FUSTER
ET AL., ACC/AHA/ESC GUIDELINES FOR THE MANAGEMENT OF
PATIENTS WITH ATRIAL FIBRILLATION
J Am Coll Cardiol 2001;38:1266i-1xx
ACC/AHA/ESC
Guidelines for the Management of Patients with Atrial
Fibrillation
I.
Introduction
A.
Organization of Committee and Evidence Review
Atrial
fibrillation (AF) is the most common sustained rhythm
disturbance. Its prevalence is increasing along with
the age of the population. AF is often associated with
structural heart disease, but a substantial proportion
of patients with AF have no detectable heart disease.
Hemodynamic impairment and thromboembolic events related
to AF result in significant morbidity, mortality, and
cost. Accordingly, the American College of Cardiology
(ACC), the American Heart Association (AHA), and the
European Society of Cardiology (ESC) created a committee
to establish guidelines for better management of this
frequent and complex arrhythmia.
The
committee was composed of 8 members representing the
ACC and AHA, 4 members representing the ESC, 1 member
from the North American Society of Pacing and Electrophysiology
(NASPE), and a representative of the Johns Hopkins University
Evidence-Based Practice Center representing the Agency
for Healthcare Research and Quality's report on Atrial
Fibrillation in the Elderly. This document was reviewed
by 3 reviewers nominated by the ACC, 3 nominated by
the AHA, and 3 nominated by the ESC, as well as by the
ACC Clinical Electrophysiology Committee, the AHA ECG
and Arrhythmia Committee, NASPE, and 25 additional reviewers
nominated by the writing committee. The document was
approved for publication by the governing bodies of
the ACC, AHA, and ESC and officially endorsed by NASPE.
These guidelines will be reviewed annually by the task
force and will be considered current unless the task
force revises or withdraws them from distribution.
The
ACC/AHA/ESC Committee to Develop Guidelines for the
Management of Patients With Atrial Fibrillation conducted
a comprehensive review of the relevant literature from
1980 to June 2000. Literature searches were conducted
in the following databases: PubMed/Medline, EMBASE,
the Cochrane Library (including the Cochrane Database
of Systematic Reviews and the Cochrane Controlled Trials
Registry), and Best Evidence. Searches were limited
to English language sources and to human subjects. Major
search terms included atrial fibrillation, aged, atrial
remodeling, atrioventricular conduction, atrioventricular
node, cardioversion, classification, clinical trial,
complications, concealed conduction, cost-effectiveness,
defibrillator, demographics, epidemiology, heart failure
(HF), hemodynamics, human, hyperthyroidism, hypothyroidism,
meta-analysis, myocardial infarction, nomenclature,
pharmacology, postoperative, pregnancy, pulmonary disease,
quality of life, rate control, risks, sinus rhythm,
symptoms, and tachycardia-mediated cardiomyopathy.
Recommendations
are evidence based and derived primarily from published
data. The weight of evidence was ranked highest (A)
when the data were derived from multiple randomized
clinical trials and intermediate (B) when based on a
limited number of randomized trials, nonrandomized studies,
or observational registries. The lowest rank (C) was
given when the primary basis for the recommendation
was expert consensus.
Recommendations
follow the format of previous ACC/AHA guidelines for
classifying indications, summarizing both the evidence
and expert opinion
Class
I: Conditions for which there is evidence for and/or
general agreement that the procedure or treatment is
useful and effective.
Class
II: Conditions for which there is conflicting evidence
and/or a divergence of opinion about the usefulness/efficacy
of a procedure or treatment.
Class
IIa: The weight of evidence or opinion is in favor
of the procedure or treatment.
Class
IIb: Usefulness/efficacy is less well established
by evidence or opinion.
Class
III: Conditions for which there is evidence and/or general
agreement that the procedure or treatment is not useful/effective
and in some cases may be harmful.
B.
Contents of this Guideline
These
guidelines first present a comprehensive review of the
latest information about the definition, classification,
epidemiology, mechanisms, and clinical characteristics
of AF. The management of this complex and potentially
dangerous arrhythmia is then reviewed. This includes
conversion to and maintenance of sinus rhythm, control
of heart rate, and prevention of thromboembolism. The
treatment algorithms include pharmacological and nonpharmacological
antiarrhythmic approaches, as well as antithrombotic
strategies thought to be most appropriate for each particular
patient's condition. Overall, this is a consensus document
that attempts to reconcile evidence and opinion from
both sides of the Atlantic Ocean. The pharmacological
and nonpharmacological antiarrhythmic approaches discussed
may include some drugs and devices that do not have
the approval of governmental regulatory agencies. Additional
information may be obtained from the package inserts.
Because
atrial flutter can precede or coexist with AF, special
consideration is given in each of these sections to
this arrhythmia. There are important differences in
the mechanisms of AF and atrial flutter, and the body
of evidence available to support therapeutic recommendations
is distinct for the 2 arrhythmias. Atrial flutter is
not addressed comprehensively in these guidelines but
will be addressed in the upcoming ACC/AHA/ESC Guidelines
on the Management of Patients With Supraventricular
Arrhythmias.
Copyright
© 2001 by the American College of Cardiology, American
Heart Association, Inc., and the European Society of
Cardiology.
Published by Elsevier Science Inc.
|
