Atrial Fibrillation
Authors: David J. Callans
Journal: Annals of Internal Medicine (2008)

In the Clinic4 November 2008Atrial FibrillationChristine Laine, MD, MPH, David R. Goldman, MD, and David J. Callans, MDChristine Laine, MD, MPHSearch for more papers by this author, David R. Goldman, MDSearch for more papers by this author, and David J. Callans, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-149-9-200811040-01005 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Editor's Note: This issue of In the Clinic has been updated.DiagnosisAtrial fibrillation, the most common clinically significant arrhythmia, occurs when a diffuse and chaotic pattern of electrical activity in the atria replaces the normal sinus mechanism, leading to deterioration of mechanical function. Atrial fibrillation is a major cause of morbidity, mortality, and health care expenditures, with a current prevalence of 2.3 million cases in the United States and an estimated increase in prevalence to 15.9 million by the year 2050 (1). Atrial fibrillation is associated with a 5-fold increased risk for stroke and is estimated to cause 15% ...References1. Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114:119-25. [PMID: 16818816] Google Scholar2. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999;131:492-501. [PMID: 10507957] Google Scholar3. Benjamin EJ, Wolf PA, D'Agostino RB, et al. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998;98:946-52. [PMID: 9737513] Google Scholar4. Page RL, Wilkinson WE, Clair WK, et al. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation. 1994;89:224-7. [PMID: 8281651] Google Scholar5. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114:e257-354. [PMID: 16908781] Google Scholar6. Brand FN, Abbott RD, Kannel WB, Wolf PA. Characteristics and prognosis of lone atrial fibrillation. 30-year follow-up in the Framingham Study. JAMA. 1985;254:3449-53. [PMID: 4068186] Google Scholar7. Furberg CD, Psaty BM, Manolio TA, et al. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Am J Cardiol. 1994;74:236-41. [PMID: 8037127] Google Scholar8. Naito M, David D, Michelson EL, et al. The hemodynamic consequences of cardiac arrhythmias: evaluation of the relative roles of abnormal atrioventricular sequencing, irregularity of ventricular rhythm and atrial fibrillation in a canine model. Am Heart J. 1983;106:284-91. [PMID: 6869209] Google Scholar9. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994;154:1449-57. [PMID: 8018000] Google Scholar10. Hart RG, Sherman DG, Easton JD, Cairns JA. Prevention of stroke in patients with nonvalvular atrial fibrillation. Neurology. 1998;51:674-81. [PMID: 9748009] Google Scholar11. Redfield MM, Kay GN, Jenkins LS, et al. Tachycardia-related cardiomyopathy: a common cause of ventricular dysfunction in patients with atrial fibrillation referred for atrioventricular ablation. Mayo Clin Proc. 2000;75:790-5. [PMID: 10943231] Google Scholar12. Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825-33. [PMID: 12466506] Google Scholar13. STAF Investigators. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol. 2003;41:1690-6. [PMID: 12767648] Google Scholar14. Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation—-Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet. 2000;356:1789-94. [PMID: 11117910] Google Scholar15. AFFIRM Investigators. Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation. 2004;109:1509-13. [PMID: 15007003] Google Scholar16. Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667-77. [PMID: 18565859] Google Scholar17. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation. Circulation. 2006;114:e257-354. [PMID: 16908781] Google Scholar18. Roy D, Talajic M, Dorian P, et al. Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med. 2000;342:913-20. [PMID: 10738049] Google Scholar19. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406-12. [PMID: 2473403] Google Scholar20. CHARM Investigators. Prevention of atrial fibrillation in patients with symptomatic chronic heart failure by candesartan in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Am Heart J. 2006;152:86-92. [PMID: 16838426] Google Scholar21. Maisel WH, Kuntz KM, Reimold SC, et al. Risk of initiating antiarrhythmic drug therapy for atrial fibrillation in patients admitted to a university hospital. Ann Intern Med. 1997;127:281-4. [PMID: 9265427] Google Scholar22. Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation. 1991;84:527-39. [PMID: 1860198] Google Scholar23. Petersen P, Boysen G, Godtfredsen J, et al. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study. Lancet. 1989;1:175-9. [PMID: 2563096] Google Scholar24. Connolly SJ, Laupacis A, Gent M, et al. Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J Am Coll Cardiol. 1991;18:349-55. [PMID: 1856403] Google Scholar25. Ezekowitz MD, Bridgers SL, James KE, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators. N Engl J Med. 1992;327:1406-12. [PMID: 1406859] Google Scholar26. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med. 1990;323:1505-11. [PMID: 2233931] Google Scholar27. Stroke Prevention in Atrial Fibrillation Investigators. Lessons from the Stroke Prevention in Atrial Fibrillation trials. Ann Intern Med. 2003;138:831-8. [PMID: 12755555] Google Scholar28. Jung F, DiMarco JP. Treatment strategies for atrial fibrillation. Am J Med. 1998;104:272-86. [PMID: 9552091] Google Scholar29. Zabalgoitia M, Halperin JL, Pearce LA, et al. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators. J Am Coll Cardiol. 1998;31:1622-6. [PMID: 9626843] Google Scholar30. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864-70. [PMID: 11401607] Google Scholar31. van Walraven C, Hart RG, Wells GA, et al. A clinical prediction rule to identify patients with atrial fibrillation and a low risk for stroke while taking aspirin. Arch Intern Med. 2003;163:936-43. [PMID: 12719203] Google Scholar32. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857-67. [PMID: 17577005] Google Scholar33. Hart RG, Tonarelli SB, Pearce LA. Avoiding central nervous system bleeding during antithrombotic therapy: recent data and ideas. Stroke. 2005;36:1588-93. [PMID: 15947271] Google Scholar34. Hylek EM, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115:2689-96. [PMID: 17515465] Google Scholar35. The SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators. Patients with nonvalvular atrial fibrillation at low risk of stroke during treatment with aspirin: Stroke Prevention in Atrial Fibrillation III Study. JAMA. 1998;279:1273-7. [PMID: 9565007] Google Scholar36. ACTIVE Writing Group of the ACTIVE Investigators. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367:1903-12. [PMID: 16765759] Google Scholar37. Kaul S, Diamond GA, Weintraub WS. Trials and tribulations of non-inferiority: the ximelagatran experience. J Am Coll Cardiol. 2005;46:1986-95. [PMID: 16325029] Google Scholar38. Wood MA, Brown-Mahoney C, Kay GN, Ellenbogen KA. Clinical outcomes after ablation and pacing therapy for atrial fibrillation : a meta-analysis. Circulation. 2000;101:1138-44. [PMID: 10715260] Google Scholar39. Packer DL, Asirvatham S, Munger TM. Progress in nonpharmacologic therapy of atrial fibrillation. J Cardiovasc Electrophysiol. 2003;14:S296-309. [PMID: 15005218] Google Scholar40. Snow V, Weiss KB, LeFevre M, et al. 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;139:1009-17. [PMID: 14678921] Google Scholar Author, Article, and Disclosure InformationAffiliations: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCorrection: In the Clinic: Atrial Fibrillation Metrics Cited byAtrial Fibrillation Risk Prediction from Electrocardiogram and Related Health Data with Deep Neural NetworkTreatment strategies for atrial fibrillationA Minimally Invasive Cox-Maze Procedure Operative Technique and ResultsA Minimally Invasive Cox-Maze Procedure Operative Technique and ResultsNew Approaches to Stroke Prevention in Atrial Fibrillation 4 November 2008Volume 149, Issue 9Page: ITC5-1KeywordsArrhythmiaAtrial fibrillationCardiovascular therapyDrugsHeartHeart failureHeart rateMedical risk factorsStrokeThromboembolism ePublished: 4 November 2008 Issue Published: 4 November 2008 Copyright & PermissionsCopyright © 2008 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...