The AHA Guidelines and Scientific Statements Handbook

Atrial Fibrillation

Valentin Fuster and Lars Rydén

15

Organization of committee and evidence

Review

Changes since the initial publication of the 2001

guidelines

Recommendations for management of patients with

atrial fi brillation

Pharmacological rate control during atrial fi brillation

Preventing thromboembolism

Cardioversion of atrial fi brillation

Pharmacological cardioversion

Direct-current cardioversion

Pharmacological enhancement of direct-current

cardioversion

Prevention of thromboembolism in patients with atrial

fi brillation undergoing cardioversion

Maintenance of sinus rhythm

Future directions

Novel antithrombotic compounds

Ablation strategies

Organization of committee and evidence

Review

Atrial fi brillation (AF) is the most common sus-

tained cardiac rhythm disturbance, increasing in

prevalence with age. AF is often associated with

structural heart disease, although a substantial pro-

portion of patients with AF have no detectable

heart disease [1,2]. Hemodynamic impairment and

thromboembolic events related to AF result in sig-

nifi cant morbidity, mortality, and cost [3,4]. Accord-

ingly, the American College of Cardiology (ACC),

the American Heart Association (AHA), and the

European Society of Cardiology (ESC) created a

committee, composed of representatives of the ACC,

AHA, ESC, the European Heart Rhythm Association

(EHRA), and the Heart Rhythm Society (HRS), to

establish guidelines for optimum management of

this frequent and complex arrhythmia. The fi rst

version of these guidelines was released in 2001. The

ACC/AHA/ESC Writing Committee to revise the

2001 Guidelines conducted a comprehensive review

of the relevant literature from 2001 to 2006 using

the PubMed/MEDLINE and Cochrane Library data-

bases [1].

Changes since the initial publication of

the 2001 guidelines

Besides incorporating major clinical trials such as

those that compared rhythm control and rate control

approaches to long-term management the text was

reorganized to better refl ect implications for patient

care. Presently it starts with recognition of AF and

its pathogenesis and the general priorities of rate

control, prevention of thromboembolism, and

methods available for use in selected patients to

correct the arrhythmia and maintain normal sinus

rhythm. Advances in catheter-based ablation tech-

nologies have been incorporated. Recommenda-

tions do, however, recognize that such vital details

as patient selection, optimum catheter positioning,

absolute rates of treatment success, and the fre-

quency of complications remain incompletely eval-

uated in prospective, randomised trials. Sections on

drug therapy have been confi ned to human studies

with compounds approved for clinical use in North

America and/or Europe. As data on the manage-

ment of patients prone to AF in special circum-

stances are more robust, recommendations are

based on a higher level of evidence than in the fi rst

The AHA Guidelines and Scientific Statements Handbook
Edited by Valentin Fuster © 2009 American Heart Association
ISBN: 978-1-405-18463-2