equally reasonable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The American Academy of Family Physicians (AAFP) and the American
College of Physicians (ACP) created this guideline in collaboration.
Drafts of the manuscript were reviewed by members of the American
Academy of Family Physicians/American College of Physicians guidelines
committee for management of atrial fibrillation. This manuscript was
approved by the American College of Physicians Board of Regents on March
31, 2003 and by the American Academy of Family Physicians Board of
Directors on April 29, 2003.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The grades of recommendations (1A, 1B, 1C+, 1C, 2A, 2B, 2C) are defined
at the end of the \"Major Recommendations\" field.

**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**

**[Definitions]{.underline}**:

**Grade of Recommendation**

**1A**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations\
*Implications*: Strong recommendation, can apply to most patients in
most circumstances without reservation

**1B**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations (inconsistent results, nonfatal
methodologic flaws)\
*Implications*: Strong recommendation; likely to apply to most patients

**1C+**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: No randomized trials for
this specific patient or patient population, but results from randomized
trial(s) including different patients can be unequivocally extrapolated
to the patient under current consideration; or overwhelming evidence
from observational studies is available\
*Implications*: Strong recommendation; can apply to most patients in
most circumstances

**1C**\
*Clarity of Risk-Benefit*: Clear\
*Methodologic Strength of Supporting Evidence*: Observational studies\
*Implications*: Intermediate-strength recommendation; may change when
stronger evidence is available

**2A**\
*Clarity of Risk-Benefit*: Unclear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations\
*Implications*: Intermediate-strength recommendation; best action may
differ depending on circumstances or patients´ or societal values

**2B**\
*Clarity of Risk-Benefit*: Unclear\
*Methodologic Strength of Supporting Evidence*: Randomized trials
without important limitations (inconsistent results, nonfatal
methodologic flaws)\
*Implications*: Weak recommendation; alternative approaches likely to be
better for some patients under some circumstances

**2C**\
*Clarity of Risk-Benefit*: Unclear\
*Methodologic Strength of Supporting Evidence*: Observational studies\
*Implications*: Very weak recommendation; other alternatives may be
equally reasonable

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is identified in the
\"Major Recommendations\" field.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Relief of symptoms

-   Decreased mortality and morbidity

-   Prevention of stroke

-   Cardioversion/restoration and maintenance of sinus rhythm

-   Prevention of thromboembolism

#### POTENTIAL HARMS

**Rhythm Control**

In the Atrial Fibrillation Follow-up Investigation of Rhythm Management
(AFFIRM) trial, patients who were older than age 65 years, who did not
have congestive heart failure, and who had coronary heart disease showed
a trend towards increased mortality.

The Rate Control versus Electrical (RACE) cardioversion trial found a
trend for increased mortality in the rhythm-control group in patients
with hypertension and in women.

**Pharmacological Rate Control; Conversion**

Refer to the evidence synthesis in the original guideline document for a
discussion of side effects reported in clinical trials.

*Anticoagulation*

Warfarin is associated with an increase in major bleeding risk.

**Antiarrhythmic Therapy**

The risk for torsades de pointes and other ventricular arrhythmias
should be considered when choosing which antiarrhythmic agents to use
for maintenance of sinus rhythm. However, the true risks of each
antiarrhythmic agent are not well elucidated in the literature. Refer to
the evidence synthesis in the original guideline document.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Flecainide is contraindicated in patients with previous myocardial
infarction.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Clinical practice guidelines are \"guides\" only and may not apply
    to all patients and all clinical situations. Thus, they are not
    intended to override clinicians´ judgment. All American College of
    Physicians clinical practice guidelines are considered automatically
    withdrawn, or invalid, 5 years after publication, or once an update
    has been issued.

-   The authors of the guideline are responsible for its contents,
    including any treatment recommendations. No statement in this
    article should be construed as an official position of the Agency
    for Healthcare Research and Quality or the U.S. Department of Health
    and Human Services.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Snow V, Weiss KB, LeFevre M, McNamara R, Bass E, Green LA, Michl K,
Owens DK, Susman J, Allen DI, Mottur-Pilson C. 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 2003 Dec 16;139(12):1009-17. \[57
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14678921)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Dec 16

#### GUIDELINE DEVELOPER(S)

American Academy of Family Physicians - Medical Specialty Society\
American College of Physicians - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Physicians and American Academy of Family Physicians

#### GUIDELINE COMMITTEE

Joint American College of Physicians (ACP)/American Academy of Family
Physicians (AAFP) Panel on Atrial Fibrillation and ACP\'s Clinical
Efficacy Assessment Subcommittee (CEAS) and AAFP Commission on Clinical
Policies and Research

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Vincenza Snow, MD; Kevin B. Weiss, MD, MPH; Michael LeFevre,
MD, MSPH; Robert McNamara, MD, MHS; Eric Bass, MD, MPH; Lee A. Green,
MD, MPH; Keith Michl, MD; Douglas K. Owens, MD; Jeffrey Susman, MD;
Deborah I. Allen, MD; and Christel Mottur-Pilson, PhD, the Joint
AAFP/ACP Panel on Atrial Fibrillation

*Clinical Efficacy Assessment Subcommittee Members*: Kevin Weiss, MD,
MPH (*Chair*); Mark Aronson, MD; Patricia Barry, MD, MPH; J. Thomas
Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Douglas
K. Owens, MD; Katherine D. Sherif, MD

*American Academy of Family Physicians Commission on Clinical Policies
and Research Members*: Martin C. Mahoney, MD, PhD (*Chair*); Larry S.
Fields, MD; Richard D. Clover, MD; Deborah I. Allen, MD; Doug
Campos-Outcalt, MD; Martin L. Kabongo, MD, PhD; Evelyn L. Lewis, MD, MA;
Kevin C. Oeffinger, MD; Eric M. Wall, MD, MPH; Kevin A. Peterson, MD,
MPH; Michael Rhea King, MD; Christine Albrecht; Herbert F. Young, MD,
MA; and Bellinda K. Schoof.

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

*Consultancies*: R.L. McNamara (Aventis, EU3)

*Grants received*: L.J. Tamariz (National Heart, Lung, and Blood
Institute)

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the American College of Physicians
(ACP) Web site:

-   [HTML Format](http://www.annals.org/cgi/content/full/139/12/1009#FN)

-   [Portable Document Format
    (PDF)](http://www.annals.org/cgi/reprint/139/12/1009.pdf)

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Management of atrial fibrillation: review of the evidence for the
    role of pharmacologic therapy, electrical cardioversion, and
    echocardiography. Ann Intern Med 2003 Dec 16;139(12):1018-34.

Electronic copies: Available from the American College of Physicians
(ACP) Web site:

-   [HTML Format](http://www.annals.org/cgi/content/full/139/12/1018)

-   [Portable Document Format
    (PDF)](http://www.annals.org/cgi/reprint/139/12/1018.pdf)

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

#### PATIENT RESOURCES

The following is available:

-   Summaries for patients. Management of newly detected atrial
    fibrillation: recommendations from the American College of
    Physicians and the American Academy of Family Physicians. Ann Intern
    Med 2003 Dec 16;139(12):I32.

Electronic copies: Available from the American College of Physicians
(ACP) Web site:

-   [HTML Format](http://www.annals.org/cgi/content/summary/139/12/1018)

-   [Portable Document Format
    (PDF)](http://www.annals.org/cgi/summary_pdf/139/12/1018.pdf)

Print copies: Available from the American College of Physicians (ACP),
190 N. Independence Mall West, Philadelphia PA 19106-1572.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on May 20, 2004. The information
was verified by the guideline developer on June 4, 2004. This summary
was updated by ECRI on March 6, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Coumadin (warfarin sodium). This
summary was updated by ECRI Institute on September 7, 2007 following the
revised U.S. Food and Drug Administration (FDA) advisory on Coumadin
(warfarin).

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008