Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians 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. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Distribution and Risk Profile of Paroxysmal, Persistent, and Permanent Atrial Fibrillation in Routine Clinical Practice: Insight From the Real-Life Global Survey Evaluating Patients With Atrial Fibrillation International Registry Advanced Age, Anticoagulation Intensity, and Risk for Intracranial Hemorrhage among Patients Taking Warfarin for Atrial Fibrillation Management of atrial fibrillation by primary care physicians in Germany: baseline results of the ATRIUM registry Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Ibutilide to expedite ED therapy for recent-onset atrial fibrillation flutter. A single-center randomized, controlled trial investigating the efficacy of a mHealth ECG technology intervention to improve the detection of atrial fibrillation: the iHEART study protocol ESC-EURObservational Research Programme: the Atrial Fibrillation Ablation Pilot Study, conducted by the European Heart Rhythm Association. Superiority of ibutilide (a new class III agent) overdl-sotalol in converting atrial flutter and atrial fibrillation The cost-effectiveness of ibutilide versus electrical cardioversion in the conversion of atrial fibrillation and flutter to normal rhythm. The prevalence, incidence, management and risks of atrial fibrillation in an elderly Chinese population: a prospective study Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. [A longitudinal study on left atrial thrombosis in patients with non-rheumatic atrial fibrillation treated with anticoagulants]. Unexpected low prevalence of atrial fibrillation in cryptogenic ischemic stroke: a prospective study Rising Rates of Hospital Admissions for Atrial Fibrillation [Sotalol and quinidine/verapamil (Cordichin) in chronic atrial fibrillation--conversion and 12-month follow-up--a randomized comparison]. Atrial pacing for the prevention of atrial fibrillation after cardiovascular surgery. Positive pressure therapy in patients with cardiac arrhythmias and obstructive sleep apnea. Progression of atrial fibrillation in the REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation cohort: clinical correlates and the effect of rhythm-control therapy. Hazards of postoperative atrial arrhythmias. Chronic atrial fibrillation--epidemiologic features and 14 year follow-up: a case control study.
Atrial fibrillation is the most common type of arrhythmia in adults . It is more common as patients age ; the prevalence is 1 % among those younger than age 60 years and increases to more than 8 % in those older than age 80 years . When data are adjusted for age , men are affected more often than women . Cardiac conditions associated with the development of atrial fibrillation are hypertension , rheumatic mitral valve disease , coronary artery disease , and congestive heart failure . Noncardiac causes include hyperthyroidism , hypoxic pulmonary conditions , surgery , and alcohol intoxication . Patients with atrial fibrillation may have symptoms of hemodynamic compromise , such as irregular palpitations and lightheadedness , or more vague symptoms , such as malaise , but may be asymptomatic . Patients with atrial fibrillation are at increased risk for thromboembolic disease . The purpose of this guideline is to make recommendations on the pharmacologic management of newly detected atrial fibrillation in primary care . The target patient population is adult patients with first-detected atrial fibrillation , defined as the presence of symptoms or electrocardiographic evidence of atrial fibrillation . The American College of Cardiology/American Heart Association has recommended using first-detected atrial fibrillation regardless of whether it is symptomatic or self-limited , recognizing that there can be uncertainty about the duration of the episode and about previous undetected episodes ( 1 ) . This guideline does not apply to patients with postoperative or postmyocardial infa rct ion 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 . This guideline is based on the accompanying background paper by McNamara and colleagues ( 2 ) and on the evidence report Management of New-Onset Atrial Fibrillation ( 3 ) , which was produced by the Johns Hopkins Evidence -based Practice Center under contract to the Agency for Healthcare Research and Quality ( AHRQ ) , Rockville , Maryl and . The American Academy of Family Physicians ( AAFP ) and the American College of Physicians ( ACP ) created this guideline in collaboration . The Joint AAFP/ACP Panel review ed the evidence and developed and grade d the recommendations ( Table 1 ) . The guideline was then approved by both organizations . The guideline makes recommendations in the following areas : rate control versus rhythm control , stroke prevention and anticoagulation , electrical cardioversion versus pharmacologic cardioversion , the role of transesophageal echocardiography in guiding therapy , and maintenance therapy . Table 1 . The Guyatt Approach to Grading Recommendations * Section 1 : Rate Control versus Rhythm Control One of the fundamental questions in the management of atrial fibrillation is whether to attempt cardioversion . The answer to this question depends on whether rate control or rhythm control provides more effective protection from thromboembolic events , improved mortality , better relief of symptoms , or improved quality of life . Another significant clinical question is whether certain population s , such as women , patients with hypertension or congestive heart failure , or young people with structurally healthy hearts , have better outcomes with one or the other strategy . Four studies have compared rate control with rhythm control . The study sample s have generally involved older patients ( > 65 years of age ) , and women and younger patients with healthy hearts and paroxysmal atrial fibrillation have not been well represented ( 5 ) . The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) trial compared rhythm control versus rate control , and use of anticoagulation was recommended in both arms ( 6 ) . More than 4000 patients who were at least 65 years of age or who had at least 1 risk factor for stroke or death , such as hypertension , diabetes , previous stroke , or poor ventricular function , were followed for a mean of 3.5 years . Slightly more than one third of the patients were enrolled after their first episode of atrial fibrillation , and more than 90 % had had their qualifying episode within the previous 6 weeks . In more than two thirds of patients , the qualifying episode lasted at least 2 days . The average patient age was 70 years . Sixty-one percent of patients were men , and 89 % were white . Seventy-one percent of patients had hypertension , 38 % had coronary heart disease , 18 % had previously had failure of antiarrhythmic therapy , and 12 % had no apparent heart disease ( lone atrial fibrillation ) . Patients were r and omly assigned to rate or rhythm control , and their physicians chose the specific therapies ( pharmacologic first , then nonpharmacologic if needed ) . Anticoagulation was continued indefinitely in the rate-control group and was encouraged in the rhythm-control group but could be stopped at the physician 's discretion if sinus rhythm had been maintained for at least 4 , and preferably 12 , consecutive weeks with antiarrhythmic therapy . The prevalence of sinus rhythm in the rhythm-control group was 82 % , 73 % , and 63 % at 1 , 3 , and 5 years , respectively . The prevalence of sinus rhythm in the rate-control group was 34.6 % at 5 years . The primary end point in the AFFIRM trial , overall mortality , was not statistically significantly different between the groups . However , the rhythm-control strategy was associated with a higher risk for death than the rate-control strategy among older patients , those without congestive heart failure , and those with coronary disease .  Rates of stroke also did not differ between groups ; 70 % of all strokes occurred in patients who had stopped receiving anticoagulation or who had subtherapeutic international normalized ratios ( < 2.0 ) . More hospitalizations were reported in the rhythm-control group ( P < 0.001 ) . Another recent study , the RAte Control versus Electrical cardioversion for persistent atrial fibrillation ( RACE ) study , r and omly assigned patients to receive aggressive rhythm control or rate control ( 7 ) . This was a smaller study , involving 522 patients ( mean age , 68 years ) . Sixty-four percent of patients were men , 49 % had hypertension , and 27 % had coronary artery disease . All patients had persistent atrial fibrillation lasting less than 1 year and had had at least 1 previous electrical cardioversion ( a maximum of 2 previous cardioversions was permitted for study inclusion ) . The primary end point was a composite of cardiovascular mortality , heart failure , thromboembolic complications , bleeding , pacemaker implantation , and severe side effects of antiarrhythmic drugs . Again , no difference was seen between groups in the primary composite end point . As in the AFFIRM study , most of the strokes occurred in patients whose anticoagulation had been halted or patients whose international normalized ratio was subtherapeutic ( < 2.0 ) . In post hoc analysis , a benefit for rate control over rhythm control was seen in patients with hypertension and in women . Since this was a post hoc analysis , these results will need to be confirmed by further studies . Of note , despite an aggressive treatment protocol , at the end of follow-up only 39 % of the patients in the rhythm-control group were in sinus rhythm . The Pharmacological Intervention in Atrial Fibrillation ( PIAF ) trial r and omly assigned 252 patients 18 to 75 years of age with new-onset or permanent symptomatic atrial fibrillation ( mean duration of atrial fibrillation , approximately 4 months ) to rate control with diltiazem or aggressive conversion ( many times if necessary ) and maintenance therapy with amiodarone ( 8) . The primary end point of the study was improvement in symptoms related to atrial fibrillation . After 1 year of follow-up , relief of symptoms was similar in both groups , as were quality -of-life measures . Walking distance was improved in the rhythm-control group , but hospital admissions were more frequent in this group . Although final results are not yet available , preliminary reports of the Strategies of Treatment of Atrial Fibrillation ( STAF ) trial have been presented ( 9 ) . Patients were r and omly assigned to receive anticoagulation for 3 weeks before conversion and for 4 weeks after attempted conversion , with antiarrhythmic therapy to maintain sinus rhythm , or to long-term anticoagulation and rate control . ( Patients included in this study had at least 1 previous conversion attempt . ) After more than 1.5 years of follow-up , no difference was seen between the groups in rates of the primary end points of death , stroke , transient ischemic attacks , cardiopulmonary resuscitation , or thromboembolism . Of interest , only 40 % of patients in the rhythm-control group were still in sinus rhythm at 1 year , and all primary end points occurred in patients in atrial fibrillation , even in the rhythm-control group . This result has created speculation about whether fewer events would have occurred if anticoagulation had been continued indefinitely in the conversion group . It also suggests that despite aggressive rhythm management , a substantial number of patients can not maintain sinus rhythm . In general , the trial sample s were older and male and had risk factors for stroke , such as hypertension , congestive heart failure , and coronary disease . Certain subgroups of patients with atrial fibrillation , such as younger patients with healthy hearts or paroxysmal atrial fibrillation , were not well represented in the trials . Therefore , it is not certain whether these subgroups of patients may benefit from more aggressive rhythm control or rate control . 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 ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on Atrial  fibrillation ( AF ) is a common arrhythmia in elderly persons and a common cause of embolic stroke . Most studies of the prevalence and correlates of AF have used selected , hospital-based population s. The Cardiovascular Health Study is a population -based , longitudinal study of risk factors for coronary artery disease and stroke in 5,201 men and women aged > or = 65 years .  AF  was diagnosed in 4.8 % of women and in 6.2 % of men at the baseline examination , and prevalence was strongly associated with advanced age in women . Prevalence of AF  was 9.1 % in men and women with clinical cardiovascular disease , 4.6 % in patients with evidence of sub clinical but no clinical cardiovascular disease , and only 1.6 % in subjects with neither clinical nor sub clinical cardiovascular disease . A history of congestive heart failure , valvular heart disease and stroke , echocardiographic evidence of enlarged left atrial dimension , abnormal mitral or aortic valve function , treated systemic hypertension , and advanced age were independently associated with the prevalence of AF .  The low prevalence of AF in the absence of clinical and sub clinical cardiovascular disease calls into question the existence and clinical usefulness of the concept of so-called " lone atrial fibrillation " in the elderly Background — There is a paucity of international data on the various types of atrial fibrillation ( AF ) outside the highly selected population s from r and omized trials . This study aim ed to describe patient characteristics , risk factors , comorbidities , symptoms , management strategy , and control of different types of AF in real-life practice . Methods and Results — Real-life global survey evaluating patients with atrial fibrillation ( RealiseAF ) was a contemporary , large-scale , cross-sectional international survey of patients with AF who had ≥1 episode in the past 12 months . Investigators were r and omly selected to avoid bias . Among 9816 eligible patients from 831 sites in 26 countries , 2606 ( 26.5 % ) had paroxysmal , 2341 ( 23.8 % ) had persistent , and 4869 ( 49.6 % ) had permanent AF . As AF progressed from paroxysmal to persistent and permanent forms , the prevalence of comorbidities , such as heart failure ( 32.9 % , 44.3 % , and 55.6 % ) , coronary artery disease ( 30.0 % , 32.9 % , and 34.3 % ) , cerebrovascular disease ( 11.7 % , 10.8 % , and 17.6 % ) , and valvular disease ( 16.7 % , 21.2 % , and 35.8 % ) , increased , and the prevalence of lone AF decreased . Similarly , there was an increase in mean CHADS2 [ cardiac failure , hypertension , age , diabetes , stroke ( doubled ) ] score ( 1.7 , 1.8 , and 2.2 ) , and more than half of patients ( 51.0 % , 56.7 % , and 67.3 % ) qualified for oral anticoagulants . Almost 90 % of patients received ≥1 antiarrhythmic drug , but > 60 % had European Heart Rhythm Association symptom scores from II to IV . Furthermore , 40.7 % of persistent and 49.8 % of permanent AF patients were still in AF with a heart rate > 80 beats per minute . Conclusions — This survey disclosed high cardiovascular risks and an unmet need in daily practice for patients with any type of AF , especially those with the permanent form Context The appropriate level of warfarin anticoagulation in elderly patients with atrial fibrillation has been debated because of an age-associated increase in intracerebral hemorrhage . Contribution Patients with atrial fibrillation and intracerebral hemorrhage who were receiving anticoagulation were matched with similar patients who did not develop intracerebral hemorrhage . Although intracerebral hemorrhage was associated with increasing age ( especially > 85 years ) and increasing international normalized ratios ( INRs ) ( especially > 3.5 ) , the incidence of intracerebral hemorrhage was not statistically different in patients with INRs less than 2.0 and those with INRs between 2.0 and 3.0 . This was true even among those older than 75 years of age . Implication s Risk for intracerebral hemorrhage is not diminished in elderly patients with atrial fibrillation when anticoagulation is maintained below an INR of 2.0 . The Editors Intracranial hemorrhage is the most dangerous complication of warfarin anticoagulant therapy because of its high short-term risk for death and severe neurologic deficit ( 1 - 5 ) . Warfarin is extremely effective in reducing the risk for ischemic stroke associated with atrial fibrillation ( 6 , 7 ) . However , fear of hemorrhage may prompt some physicians to avoid prescribing anticoagulation ( 8) , especially in elderly patients , who appear to have a higher risk for hemorrhage ( 8 - 13 ) . Prominent recent guidelines recommend using lower-intensity anticoagulation for the primary prevention of stroke in patients older than 75 years of age who have atrial fibrillation ( 14 ) and suggest a target international normalized ratio ( INR ) range of 1.6 to 2.5 , despite evidence that the risk for ischemic stroke increases sharply at INRs less than 2.0 ( 15 , 16 ) . Previous studies have not thoroughly addressed the relationship of age and anticoagulation intensity to the risk for intracranial hemorrhage among patients with atrial fibrillation ( 1 , 2 ) . A study of 121 patients with warfarin-associated intracranial hemorrhage used the now-out date d prothrombin time ratio as a measure of anticoagulation intensity and did not specifically address risk in patients with atrial fibrillation ( 1 ) . Earlier studies also included patients receiving anticoagulation for mechanical valves , whose risk-to-benefit ratio is different from that of patients with atrial fibrillation ( 1 , 2 , 17 ) . As the number of individuals with atrial fibrillation increases ( 18 - 21 ) and as a greater proportion of older adults receive anticoagulant therapy ( 22 ) , more precise data are needed about the association of age , INR , and risk for intracranial hemorrhage . Intracranial hemorrhage , although critically important , is an uncommon complication among patients with atrial fibrillation who are receiving anticoagulation . As a result , r and omized trials and cohort studies have difficulty accumulating enough hemorrhage events to powerfully assess risk factors . To address these limitations , we performed a large casecontrol study to evaluate the relationship of increasing age and INR to the risk for intracranial hemorrhage among patients with nonvalvular atrial fibrillation . Methods Case- Patients We performed a casecontrol study comparing 2 groups : 1 ) case- patients with nonvalvular atrial fibrillation who developed intracranial hemorrhage while taking warfarin and 2 ) controls who were receiving anticoagulation for nonvalvular atrial fibrillation but did not develop intracranial hemorrhage . We found potential case- patients using the Partners HealthCare System Research Patient Data Registry , which can identify patients with specific International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) diagnoses by search ing the Massachusetts General Hospital billing system . We search ed for patients 18 years of age or older who had diagnoses of atrial fibrillation ( ICD-9-CM code 427.31 ) and intracranial hemorrhage ( ICD-9-CM codes 430 , 431 , 432.0 , 432.1 , 432.9 ) at any time from October 1993 to June 2002 . By 1993 , nearly all prothrombin time ratios at the hospital were reported as INRs . We review ed medical records to confirm whether patients were eligible , that is , whether they had intracranial hemorrhage documented by computed tomography or magnetic resonance imaging and documentation of warfarin therapy for atrial fibrillation at the time of the event . We excluded patients who were not taking warfarin at the time of hemorrhage ; those who were receiving anticoagulation for rheumatic heart disease , mitral stenosis , or mechanical valve placement ; those whose event was an ischemic stroke with hemorrhagic conversion ; or those in whom clinical factors may have led to hemorrhage independent of warfarin therapy . These factors included underlying anatomic brain abnormalities ( such as tumors or aneurysms ) , antecedent major head trauma ( skull fracture , trauma with loss of consciousness , motor vehicle injury , or neurosurgical procedures ) , or platelet count less than 50 109 cells/L. Starting in July 1994 , consecutive patients with intracerebral hemorrhage have been enrolled through the Massachusetts General Hospital emergency department as part of a longitudinal cohort study ( 23 ) . To vali date our automated search strategy , we compared our case-patient list with the list of patients identified through the cohort study and found that our search strategy missed only 4 patients with intracerebral hemorrhage . We obtained data on patient date of birth , sex , and ethnicity from computerized records . The type of hemorrhage ( intracerebral , subdural , subarachnoid , intraventricular , or epidural ) was determined through review of radiology reports . Data on presenting symptoms , history of minor head trauma , concomitant aspirin use , and disposition status were obtained from review of the admission medical record and were recorded on a st and ardized data collection form . We recorded the INR measurement obtained closest to the onset of symptoms . If an INR was not available or fresh frozen plasma or vitamin K was administered before the measurement , we considered INR data missing . We review ed medical charts for documentation of the following comorbid conditions : history of cerebrovascular disease ( defined as previous ischemic stroke or carotid artery disease ) , hypertension , congestive heart failure , coronary artery disease , diabetes mellitus , and cancer ( excluding nonmelanoma skin cancer ) . Controls Controls were sample d from patients managed by the Massachusetts General Hospital Anticoagulation Management Services clinic , which followed approximately 1000 patients receiving anticoagulation for atrial fibrillation at any given time during the study period . All patients who were followed in the anticoagulation clinic , received anticoagulation for atrial fibrillation , and had an INR measurement obtained in the same month and year as the given case date were assigned a r and om number . Six controls per case-patient were then r and omly selected . We matched case- patients to controls by INR date to account for any technical changes in INR testing that may have occurred over time . Because of this sampling method , an individual patient could potentially serve as a control for more than 1 case-patient ( 24 ) . Like case- patients , controls were 18 years of age or older ; were receiving anticoagulation for atrial fibrillation ; and had no documented rheumatic heart disease , mitral stenosis , or valve replacement . We sought data on potential confounders of the association of age , INR , and risk for intracranial hemorrhage , focusing on relevant comorbid conditions and combined use of aspirin with warfarin . We review ed available computerized discharge summaries , outpatient clinic notes , and medication lists from up to 2 years before the admission date . If combination warfarin and aspirin use was not documented , patients were considered to not be taking aspirin . Statistical Analysis Case- patients were categorized by type of hemorrhage : intracerebral , subdural , and other ( subarachnoid , intraventricular , or epidural ) . Clinical differences between types of hemorrhage were compared by using the KruskalWallis test for continuous variables ( age and INR ) and chi-square tests for categorical variables . We compared case- patients with controls by using multivariable conditional logistic regression , matching on INR date . Patient age was divided into 5-year intervals that were coded as indicator variables , and the odds of intracranial hemorrhage for each interval were compared with the odds of hemorrhage at a referent age of 70 to 74 years . The INR was divided into a set of ordered intervals that were coded as indicator variables . The relative odds for intracranial hemorrhage at each interval were calculated by using an INR of 2.0 to 3.0 as the referent category . In addition to age , INR , sex , and ethnicity , the following variables were included in the multivariable models to control for potential confounding effects of clinical factors and aspirin use : cerebrovascular disease , hypertension , congestive heart failure , coronary artery disease , diabetes mellitus , cancer , and concomitant aspirin use . If no records were available for review , comorbid conditions and aspirin use were coded as missing . We used multiple imputations for missing data on ethnicity , comorbid conditions , and aspirin use ( 25 ) . We tested for interactions between age and INR and comorbid conditions using 2-way interactions . None of the interaction terms were included in the model if they were not statistically significant when tested collectively . We tested the model 's goodness of fit using the HosmerLemeshow method ( 26 ) . Because the hospital 's anticoagulation clinic did not follow some case- patients before the event , and since factors relating to differences in outpatient care and monitoring could have confounded our analyses , we repeated these analyses in the subgroup of case- patients managed by the anticoagulation clinic . These restricted analyses Background In contrast to surveys in cardiologist setting s , presentation and management of  atrial fibrillation ( AF ) in primary care patients is less well studied . Methods and results The prospect i ve ATRIUM ( OutpatientRegistry Upon Morbidity of Atrial Fibrillation ) collected data from patients with AF seen by 730 physicians representing a r and om sample of all primary care physicians in Germany . ATRIUM enrolled 3,667 patients ( mean age , 72 ± 9 years ; 58 % male , mean CHADS2 score 2.2 ± 1.3 ) , 994 ( 27.1 % ) with paroxysmal , 944 ( 25.7 % ) with persistent or long-st and ing persistent and 1,525 ( 41.6 % ) with permanent AF ( no AF type was specified in 204 patients ) . Mean duration since initial diagnosis of AF was 61 ± 66 months ( median 42 , interquartile range 14–88 ) . Reported symptoms included palpitations ( 43 % ) , shortness of breath ( 49 % ) , fatigue ( 49 % ) , dizziness ( 37 % ) and angina ( 20 % ) . Most common concomitant conditions were hypertension ( 84 % ) , heart failure ( 43 % ) , coronary artery disease ( 345 % ) , diabetes ( 35 % ) and chronic kidney disease ( 20 % ) . Prior myocardial infa rct ion was present in 11 % of patients , prior stroke in 10 % and prior transient ischemic attack in 10 % .  Antithrombotic medication was used by 93 % of the patients ( oral anticoagulants , 83 % ) .  Rate control  therapy was reported in 75 % and rhythm control therapy in 33 % , often added to rate control . Drugs for rhythm and rate control included ß-blockers ( 75 % ) , calcium antagonists ( 15 % ) , digitalis ( 29 % ) , sodium channel blockers of type IA ( quinidine , 1.0 % ) or IC ( flecainide or propafenone , 5 % ) , and potassium channel blockers including amiodarone ( 11 % ) . In the year prior to enrollment , 46 % of the patients had been cardioverted ( 23 % by drugs , 22 % electrically ) , catheter ablation had been performed in 5 % , and 10 % received a pacemaker or  defibrillator . A high proportion ( 44 % ) of the patients were hospitalized in the year prior to enrollment . Conclusions Patients with AF managed in primary care often receive guideline -conforming therapy including antithrombotic therapy , rate control and rhythm control ( numbers given above ) . Despite this apparent adherence , almost half of the patients were hospitalized in the year prior to enrollment , suggesting that the therapies applied do not stabilize patients sufficiently to keep them out of hospital The present study was undertaken to reassess prospect ively the immediate and long-term results of direct-current electrical cardioversion in chronic atrial fibrillation or atrial flutter , and to determine factors predicting clinical outcome of the arrhythmia after direct-current cardioversion .  Two-hundred forty-six patients underwent direct-current electrical cardioversion  and were followed during a mean of 260 days . Multivariate analysis was used to identify factors predicting short- and long-term arrhythmia outcome . Cardioversion was achieved in 70 % of patients with atrial fibrillation and in 96 % of patients with atrial flutter . Stepwise logistic regression analysis revealed that arrhythmia duration ( p less than 0.001 ) , type of arrhythmia ( fibrillation vs flutter , p less than 0.02 ) and age ( p less than 0.05 ) independently influenced conversion rate . On an actuarial basis , 42 and 36 % of patients remained in sinus rhythm during 1 and 2 years , respectively . Multivariate regression analysis revealed that the type of arrhythmia ( p = 0.0008 ) , low precardioversion functional class ( p = 0.002 ) and the presence of nonrheumatic mitral valve disease ( p = 0.03 ) independently increased the length of the arrhythmia-free episode . Rheumatic heart disease shortened this period ( p = 0.03 ) . In conclusion , patients having a high probability of conversion together with a prolonged post-shock arrhythmia-free episode can be identified . This may improve the cost-benefit ratio of cardioversion OBJECTIVE Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation ( AF ) and atrial flutter ( AFl ) . Previous studies conducted outside the ED setting have demonstrated conversion rates of 60 % to 80 % . This response has been highest in patients with recent-onset AF-AFl . These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED . The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days ' duration , neither angina nor heart failure , and no comorbid conditions that require admission . METHODS Among 36 enrolled patients , the admission electrocardiogram demonstrated AF in 26 and AFl in 10 .  Ibutilide 1 mg was administered intravenously for 10 minutes . If sinus rhythm was not present 10 minutes after the infusion concluded , a second infusion of 1 mg was given . Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide . RESULTS Sixteen ( 61.5 % ) of 26 patients with AF and 9 ( 90 % ) of 10 patients with AFl converted to sinus rhythm ( overall conversion rate=69 % ) . The mean time to arrhythmia termination was 19+/-9 minutes . The mean stay in the ED was 16.2 hours . No significant complications occurred . CONCLUSION We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED . Its use may obviate the need for admission , avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion , and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias Background Atrial fibrillation is a major public health problem and is the most common cardiac arrhythmia , affecting an estimated 2.7 million Americans . The true prevalence of atrial fibrillation is likely underestimated because episodes are often sporadic ; therefore , it is challenging to detect and record an occurrence in a “ real world ” setting . To date , mobile health tools that promote earlier detection and treatment of atrial fibrillation and improvement in self-management behaviors and knowledge have not been evaluated . This study will be the first to address the epidemic problem of atrial fibrillation with a novel approach utilizing advancements in mobile health electrocardiogram technology to empower patients to actively engage in their healthcare and to evaluate impact on quality of life and quality -adjusted life years . Furthermore , sending a daily electrocardiogram transmission , coupled with receiving educational and motivational text messages aim ed at promoting self-management and a healthy lifestyle may improve the management of chronic cardiovascular conditions ( e.g. , hypertension , diabetes , heart failure , etc . ) . Therefore , we are currently conducting a r and omized controlled trial to assess the efficacy of a mobile health intervention , iPhone ® Helping Evaluate Atrial fibrillation Rhythm through Technology ( iHEART ) versus usual cardiac care . Methods The iHEART study is a single center , prospect i ve , r and omized controlled trial . A total of 300 participants with a recent history of atrial fibrillation will be enrolled . Participants will be r and omized 1:1 to receive the iHEART intervention , receiving an iPhone ® equipped with an AliveCor ® Mobile ECG and accompanying Kardia application and behavioral altering motivational text messages or usual cardiac care for 6 months . Discussion This will be the first study to investigate the utility of a mobile health intervention in a “ real world ” setting . We will evaluate the ability of the iHEART intervention to improve the detection and treatment of recurrent atrial fibrillation and assess the intervention 's impact on improving clinical outcomes , quality of life , quality -adjusted life-years and disease-specific knowledge . Trial registration NCT02731326 ; Verified April AIMS The Atrial Fibrillation Ablation Pilot Study is a prospect i ve , multinational registry conducted by the European Heart Rhythm Association of the European Society of Cardiology that has been design ed to describe the clinical epidemiology of patients undergoing an atrial fibrillation ( AFib ) ablation procedure  , and the diagnostic/therapeutic processes applied in these patients across Europe . We present the results of the short-term ( in-hospital ) analysis . METHODS AND RESULTS A total of 72 centres in 10 European countries were asked to enrol 20 consecutive patients scheduled for a first AFib ablation procedure . Between October 2010 and May 2011 , 1410 patients were included , of which 1391 underwent an AFib ablation ( 98.7 % ) . The median age was 60 years [ inter-quartile range ( IQR ) 52 - 66 ] , and 28 % were females . Two-thirds presented paroxysmal AFib and 38 % lone AFib . Symptoms were present in 86 % . The indications for ablation were mostly symptomatic AFib , but in over a third of patients there was also a desire for a drug-free lifestyle and the maintenance of sinus rhythm . Pulmonary vein isolation was attempted in 98.4 % of patients , the roof line in 21.3 % and the mitral isthmus line in 12.8 % . Complex-fractionated atrial electrograms were targeted in 17.9 % and the ganglionated plexi in 3.3 % . Complications occurred in 7.7 % , of which 1.7 % was major ( i.e. cardiac perforation , myocardial infraction , endocarditis , cardiac arrest , stroke , hemothorax , pneumothorax , and sepsis ) . The median duration of hospitalization was 3 days ( IQR 2 - 4 ) . At discharge , 91.4 % of patients were in sinus rhythm , 88.3 % of patients were given vitamin K antagonists , and 67 % antiarrhythmic medication . There was one death after the ablation procedure . CONCLUSION The AFib Ablation Pilot Study provides crucial information on AF ablation in clinical practice across Europe . These data are relevant for further improvement of the management strategies of patients suffering from atrial fibrillation Objective To compare the efficacy and safety of a single dose of ibutilide , a new class III antiarrhythmic drug , with that of dl-sotalol in terminating chronic atrial fibrillation or flutter in haemodynamically stable patients . Design Double blind , r and omised study . Setting 43 European hospitals . Patients 308 patients ( mean age 60 years , 70 % men , 48 % with heart disease ) with sustained atrial fibrillation ( n = 251 ) or atrial flutter ( n = 57 ) ( duration three hours to 45 days ) were r and omised to three groups to receive a 10 minute infusion of 1 mg ibutilide ( n = 99 ) , 2 mg ibutilide ( n = 106 ) , or 1.5 mg/kg dl-sotalol ( n = 103 ) . Infusion was discontinued at termination of the arrhythmia . Main outcome measure Successful conversion of atrial fibrillation or flutter , defined as termination of arrhythmia within one hour of treatment . Results Both drugs were more effective against atrial flutter than against atrial fibrillation .  Ibutilide was superior to dl-sotalol for treating atrial flutter ( 70 % and 56%v 19 % ) , while the high dose of ibutilide was more effective for treating atrial fibrillation than dl-sotalol ( 44 % v 11 % ) and the lower dose of ibutilide ( 44%v 20 % , p < 0.01 ) . The mean ( SD ) time to arrhythmia termination was 13 ( 7 ) minutes with 2 mg ibutilide , 19 ( 15 ) minutes with 1 mg ibutilide , and 25 ( 17 ) minutes with dl-sotalol . In all patients , the duration of arrhythmia before treatment was a predictor of arrhythmia termination , although this was less obvious in the group that received 2 mg ibutilide . This dose converted almost 48 % of atrial fibrillation that was present for more than 30 days . Concomitant use of digitalis or nifedipine and prolongation of the QTc interval were not predictive of arrhythmia termination . Bradycardia ( 6.5 % ) and hypotension ( 3.7 % ) were more common side effects withdl-sotalol . Of 211 patients given ibutilide  , two ( 0.9 % ) who received the higher dose developed polymorphic ventricular tachycardia , one of whom required direct current cardioversion . Conclusion Ibutilide ( given in 1 or 2 mg doses over 10 minutes ) is highly effective for rapidly terminating persistent atrial fibrillation or atrial flutter . This new class III drug , under monitored conditions , is a potential alternative to currently available cardioversion options Atrial fibrillation and atrial flutter are cardiac rhythm disorders that are often symptomatic and may interfere with the heart 's function , limiting its effectiveness . These arrhythmias are responsible for a large number of hospitalizations at a significant cost to the healthcare system . Electrical cardioversion ( EC ) is the most common nonpharmacologic intervention used to convert atrial fibrillation and atrial flutter to normal rhythm . Electrical cardioversion is highly successful in converting patients to normal rhythm ; however , it is more traumatic and re source intensive than pharmacologic treatment . Recently , a new rapid-acting drug , ibutilide , was approved for the conversion of atrial fibrillation and atrial flutter . Ibutilide is administered through intravenous infusion and does not require anesthetization of the patient , as is required for EC . A decision-tree model was developed to estimate the cost-effectiveness of ibutilide therapy compared with EC therapy . Clinical outcomes were based on a phase III trial of ibutilide , and re source use was based on the literature and physician clinical judgment . A stepped conversion regimen of first-line ibutilide followed by EC for patients who fail to convert is less expensive and has a higher conversion rate than first-line EC . Sensitivity analysis shows that our results are robust to changes in cost and effectiveness estimates Background There is limited information on prevalent and incident atrial fibrillation in Chinese . We aim ed to investigate the prevalence , incidence , management and risks of atrial fibrillation in an elderly Chinese population . Methods In a population —based prospect i ve study in elderly ( ≥60 years ) Chinese , we performed cardiovascular health examinations including a 12-lead electrocardiogram at baseline in 3,922 participants  and biennially during follow-up in 2,017 participants . We collected information on vital status during the whole follow-up period . Results The baseline prevalence of atrial fibrillation was 2.0 % ( n = 34 ) in 1718 men and 1.6 % ( n = 36 ) in 2204 women . During a median 3.8 years of follow-up , the incidence rate of atrial fibrillation ( n = 34 ) was 4.9 per 1000 person-years ( 95 % confidence interval [ CI ] , 3.4–6.9 ) . In univariate analysis , both the prevalence and incidence of atrial fibrillation were higher with age advancing ( P < 0.0001 ) and in the presence of coronary heart disease ( P ≤ 0.02 ) . Of the 104 prevalent and incident cases of atrial fibrillation , only 1 ( 1.0 % ) received anticoagulant therapy ( warfarin ) . These patients with atrial fibrillation , compared with those with sinus rhythm , had significantly higher risks of all-cause ( n = 261 , hazard ratio [ HR ] 1.87 , 95 % CI , 1.09–3.20 , P = 0.02 ) , cardiovascular ( n = 136 , HR 3.78 , 95 % CI 2.17–6.58 , P < 0.0001 ) and stroke mortality ( n = 44 , HR 6.31 , 95 % CI 2.81–14.19 , P = 0.0003 ) . Conclusions Atrial fibrillation was relatively frequent in elderly Chinese , poorly managed and associated with higher risks of mortality The Canadian Cardiovascular Society ( CCS ) published the complete set of 2010 Atrial Fibrillation ( AF ) Guidelines in the January , 2011 issue of the Canadian Journal of Cardiology . During its deliberations , the CCS Guidelines Committee engaged to a timely review of future evidence , with periodic composition of focused up date s to address clinical ly important advances . In 2011 , results were published from 3 pivotal AF trials : the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) , the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation ( ARISTOTLE ) study , and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of St and ard Therapy ( PALLAS ) , comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden . Each of these large r and omized trials provided clear results with major implication s for AF management . Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk , stroke risk in paroxysmal-AF patients , risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease , and risk/benefit considerations in the use of antiplatelet agents , alone and in combination with each other or with oral anticoagulants , in AF patients . The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control . This report presents the details of the new recommendations , along with the background and rationale BACKGROUND Although atrial thrombosis is common in patients with non-rheumatic atrial fibrillation ( NRAF ) ( 6 - 27 % ) , there are no studies about the effect that anticoagulant or antiplatelet drugs have on it . AIM OF THE STUDY We have investigated the role of anticoagulant therapy , followed by family physicians , on left atrial thrombosis detected via transesophageal echocardiography ( TEE ) in patients with NRAF . METHODS Sixty patients enrolled in the TASAF ( Trieste Area Study on non-rheumatic Atrial Fibrillation ) ( 60 % males , mean age 72 + /- 7 years , 17 % with lone atrial fibrillation , duration of arrhythmia 111 + /- 79 months ) , in whom we found a left atrial and /or left atrial appendage thrombus via TEE , were anticoagulated .  The thrombus was in the left atrial appendage in 57 patients and in the left atrium in the others . In 28 of them it was mobile and in 50 , the left atrial appendage flow was low or absent . Lastly , in 46 patients we found  spontaneous echocontrast  and a bilobate appendage was present in 8 of them . At follow-up , we repeated the TEE to evaluate the effect of the therapy on the atrial thrombosis . RESULTS Only 53 patients received anticoagulant therapy  ( 45 correctly ) , while 7 were treated with antiplatelet drugs by their family physicians . After a mean follow-up of 16 months , all patients underwent a repeat TEE and the thrombus was no longer evident in 35 cases ( 58 % ) . The thrombosis disappeared in 26 ( 58 % ) of the 45 patients who correctly took anticoagulant therapy and in 5 of the 8 who were not adequately anticoagulated . Moreover , we did n't observe the thrombus in 4 of the 7 patients who were treated with antiplatelet drugs . There was no significant statistical difference between the benefits of anticoagulants and antiplatelet therapy in dissolving left atrial thrombosis . During follow-up , we recorded only one embolic event in the retina . None of the patients on antiplatelet drugs complained of any side effects , whereas in 5 of the 53 on anticoagulant therapy , we recorded one fatal intracranial hemorrhage , one gastric hemorrhage and three minor complications . CONCLUSIONS Left atrial thrombosis in NRAF disappears in anticoagulated patients in an high percentage of cases ( the therapy probably acts on more recent thrombi ) . Moreover , this therapy decreases the incidence of embolic events , although it increases the risk of hemorrages . Since the management of this preventive treatment in general medicine is very difficult , we hope that our health organization will establish Anticoagulation Clinics for the central ized management of this therapy Purpose Ischemic stroke is a frequent pathology with high rate of recurrence and significant morbidity and mortality . There are several causes of stroke , affecting prognosis , outcomes , and management , but in many cases , the etiology remains undetermined . We hypothesized that atrial fibrillation was involved in this pathology but underdiagnosed by st and ard methods . The aim of the study was to determine the incidence of atrial fibrillation in cryptogenic ischemic stroke by using continuous monitoring of the heart rate over several months . The secondary objective was to test the value of atrial vulnerability assessment in predicting spontaneous atrial fibrillation . Methods and results We prospect ively enrolled 24 patients under 75 years of age , 15 men and 9 women of mean age 49 years , who within the last 4 months had experienced cryptogenic stroke diagnosed by clinical presentation and brain imaging and presumed to be of cardioembolic mechanism . All causes of stroke were excluded by normal 12-lead ECG , 24-h Holter monitoring , echocardiography , cervical Doppler , hematological , and inflammatory tests . All patients underwent electrophysiological study . Of the patients , 37.5 % had latent atrial vulnerability , and 33.3 % had inducible sustained arrhythmia . Patients were secondarily implanted with an implantable loop recorder to look for spontaneous atrial fibrillation over a mean follow-up interval of 14.5 months . No sustained arrhythmia was found . Only one patient had non-significant episodes of atrial fibrillation . Conclusion In this study , symptomatic atrial fibrillation or AF with fast ventricular rate has not been demonstrated by the implantable loop recorder  in patients under 75 years with unexplained cerebral ischemia . The use of this device should not be generalized in the systematic evaluation of these patients . In addition , this study attests that the assessment of atrial vulnerability is poor at predicting spontaneous arrhythmia in such patients Background : Atrial fibrillation is a common arrhythmia associated with excess morbidity and mortality . We studied temporal changes in hospital admission rates for atrial fibrillation using data from a prospect i ve population -based cohort study spanning 2 decades ( the Copenhagen City Heart Study ) . Methods : The study included baseline data collected in 1981 through 1983 on 10,955 persons age 40 to 79 years and baseline data collected in 1991 through 1994 on 7212 persons age 40 to 79 years . We used hospital diagnosis data from the Danish National Hospital Discharge Register to determine the rate of first hospital admission for atrial fibrillation during 7 years following each of the 2 baseline data collecting periods . Changes in admission rates were analyzed using Cox proportional hazard models . Results : During the 2 7-year periods , 379 subjects were admitted with a hospital diagnosis of atrial fibrillation . The rate of hospital admissions for atrial fibrillation increased among both men and women from the first to the second period ( relative risk = 1.6 ; 95 % confidence interval = 1.3–1.9 [ adjusted for age , sex , prior myocardial infa rct ion , arterial hypertension , diabetes mellitus , electrocardiographic left ventricular hypertrophy , decreased lung function , smoking , height , and weight ] ) . Conclusion : During the latest 10 to 20 years , there has been a 60 % increase in hospital admissions for atrial fibrillation independent of changes in known risk factors . This increase could result from changes in admission threshold or coding practice s , or it could reflect a genuine increase in the population incidence of atrial fibrillation Atrial fibrillation is one of the most common arrhythmias , leading at least in a subset of patients to severe symptoms ( palpitations , weakness , syncope ) , and to hemodynamic impairment especially in the clinical setting of left ventricular dysfunction . Thus , in many cases restauration of sinus rhythm is indicated because of the negative effects of reduced cardiac output .  Quinidine has been the first line drug for many years and has been proven to be highly effective especially when combined with Verapamil . But there is growing concern about using quinidine and other class I-anti-arrhythmic agents because of some hints in clinical trials for increased longterm mortality on these drugs . This study was undertaken to test the efficacy of Sotalol , a beta-blocker with additional strong class-III antiarrhythmic action , compared to a fixed combination of Quinidine and Verapamil for conversion of chronic atrial fibrillation and maintenance of sinus rhythm after medical or electrical cardioversion . To avoid early proarrhythmic effects , potassium values in the range of " high"-normal values ( > 4.3 mval/L ) were tried to be obtained . 82 patients were r and omly assigned to receive either  Sotalol or Quinidine/Verapamil . There was no difference between the groups as far as the underlying heart disease , duration of atrial fibrillation ( mean 219 days ) and other clinical features including echocardiographic parameters were concerned . The dose of the drug was weight-related individually adjusted , and the drug was continued thereafter . If sinus rhythm could not be established at that time , electric cardioversion was performed and the drug was continued in lower dosage thereafter . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVE The purpose of this study was to determine the efficacy of atrial pacing in the prevention of atrial fibrillation following cardiovascular surgery . BACKGROUND Although pharmacologic therapy has been used to help prevent postoperative atrial fibrillation , it suffers from limited efficacy and adverse effects . In the nonoperative setting , novel pacing strategies have been shown to reduce recurrences of atrial fibrillation and prolong arrhythmia-free periods in patients with paroxysmal atrial arrhythmias . METHODS A total of 154 patients ( 115 men ; mean age , 65 + /- 10 years ; ejection fraction , 53 + /- 10 % ) undergoing cardiac surgery ( coronary artery bypass surgery , 88.3 % ; aortic valve replacement , 4.5 % ; coronary bypass + aortic valve replacement , 7.1 % ) had right and left atrial epicardial pacing electrodes placed at the time of surgery . Patients were r and omized to either no pacing , right atrial ( RAP ) , left atrial ( LAP ) or biatrial pacing ( BAP ) for 72 h after surgery . Beta-adrenergic blocking agents were administered concurrently to all patients following surgery . RESULTS There was a reduction in the incidence of postoperative atrial fibrillation from 37.5 % in patients receiving no postoperative pacing to 17 % ( p < 0.005 ) in patients assigned to one of the three pacing strategies . The length of hospital stay was reduced by 22 % from 7.8 + /- 3.7 days to 6.1 + /- 2.3 days ( p = 0.003 ) in patients assigned to postoperative atrial pacing . The incidence of atrial fibrillation was lower in each of the paced groups ( RAP , 8 % ; LAP , 20 % ; BAP , 26 % ) compared with patients who did not receive postoperative pacing ( 37.5 % ) . CONCLUSION Postoperative atrial pacing , in conjunction with beta-blockade , significantly reduced both the incidence of atrial fibrillation and the length of hospital stay following cardiovascular surgery . Additional studies are needed to determine the most effective anatomic pacing site BACKGROUND Positive pressure therapy ( CPAP ) in patients with cardiac arrhythmias and obstructive sleep apnea ( OSAS ) may have favorable effects by correcting intermittent hypoxemia and sympathetic activation . OBJECTIVE To assess the effect of CPAP added to pharmacological treatment in the rate control and prevention of arrhythmias recurrence in patients with OSA . MATERIAL S AND METHODS Prospect i ve , interventional study study which included patients diagnosed with OSAS ( cardiorespiratorypolygraphy , AHI>5/hour ) , and arrhythmias ( ECG , Holter ECG ) , divided in two groups : group A ( pharmacological therapy only ) and group B ( pharmacological therapy and CPAP ) . The patients were evaluated at enrollment ( T0 ) , at 3 and 6 months ( T3 and T6 ) regarding the type , severity and recurrence of cardiac arrhythmias . RESULTS 36 patients ( 31 men ) , mean age : 63.2 ± 12 years were enroled . In group A : 7 patients with ventricular extrasystoles , 8 with permanent atrial fibrillation , 1 patient with atrial flutter and 2 patients with paroxystic supraventricular tachycardia . In group B : 8 patients with ventricular extrasystoles , 5 with permanent atrial fibrillation , 2 patients with recurrent episodes of atrial fibrillation and 3 with paroxystic supraventricular tachycardia . A positive correlation ( r : 0.74 , p < 0.001 ) between Oxygen Desaturation Index and AHI was found . At T6 , 12 patients from group B , and 18 from group A were evaluated . In group B , the mean heart rate in patients with atrial fibrillation was 69/min . , lower than in group A ( 82/min . ) , no cases with recurrent atrial fibrillation were found , and more patients with class II Lown ventricular extrasystoles passed in class I Lown , compared to group A. In group B , heart rate statistically correlated with AHI ( r : 0.53 , p < 0.005 ) . CONCLUSION In patients with OSAS , adding CPAP to pharmacological therapy has favorable effects on preventing recurrences , heart rate control in patients with atrial fibrillation and in reducing frequency and /or severity of ventricular extrasystoles INTRODUCTION Paroxysmal atrial fibrillation ( AF ) may progress to persistent AF . We studied the clinical correlates and the effect of rhythm-control strategy on AF progression . METHODS RecordAF was a worldwide prospect i ve survey of AF management . Consecutive eligible patients with recent-onset AF were included and allocated to rate or rhythm control according to patient/physician choice . A total of 2,137 patients were followed up for 12 months . Atrial fibrillation progression was defined as a change from paroxysmal to persistent/permanent AF . RESULTS Progression of AF occurred in 318 patients ( 15 % ) after 1 year . Patients with AF progression  were older ; had a higher diastolic blood pressure ; and more often had a history of coronary artery disease , stroke or transient ischemic attack , hypertension , or heart failure . Patients treated with rhythm control were less likely to show progression than those treated only with rate control ( 164/1542 [ 11 % ] vs 154/595 [ 26 % ] , P < .001 ) . Multivariable analysis showed that history of heart failure ( odds ratio [ OR ] 2.2 , 95 % CI 1.7 - 2.9 , P < .0001 ) , history of hypertension ( OR 1.5 , 95 % CI 1.1 - 2.0 , P = .01 ) , and rate control rather than rhythm control ( OR 3.2 , 95 % CI 2.5 - 4.1 , P < .0001 ) were independent predictors of AF progression . The propensity score-adjusted OR of AF progression in patients with rate rather than rhythm control was 3.3 ( 95 % CI 2.4 - 4.6 , P < .0001 ) . CONCLUSIONS Although heart failure and hypertension are associated with AF progression , rhythm control is associated with lower risk of AF progression Between January 1 , 1986 , and December 31 , 1991 , 4,507 adult patients underwent cardiac surgical procedures requiring cardiopulmonary bypass .  Of these patients , 3,983 patients who did not undergo operation for supraventricular tachycardia and who were in normal sinus rhythm preoperatively form the study group for the present study . Postoperatively , all patients were monitored continuously for the development of arrhythmias until the time of hospital discharge . The incidence of atrial arrhythmias requiring treatment for the most commonly performed operative procedures were as follows : coronary artery bypass grafting , 31.9 % ; coronary artery bypass grafting and mitral valve replacement , 63.6 % ; coronary artery bypass grafting and aortic valve replacement , 48.8 % ; and heart transplantation , 11.1 % . For all patients considered collectively , the risk factors associated with an increased incidence of postoperative atrial arrhythmias ( p < 0.05 by multivariate logistic regression ) included increasing patient age , preoperative use of digoxin , history of rheumatic heart disease , chronic obstructive pulmonary disease , and increasing aortic cross-clamp time . Postoperative atrial fibrillation was associated with an increased incidence of postoperative stroke ( 3.3 % versus 1.4 % ; p < 0.0005 ) , increased length of hospitalization in the intensive care unit ( 5.7 versus 3.4 days ; p = 0.001 ) and postoperative nursing ward ( 10.9 versus 7.5 days ; p = 0.0001 ) , increased incidence of postoperative ventricular tachycardia or fibrillation ( 9.2 % versus 4.0 % ; p < 0.0005 ) , and an increased need for placement of a permanent pacemaker ( 3.7 % versus 1.6 % ; p < 0.0005 ) . These data provide a basis for targeting specific patient subgroups for prospect i ve , r and omized trials of therapeutic modalities design ed to decrease the incidence of postoperative atrial arrhythmias In a r and omly selected population of 9067 individuals , 32 - 64 years of age in 1967 - 1970 , 25 ( 0.28 % ) had chronic atrial fibrillation ( CAF ) . Eight had lone atrial fibrillation .  In 1984 the cases were compared with an age- and sex-matched control group of 50 and found to have more cerebrovascular accidents ( 6 versus 2 ; P less than 0.05 ) , congestive heart failure ( 9 versus 1 ; P less than 0.001 ) , and valvular rheumatic heart disease ( 3 versus 0 ) or history consistent with rheumatic fever ( 6 versus 0 ; P less than 0.01 ) . The mortality in the CAF group was 60 % higher due to an excess in cardiovascular ( relative risk 6.1 ; P less than 0.05 ) and cerebrovascular ( relative risk 12.2 ; P less than 0.05 ) causes . The prevalence or incidence of ischaemic or hypertensive heart disease or the presence of coronary risk factors did not significantly differ in the two groups . By M-mode echocardiography the left atrial size , left ventricular enddiastolic dimension and left ventricular mass were increased in the CAF patients , while the systolic left ventricular shortening was significantly less . Thus , the prevalence of CAF is low in a r and omly selected population 32 - 64 years of age and CAF is not strongly associated with ischaemic heart disease or hypertension . The CAF patients have an increased risk of dying prematurely particularly from cerebrovascular causes , even in the absence of valve disease
They also have an increased risk for thromboembolism .
Comparing with age-matched controls , the relative risk for stroke is increased 2- to 7-fold in patients with nonrheumatic atrial fibrillation ( 3 , 8 , 13 ) , and the absolute risk for stroke is between 1 % and 5 % per year , depending on clinical characteristics ( 3 , 12 , 14 - 16 ) .
Paroxysmal atrial fibrillation disrupts the lives of patients ( 17 ) , but this perception may not be associated with frequency or duration of symptoms .
Warfarin therapy affects quality of life because of frequent blood testing and recommendations for limiting some activities .
Data Synthesis Does Aggressive Rhythm Control Improve Mortality and Morbidity Compared with Rate Control ?
Atrial fibrillation is the most common type of arrhythmia in adults , accounting for about one third of hospitalizations for arrhythmia ( 1 ) .
The prevalence increases from less than 1 % in persons younger than 60 years of age to more than 8 % in those older than 80 years of age ( 2 - 6 ) .
The incidence ranges from 0.2 % per year for men 30 to 39 years of age to 2.3 % per year in men 80 to 89 years of age ( 7 , 8) .
The age-adjusted incidence for women is about half that of men ( 9 ) .
The cardiac conditions most commonly associated with atrial fibrillation are rheumatic mitral valve disease , coronary artery disease , congestive heart failure , and hypertension ( 8 , 10 ) .
Noncardiac causes include hyperthyroidism , hypoxic conditions , surgery , and alcohol intoxication .
A predisposing condition exists in more than 90 % of cases ( 5 , 11 , 12 ) ; the remaining cases have what is called lone atrial fibrillation .
Patients with atrial fibrillation frequently have symptoms of hemodynamic compromise , ranging from irregular palpitations to the more insidious feeling of malaise .
Little is known about the direct effects of antiarrhythmic therapy and rate-control therapy on quality of life .
The American College of Cardiology/American Heart Association/European Society of Cardiology Task Force on Clinical Guidelines for the Management of Atrial Fibrillation classified atrial fibrillation into 4 types ( 20 ) : first detected episode , paroxysmal ( terminates spontaneously ) , persistent ( electrical or pharmacologic termination necessary ) , and permanent ( resistant to electrical or pharmacologic conversion or accepted by the physician ) .
The purpose of this review was to summarize the evidence that was available during formulation of the guidelines developed by the American College of Physicians ( ACP ) and the American Academy of Family Physicians ( AAFP ) for management of adult patients with nonpostoperative atrial fibrillation .
Although the relative benefits and risks of rate versus rhythm control are of paramount importance in the management of atrial fibrillation , studies directly addressed this issue only recently .