2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for ...

99 Pages·2011·5.31 MB·English

ACC/AHA/ESC Practice Guidelines
Thisguidelinecontainshyperlinkstorecommendationsandsupportingtextthathavebeenupdatedbythe“2011ACCF/AHA/HRSFocusedUpdateonthe
ManagementofPatientsWithAtrialFibrillation(Updatingthe2006Guideline)”(Circulation.2011;123:104–123;doi:10.1161/CIR.0b013e3181fa3cf4)
and the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran)” (Circulation.
2011;123:1161–1167;doi:10.1161/CIR.0b013e31820f14c0).UpdatedsectionsareindicatedintheTableofContentsandtext.
2011 ACCF/AHA/HRS Focused Updates Incorporated Into
the ACC/AHA/ESC 2006 Guidelines for the Management of
Patients With Atrial Fibrillation
A Report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines
2006 WRITING COMMITTEE MEMBERS
Developed in partnership with the European Society of Cardiology and in collaboration with
the European Heart Rhythm Association and the Heart Rhythm Society
Valentin Fuster, MD, PhD, FACC, FAHA, FESC, Co-Chair;
Lars E. Ryde´n, MD, PhD, FACC, FAHA, FESC, Co-Chair; Davis S. Cannom, MD, FACC;
Harry J. Crijns, MD, FACC, FESC*; Anne B. Curtis, MD, FACC, FAHA;
Kenneth A. Ellenbogen, MD, FACC†; Jonathan L. Halperin, MD, FACC, FAHA;
G. Neal Kay, MD, FACC; Jean-Yves Le Huezey, MD, FESC; James E. Lowe, MD, FACC;
S. Bertil Olsson, MD, PhD, FESC; Eric N. Prystowsky, MD, FACC;
Juan Luis Tamargo, MD, FESC; L. Samuel Wann, MD, MACC, FAHA, FESC
2011 WRITING GROUP MEMBERS
Developed in partnership with the Heart Rhythm Society
L. Samuel Wann, MD, MACC, FAHA, Chair‡; Anne B. Curtis, MD, FACC, FAHA‡§;
Kenneth A. Ellenbogen, MD, FACC, FHRS†§; N.A. Mark Estes III, MD, FACC, FHRS(cid:1);
Michael D. Ezekowitz, MB, ChB, FACC‡; Warren M. Jackman, MD, FACC, FHRS‡;
Craig T. January, MD, PhD, FACC‡§; James E. Lowe, MD, FACC‡;
Richard L. Page, MD, FACC, FHRS†; David J. Slotwiner, MD, FACC†;
William G. Stevenson, MD, FACC, FAHA¶; Cynthia M. Tracy, MD, FACC‡
*European Heart Rhythm Association Representative. †Heart Rhythm Society Representative. ‡ACCF/AHA Representative. §Recused from 2011
Update Section 8.1.8.3, Recommendations for Dronedarone. (cid:1)ACCF/AHA Task Force on Performance Measures Representative. ¶ACCF/AHA Task
ForceonPracticeGuidelinesLiaison.#FormerTaskForcememberduringthiswritingeffort.
The2011focusedupdatestothisdocumentwereapprovedbytheleadershipoftheAmericanCollegeofCardiologyFoundation,AmericanHeart
Association,andtheHeartRhythmSociety,andthesectionsthathavebeenupdatedareindicatedwithhyperlinkstothefocusedupdateswhereapplicable.
TheAmericanHeartAssociationrequeststhatthisdocumentbecitedasfollows:FusterV,Ryde´nLE,CannomDS,CrijnsHJ,CurtisAB,Ellenbogen
KA,HalperinJL,KayGN,LeHeuzeyJ-Y,LoweJE,OlssonSB,PrystowskyEN,TamargoJL,WannLS.2011ACCF/AHA/HRSfocusedupdates
incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of
CardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuidelines.Circulation.2011;123:e269–e367.
ThisarticlehasbeencopublishedintheJournaloftheAmericanCollegeofCardiology.
Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmericanCollegeofCardiology(www.cardiosource.org)andtheAmericanHeart
Association(http://my.americanheart.org).Acopyofthedocumentisalsoavailableathttp://www.americanheart.org/presenter.jhtml?identifier(cid:1)3003999by
selecting either the “topic list” link or the “chronological list” link. To purchase additional reprints, call 843-216-2533 or e-mail
[email protected].
ExpertpeerreviewofAHAScientificStatementsisconductedattheAHANationalCenter.FormoreonAHAstatementsandguidelinesdevelopment,
visithttp://www.americanheart.org/presenter.jhtml?identifier(cid:1)3023366.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
permissionoftheAmericanHeartAssociation.Instructionsforobtainingpermissionarelocatedathttp://www.americanheart.org/presenter.jhtml?identifier(cid:1)
4431.Alinktothe“PermissionRequestForm”appearsontherightsideofthepage.
(Circulation.2011;123:e269–e367.)
©2011bytheAmericanCollegeofCardiologyFoundation,theAmericanHeartAssociation,Inc.,andtheEuropeanSocietyofCardiology.
Circulationisavailableathttp://circ.ahajournals.org DOI:10.1161/CIR.0b013e318214876d
e269
e270 Circulation March 15, 2011
ACCF/AHA TASK FORCE MEMBERS
Alice K. Jacobs, MD, FACC, FAHA, Chair; Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect;
Nancy Albert, PhD, CCNS, CCRN; Christopher E. Buller, MD, FACC#;
Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC;
Robert A. Guyton, MD, FACC; Jonathan L. Halperin, MD, FACC, FAHA;
Judith S. Hochman, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA;
Erik Magnus Ohman, MD, FACC; William G. Stevenson, MD, FACC, FAHA;
Lynn G. Tarkington, RN#; Clyde W. Yancy, MD, FACC, FAHA
Table of Contents 6. Causes, Associated Conditions, Clinical
Manifestations, and Quality of Life ............e287
Preamble (UPDATED) .........................e273 6.1. Causes and Associated Conditions .........e287
1. Introduction (UPDATED) ...................e274 6.1.1. Reversible Causes of Atrial
1.1. Organization of Committee and Evidence Fibrillation ......................e287
Review (UPDATED) ...................e274 6.1.2. Atrial Fibrillation Without
1.2. Contents of These Guidelines.............e274 Associated Heart Disease ..........e287
1.3. Changes Since the Initial Publication of 6.1.3. Medical Conditions Associated With
These Guidelines in 2001 ................e275 Atrial Fibrillation .................e287
2. Definition ...............................e276 6.1.4. Atrial Fibrillation With Associated
2.1. Atrial Fibrillation ......................e276
Heart Disease ...................e287
2.2. Related Arrhythmias ...................e276
6.1.5. Familial (Genetic) Atrial
3. Classification .............................e277
Fibrillation ......................e287
4. Epidemiology and Prognosis .................e278
6.1.6. Autonomic Influences in
4.1. Prevalence ...........................e278
Atrial Fibrillation .................e287
4.2. Incidence ............................e278
6.2. Clinical Manifestations ..................e288
4.3. Prognosis.............................e279
6.3. Quality of Life ........................e288
5. Pathophysiological Mechanisms ..............e280
7. Clinical Evaluation ........................e288
5.1. Atrial Factors .........................e280
7.1. Basic Evaluation of the Patient With Atrial
5.1.1. Atrial Pathology as a Cause of
Fibrillation ...........................e288
Atrial Fibrillation .................e280
7.1.1. ClinicalHistoryandPhysical
5.1.1.1. Pathological Changes
Examination......................e288
Caused by Atrial
7.1.2. Investigations ...................e289
Fibrillation................e281
7.2. Additional Investigation of Selected
5.1.2. Mechanisms of Atrial Fibrillation ....e281
Patients With Atrial Fibrillation ...........e289
5.1.2.1. AutomaticFocusTheory.......e281
7.2.1. Electrocardiogram Monitoring and
5.1.2.2. Multiple-Wavelet
Exercise Testing .................e289
Hypothesis.................e282
7.2.2. TransesophagealEchocardiography ....e289
5.1.3. Atrial Electrical Remodeling ........e282
7.2.3. Electrophysiological Study .........e291
5.1.4. Counteracting Atrial Electrical
8. Management (UPDATED) ...................e291
Remodeling .....................e283
8.1. Pharmacological and Nonpharmacological
5.1.5. Other Factors Contributing to
Therapeutic Options ....................e292
Atrial Fibrillation .................e284
5.2. Atrioventricular Conduction ..............e284 8.1.1. Pharmacological Therapy ..........e292
5.2.1. General Aspects ..................e284 8.1.1.1. Drugs Modulating the
5.2.2. Atrioventricular Conduction in Renin-Angiotensin-
Patients With Preexcitation Aldosterone System.........e292
Syndromes ......................e284 8.1.1.2. HMG CoA-Reductase
5.3. Myocardial and Hemodynamic Inhibitors (Statins)..........e292
Consequences of Atrial Fibrillation ........e285 8.1.2. Heart Rate Control Versus Rhythm
5.4. Thromboembolism......................e285 Control ........................e292
5.4.1. Pathophysiology of Thrombus 8.1.2.1. Distinguishing Short-Term
Formation.......................e285 and Long-Term
5.4.2. Clinical Implications ..............e286 Treatment Goals ...........e292
Fuster et al ACC/AHA/ESC Practice Guidelines e271
8.1.2.2. Clinical Trials Comparing Stroke and Systemic
Rate Control and Rhythm Embolism ................e304
Control ..................e292 8.1.4.2.1. Anticoagulation
8.1.2.3. Effect on Symptoms and With Vitamin K
Quality of Life ............e294 Antagonist
8.1.2.4. Effects on Heart Failure .....e294 Agents...........e305
8.1.2.5. Effects on Thromboembolic 8.1.4.2.2. Aspirin for
Complications .............e294 Antithrombotic
8.1.2.6. Effects on Mortality and Therapy in
Hospitalization.............e294 Patients With Atrial
8.1.2.7. Implications of the Rhythm- Fibrillation........e306
Control Versus Rate- 8.1.4.2.3. Other Antiplatelet
Control Studies ............e295 Agents for
8.1.3. Rate Control During Atrial Antithrombotic
Fibrillation (UPDATED) ...........e295 Therapy in
8.1.3.1. Pharmacological Rate Patients With
Control During Atrial Atrial
Fibrillation................e295 Fibrillation........e307
8.1.3.1.1. Beta Blockers .....e296 8.1.4.2.4. Combining
8.1.3.1.2. Nondihydropyridine Anticoagulant and
Calcium Channel Platelet-Inhibitor
Antagonists.......e298 Therapy
8.1.3.1.3. Digoxin..........e298 (UPDATED)......e308
8.1.3.1.4. Antiarrhythmic 8.1.4.2.5. Emerging and
Agents...........e298 Investigational
8.1.3.1.5. Combination Antithrombotic
Therapy..........e298 Agents
8.1.3.1.6. Special (UPDATED)......e310
Considerations 8.1.4.2.6. Interruption of
in Patients With the Anticoagulation
Wolff-Parkinson- for Diagnostic or
White (WPW) Therapeutic
Syndrome ........e299 Procedures........e310
8.1.3.2. Pharmacological Therapy to 8.1.4.3. Nonpharmacological
Control Heart Rate in Approaches to Prevention
Patients With Both Atrial of Thromboembolism
Fibrillation and Atrial (UPDATED)..............e311
Flutter ...................e299 8.1.5. CardioversionofAtrialFibrillation ....e311
8.1.3.3. Regulation of 8.1.5.1. Basis for Cardioversion of
Atrioventricular Nodal Atrial Fibrillation...........e311
Conduction by Pacing.......e299 8.1.5.2. Methods of Cardioversion....e311
8.1.3.4. AV Nodal Ablation.........e299 8.1.5.3. Pharmacological
8.1.4. Preventing Thromboembolism .......e300 Cardioversion .............e311
8.1.4.1. Risk Stratification ..........e301 8.1.5.4. Agents With Proven
8.1.4.1.1. Epidemiological Efficacy for Cardioversion
Data.............e301 of Atrial Fibrillation ........e313
8.1.4.1.2. Echocardiography 8.1.5.4.1. Amiodarone.......e313
and Risk 8.1.5.4.2. Dofetilide ........e315
Stratification ......e302 8.1.5.4.3. Flecainide ........e315
8.1.4.1.3. Therapeutic 8.1.5.4.4. Ibutilide..........e316
Implications.......e303 8.1.5.4.5. Propafenone.......e316
8.1.4.2. Antithrombotic Strategies 8.1.5.5. Less Effective or
for Prevention of Ischemic Incompletely Studied Agents
e272 Circulation March 15, 2011
for Cardioversion of 8.2.5. Risks and Complications of Direct-
Atrial Fibrillation...........e316 Current Cardioversion of Atrial
8.1.5.5.1. Quinidine.........e316 Fibrillation ......................e325
8.1.5.5.2. Procainamide......e316 8.2.6. Pharmacological Enhancement of
8.1.5.5.3. Beta Blockers .....e317 Direct-Current Cardioversion ........e325
8.1.5.5.4. Nondihydropyridine 8.2.6.1. Amiodarone...............e326
Calcium Channel 8.2.6.2. Beta-Adrenergic
Antagonists Antagonists ...............e326
(Verapamil and 8.2.6.3. Nondihydropyridine
Diltiazem)........e317 Calcium Channel
8.1.5.5.5. Digoxin..........e317 Antagonists ...............e326
8.1.5.5.6. Disopyramide .....e317 8.2.6.4. Quinidine.................e326
8.1.5.5.7. Sotalol...........e317 8.2.6.5. TypeICAntiarrhythmic
Agents ...................e327
8.1.6. Pharmacological Agents to Maintain
8.2.6.6. TypeIIIAntiarrhythmic
Sinus Rhythm ...................e317
Agents ...................e327
8.1.6.1. Agents With Proven
8.2.7. Prevention of Thromboembolism in
Efficacy to Maintain Sinus
Patients With Atrial Fibrillation
Rhythm..................e317
Undergoing Cardioversion ..........e327
8.1.6.1.1. Amiodarone.......e317
8.3. Maintenance of Sinus Rhythm ............e328
8.1.6.1.2. Beta Blockers .....e318
8.3.1. Pharmacological Therapy
8.1.6.1.3. Dofetilide ........e318
(UPDATED) ....................e329
8.1.6.1.4. Disopyramide .....e319
8.3.1.1. Goals of Treatment .........e329
8.1.6.1.5. Flecainide ........e319
8.3.1.2. Endpoints in Antiarrhythmic
8.1.6.1.6. Propafenone.......e319
Drug Studies..............e329
8.1.6.1.7. Sotalol...........e319
8.3.1.3. PredictorsofRecurrentAF ....e329
8.1.6.2. Drugs With Unproven
8.3.1.4. Catheter-BasedAblationTherapy
Efficacy or no Longer
forAtrialFibrillation
Recommended.............e320
(NEWSECTION) ...........e330
8.1.6.2.1. Digoxin..........e320
8.3.2. General Approach to Antiarrhythmic
8.1.6.2.2. Procainamide......e320
Drug Therapy ...................e330
8.1.6.2.3. Quinidine.........e320
8.3.3. Selection of Antiarrhythmic Agents
8.1.6.2.4. Verapamil and
in Patients With Cardiac Diseases ....e330
Diltiazem ........e320
8.3.3.1. Heart Failure..............e330
8.1.7. Out-of-Hospital Initiation of
8.3.3.2. Coronary Artery Disease.....e331
Antiarrhythmic Drugs in Patients
8.3.3.3. HypertensiveHeartDisease.....e331
With Atrial Fibrillation ............e320
8.3.4. Nonpharmacological Therapy for
8.1.8. Drugs Under Development..........e322
Atrial Fibrillation .................e331
8.1.8.1. Atrioselective Agents........e323
8.3.4.1. Surgical Ablation...........e331
8.1.8.2. Nonselective Ion Channel–
8.3.4.2. Catheter Ablation ..........e332
Blocking Drugs............e323
8.3.4.2.1. Complicationsof
8.1.8.3. Recommendations for Catheter-Based
Dronedarone for the Ablation..........e333
Prevention of Recurrent 8.3.4.2.2. Future Directions
Atrial Fibrillation in Catheter-Based
(NEW SECTION)..........e323 Ablation Therapy
8.2. Direct-Current Cardioversion of Atrial for Atrial
Fibrillation and Flutter ..................e323 Fibrillation........e333
8.2.1. Terminology ....................e323 8.3.4.3. Suppression of Atrial
8.2.2. Technical Aspects ................e324 Fibrillation Through
8.2.3. Procedural Aspects ...............e324 Pacing...................e333
8.2.4. Direct-Current Cardioversion in 8.3.4.4. Internal Atrial
Patients With Implanted Pacemakers Defibrillators..............e334
and Defibrillators .................e325 8.4. Special Considerations ..................e334
Fuster et al ACC/AHA/ESC Practice Guidelines e273
8.4.1. Postoperative AF .................e334 actingasanindependentgroupofauthorstodeveloporupdate
writtenrecommendationsforclinicalpractice.
8.4.1.1. Clinical and
Expertsinthesubjectunderconsiderationhavebeenselected
Pathophysiological
from all 3 organizations to examine subject-specific data and
Correlates ................e335
writeguidelines.Theprocessincludesadditionalrepresentatives
8.4.1.2. Prevention of
from other medical practitioner and specialty groups when
Postoperative AF...........e335 appropriate. Writing committees are specifically charged to
8.4.1.3. Treatment of perform a formal literature review, weigh the strength of
Postoperative AF...........e336 evidencefororagainstaparticulartreatmentorprocedure,and
includeestimatesofexpectedhealthoutcomeswheredataexist.
8.4.2. Acute Myocardial Infarction.........e336
Patient-specific modifiers, comorbidities, and issues of patient
8.4.3. Wolff-Parkinson White (WPW)
preferencethatmightinfluencethechoiceofparticulartestsor
Preexcitation Syndromes ...........e337
therapiesareconsideredaswellasfrequencyoffollow-upand
8.4.4. Hyperthyroidism .................e338
cost-effectiveness.Whenavailable,informationfromstudieson
8.4.5. Pregnancy.......................e338 costwillbeconsidered;however,reviewofdataonefficacyand
8.4.6. Hypertrophic Cardiomyopathy .......e339 clinicaloutcomeswillconstitutetheprimarybasisforpreparing
8.4.7. Pulmonary Diseases ...............e340 recommendationsintheseguidelines.
8.5. Primary Prevention.....................e340 The ACC/AHA Task Force on Practice Guidelines and the
9. Proposed Management Strategies .............e340 ESC Committee for Practice Guidelines make every effort to
avoidanyactual,potential,orperceivedconflictofinterestthat
9.1. Overview of Algorithms for Management
might arise as a result of an outside relationship or personal
of Patients With Atrial Fibrillation .........e340
interest of the writing committee. Specifically, all members of
9.1.1. Newly Discovered Atrial
theWritingCommitteeandpeerreviewersofthedocumentare
Fibrillation ......................e340
askedtoprovidedisclosurestatementsofallsuchrelationships
9.1.2. Recurrent Paroxysmal Atrial thatmightbeperceivedasrealorpotentialconflictsofinterest.
Fibrillation ......................e341 Writing committee members are also strongly encouraged to
9.1.3. Recurrent Persistent Atrial declare a previous relationship with industry that might be
Fibrillation ......................e341 perceived as relevant to guideline development. If a writing
9.1.4. Permanent Atrial Fibrillation ........e341 committee member develops a new relationship with industry
duringtheirtenure,theyarerequiredtonotifyguidelinestaffin
Appendix I ..................................e362
writing. The continued participation of the writing committee
Appendix II .................................e363
memberwillbereviewed.Thesestatementsarereviewedbythe
Appendix III ................................e365
parentTaskForce,reportedorallytoallmembersofthewriting
Appendix IV (NEW SECTION) ..................e367
committee at each meeting, and updated and reviewed by the
References ..................................e342
writing committee as changes occur. Please refer to the meth-
odologymanualsforfurtherdescriptionofthepoliciesusedin
Preamble (UPDATED)
guideline development, including relationships with industry,
Forneworupdatedtext,viewthe2011FocusedUpdateand
availableonlineattheACC,AHA,andESCWorldWideWeb
the 2011 Focused Update on Dabigatran. Text supporting
sites (http://www.acc.org/clinical/manual/manual_introltr.htm,
unchangedrecommendationshasnotbeenupdated.
http://circ.ahajournals.org/manual/,andhttp://www.escardio.org/
Itisimportantthatthemedicalprofessionplayasignificantrole
knowledge/guidelines/Rules/).PleaseseeAppendixIforauthor
incriticallyevaluatingtheuseofdiagnosticproceduresandthera-
relationships with industry and Appendix II for peer reviewer
piesastheyareintroducedandtestedinthedetection,management,
relationshipswithindustrythatarepertinenttotheseguidelines.
orpreventionofdiseasestates.Rigorousandexpertanalysisofthe
These practice guidelines are intended to assist healthcare
availabledatadocumentingabsoluteandrelativebenefitsandrisks providersinclinicaldecisionmakingbydescribingarangeof
of those procedures and therapies can produce helpful guidelines generally acceptable approaches for the diagnosis, manage-
thatimprovetheeffectivenessofcare,optimizepatientoutcomes, ment, and prevention of specific diseases and conditions.
andfavorablyaffecttheoverallcostofcarebyfocusingresources These guidelines attempt to define practices that meet the
onthemosteffectivestrategies. needs of most patients in most circumstances. These guide-
The American College of Cardiology Foundation (ACCF) line recommendations reflect a consensus of expert opinion
and the American Heart Association (AHA) have jointly en- after a thorough review of the available, current scientific
gaged in the production of such guidelines in the area of evidence and are intended to improve patient care. If these
cardiovasculardiseasesince1980.TheACC/AHATaskForce guidelines are used as the basis for regulatory/payer deci-
on Practice Guidelines, whose charge is to develop, update, or sions, the ultimate goal is quality of care and serving the
revisepracticeguidelinesforimportantcardiovasculardiseases patient’sbestinterests.Theultimatejudgmentregardingcare
andprocedures,directsthiseffort.TheTaskForceispleasedto of a particular patient must be made by the healthcare
havethisguidelinedevelopedinconjunctionwiththeEuropean provider and the patient in light of all of the circumstances
Society of Cardiology (ESC). Writing committees are charged presented by that patient. There are circumstances in which
withthetaskofperforminganassessmentoftheevidenceand deviations from these guidelines are appropriate.
e274 Circulation March 15, 2011
The guidelines will be reviewed annually by the ACC/ of Systematic Reviews and the Cochrane Controlled Trials
AHA Task Force on Practice Guidelines and the ESC Registry).SearchesfocusedonEnglish-languagesourcesand
Committee for Practice Guidelines and will be considered studies in human subjects. Articles related to animal experi-
current unless they are updated, revised, or sunsetted and mentationwerecitedwhentheinformationwasimportantto
withdrawn from distribution. The executive summary and understanding pathophysiological concepts pertinent to pa-
recommendations are published in the August 15, 2006, tient management and comparable data were not available
issuesoftheJournaloftheAmericanCollegeofCardiology from human studies. Major search terms included atrial
and Circulation and the August 16, 2006, issue of the fibrillation, age, atrial remodeling, atrioventricular conduc-
European Heart Journal. The full-text guidelines are pub- tion, atrioventricular node, cardioversion, classification,
lished in the August 15, 2006, issues of the Journal of the clinical trial, complications, concealed conduction, cost-
American College of Cardiology and Circulation and the effectiveness, defibrillator, demographics, epidemiology, ex-
September 2006 issue of Europace, as well as posted on the perimental, heart failure (HF), hemodynamics, human, hy-
ACC (www.acc.org), AHA (www.americanheart.org), and perthyroidism, hypothyroidism, meta-analysis, myocardial
ESC (www.escardio.org) World Wide Web sites. Copies of infarction, pharmacology, postoperative, pregnancy, pulmo-
thefull-textguidelinesandtheexecutivesummaryareavail- nary disease, quality of life, rate control, rhythm control,
able from all 3 organizations. risks, sinus rhythm, symptoms, and tachycardia-mediated
Sidney C. Smith Jr, MD, FACC, FAHA, FESC, Chair, cardiomyopathy.The complete list of search terms is beyond
ACC/AHA Task Force on Practice Guidelines the scope of this section.
ClassificationofRecommendationsandLevelofEvidence
Silvia G. Priori, MD, PhD, FESC, Chair, are expressed in the ACC/AHA/ESC format as follows and
ESC Committee for Practice Guidelines described in Table 1. Recommendations are evidence based
and derived primarily from published data.
1. Introduction
Classification of Recommendations
1.1. Organization of Committee and Evidence • Class I: Conditions for which there is evidence and/or
Review (UPDATED) general agreement that a given procedure/therapy is bene-
For new or updated text, view the 2011 Focused Update ficial, useful, and effective.
andthe2011FocusedUpdateonDabigatran.Textsupport- • ClassII:Conditionsforwhichthereisconflictingevidence
ingunchangedrecommendationshasnotbeenupdated. and/or a divergence of opinion about the usefulness/
Atrial fibrillation (AF) is the most common sustained efficacy of performing the procedure/therapy.
cardiac rhythm disturbance, increasing in prevalence with X Class IIa: Weight of evidence/opinion is in favor of
age. AF is often associated with structural heart disease, usefulness/efficacy.
althoughasubstantialproportionofpatientswithAFhaveno X ClassIIb:Usefulness/efficacyislesswellestablishedby
detectable heart disease. Hemodynamic impairment and evidence/opinion.
thromboembolic events related to AF result in significant • Class III: Conditions for which there is evidence and/or
morbidity, mortality, and cost. Accordingly, the American generalagreementthataprocedure/therapyisnotusefulor
College of Cardiology (ACC), the American Heart Associa- effective and in some cases may be harmful.
tion (AHA), and the European Society of Cardiology (ESC)
Level of Evidence
created a committee to establish guidelines for optimum
The weight of evidence was ranked from highest (A) to
management of this frequent and complex arrhythmia.
lowest (C), as follows:
Thecommitteewascomposedofmembersrepresentingthe
ACC,AHA,andESC,aswellastheEuropeanHeartRhythm ● Level of Evidence A: Data derived from multiple random
Association(EHRA)andtheHeartRhythmSociety(HRS). ized clinical trials or meta-analyses.
This document was reviewed by 2 official reviewers nomi- ● Level of Evidence B: Data derived from a single random
nated by the ACC, 2 official reviewers nominated by the ized trial, or nonrandomized studies.
AHA,and2officialreviewersnominatedbytheESC,aswell ● Level of Evidence C: Only consensus opinion of experts,
as by the ACCF Clinical Electrophysiology Committee, the case studies, or standard-of-care.
AHA ECG and Arrhythmias Committee, the AHA Stroke
Review Committee, EHRA, HRS, and numerous additional 1.2. Contents of These Guidelines
content reviewers nominated by the writing committee. The These guidelines first present a comprehensive review of the
document was approved for publication by the governing latestinformationaboutthedefinition,classification,epidemiol-
bodiesoftheACC,AHA,andESCandofficiallyendorsedby ogy,pathophysiologicalmechanisms,andclinicalcharacteristics
the EHRA and the HRS. of AF. The management of this complex and potentially dan-
The ACC/AHA/ESC Writing Committee to Revise the gerousarrhythmiaisthenreviewed.Thisincludespreventionof
2001GuidelinesfortheManagementofPatientsWithAtrial AF,controlofheartrate,preventionofthromboembolism,and
Fibrillation conducted a comprehensive review of the rele- conversiontoandmaintenanceofsinusrhythm.Thetreatment
vant literature from 2001 to 2006. Literature searches were algorithms include pharmacological and nonpharmacological
conducted in the following databases: PubMed/MEDLINE antiarrhythmic approaches, as well as antithrombotic strategies
and the Cochrane Library (including the Cochrane Database mostappropriateforparticularclinicalconditions.Overall,this
Fuster et al ACC/AHA/ESC Practice Guidelines e275
Table1. ApplyingClassificationofRecommendationsandLevelofEvidence†(UPDATED)(seethe2011FocusedUpdateandthe
2011FocusedUpdateonDabigatran)
*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchasgender,age,historyofdiabetes,historyofpriormyocardial
infarction,historyofheartfailure,andprioraspirinuse.ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportant
clinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrials.Eventhoughrandomizedtrialsarenotavailable,theremaybeaveryclearclinical
consensusthataparticulartestortherapyisusefuloreffective.
†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline
recommendationshavebeenwritteninfullsentencesthatexpressacompletethought,suchthatarecommendation,evenifseparatedandpresentedapartfrom
therestofthedocument(includingheadingsabovesetsofrecommendations),wouldstillconveythefullintentoftherecommendation.Itishopedthatthiswill
increasereaders’comprehensionoftheguidelinesandwillallowqueriesattheindividualrecommendationlevel.
isaconsensusdocumentthatattemptstoreconcileevidenceand addressed in the ACC/AHA/ESC Guidelines on the Manage-
opinionfrombothsidesoftheAtlanticOcean.Thepharmaco- mentofPatientswithSupraventricularArrhythmias.1
logicalandnonpharmacologicalantiarrhythmicapproachesmay
includesomedrugsanddevicesthatdonothavetheapprovalof 1.3. Changes Since the Initial Publication of These
all government regulatory agencies. Additional informa-tion Guidelines in 2001
may be obtained from the package inserts when the drug or In developing this revision of the guidelines, the Writing
devicehasbeenapprovedforthestatedindication. Committee considered evidence published since 2001 and
BecauseatrialfluttercanprecedeorcoexistwithAF,special draftedrevisedrecommendationswhereappropriatetoincor-
considerationisgiventothisarrhythmiaineachsection.There porate results from major clinical trials such as those that
are important differences in the mechanisms of AF and atrial compared rhythm-control and rate-control approaches to
flutter,andthebodyofevidenceavailabletosupporttherapeutic long-term management. The text has been reorganized to
recommendationsisdistinctforthe2arrhythmias.Atrialflutter reflect the implications for patient care, beginning with
is not addressed comprehensively in these guidelines but is recognition of AF and its pathogenesis and the general
e276 Circulation March 15, 2011
Figure1.Electrocardiogramshowingatrialfibrillationwithacontrolledrateofventricularresponse.Pwavesarereplacedbyfibrillatory
wavesandtheventricularresponseiscompletelyirregular.
priorities of rate control, prevention of thromboembolism, Pwavesbyrapidoscillationsorfibrillatorywavesthatvaryin
and methods available for use in selected patients to correct amplitude, shape, and timing, associated with an irregular,
thearrhythmiaandmaintainnormalsinusrhythm.Advances frequently rapid ventricular response when atrioventricular
in catheter-based ablation technologies have been incorpo- (AV)conductionisintact2(Fig.1).Theventricularresponse
rated into expanded sections and recommendations, with the toAFdependsonelectrophysiological(EP)propertiesofthe
recognition that that such vital details as patient selection, AVnodeandotherconductingtissues,thelevelofvagaland
optimum catheter positioning, absolute rates of treatment sympathetic tone, the presence or absence of accessory
success, and the frequency of complications remain incom- conduction pathways, and the action of drugs.3 Regular
pletelydefined.Sectionsondrugtherapyhavebeencondensed cardiaccycles(R-Rintervals)arepossibleinthepresenceof
andconfinedtohumanstudieswithcompoundsthathavebeen AV block or ventricular or AV junctional tachycardia. In
approved for clinical use in North America and/or Europe. patients with implanted pacemakers, diagnosis of AF may
Accumulating evidence from clinical studies on the emerging requiretemporaryinhibitionofthepacemakertoexposeatrial
role of angiotensin inhibition to reduce the occur-rence and fibrillatoryactivity.4Arapid,irregular,sustained,wide-QRS-
complications of AF and information on approaches to the complex tachycardia strongly suggests AF with conduction
primarypreventionofAFareaddressedcomprehensivelyinthe over an accessory pathway or AF with underlying bundle-
text, as these may evolve further in the years ahead to form branch block. Extremely rapid rates (over 200 beats per
the basis for recommendations affecting patient care. Finally, minute) suggest the presence of an accessory pathway or
data on specific aspects of management of patients who are ventricular tachycardia.
pronetodevelopAFinspecialcircumstanceshavebecomemore
robust, allowing formulation of recommendations based on a 2.2. Related Arrhythmias
higher level of evidence than in the first edition of these AF may occur in isolation or in association with other
guidelines. An example is the completion of a relatively large arrhythmias, most commonly atrial flutter or atrial
randomizedtrialaddressingprophylacticadministrationofanti- tachycardia. Atrial flutter may arise during treatment with
arrhythmicmedicationforpatientsundergoingcardiacsurgery. antiarrhythmic agents prescribed to prevent recurrent AF.
In developing the updated recommendations, every effort was Atrial flutter in the typical form is characterized by a
made to maintain consistency with other ACC/AHA and ESC saw-toothpatternofregularatrialactivationcalledflutter(f)
practiceguidelinesaddressing,forexample,themanagementof waves on the ECG, particularly visible in leads II, III, aVF,
patientsundergoingmyocardialrevascularizationprocedures. andV (Fig.2).Intheuntreatedstate,theatrialrateinatrial
1
fluttertypicallyrangesfrom240to320beatsperminute,with
2. Definition
fwavesinvertedinECGleadsII,III,andaVFanduprightin
2.1. Atrial Fibrillation lead V . The direction of activation in the right atrium (RA)
1
AF is a supraventricular tachyarrhythmia characterized by maybereversed,resultinginfwavesthatareuprightinleads
uncoordinatedatrialactivationwithconsequentdeterioration II, III, and aVF and inverted in lead V . Atrial flutter
1
of atrial mechanical function. On the electrocardiogram commonlyoccurswith2:1AVblock,resultinginaregularor
(ECG),AFischaracterizedbythereplacementofconsistent irregularventricularrateof120to160beatsperminute(most
Fuster et al ACC/AHA/ESC Practice Guidelines e277
Figure2.Electrocardiogramshowingtypicalatrialflutterwithvariableatrioventricularconduction.Notethesaw-toothpattern,Fwaves,
particularlyvisibleinleadsII,III,andaVF,withoutanisoelectricbaselinebetweendeflections.
characteristically about 150 beats per minute). Atrial flutter recommendedinthisdocumentrepresentsaconsensusdriven
maydegenerateintoAFandAFmayconverttoatrialflutter. by a desire for simplicity and clinical relevance.
TheECGpatternmayfluctuatebetweenatrialflutterandAF, Theclinicianshoulddistinguishafirst-detectedepisodeof
reflecting changing activation of the atria. Atrial flutter is AF, whether or not it is symptomatic or self-limited, recog-
usuallyreadilydistinguishedfromAF,butwhenatrialactiv- nizingthattheremaybeuncertaintyaboutthedurationofthe
ityisprominentontheECGinmorethan1lead,AFmaybe episode and about previous undetected episodes (Fig. 3).
misdiagnosed as atrial flutter.5 Whenapatienthashad2ormoreepisodes,AFisconsidered
recurrent. If the arrhythmia terminates spontaneously, recur-
Focal atrial tachycardias, AV reentrant tachycardias, and
rent AF is designated paroxysmal; when sustained beyond
AVnodalreentranttachycardiasmayalsotriggerAF.Inother
7 d, AF is designated persistent. Termination with pharma-
atrialtachycardias,Pwavesmaybereadilyidentifiedandare
cological therapy or direct-current cardioversion does not
separatedbyanisoelectricbaselinein1ormoreECGleads.
change the designation. First-detected AF may be either
ThemorphologyofthePwavesmayhelplocalizetheorigin
paroxysmal or persistent AF. The category of persistent AF
of the tachycardias.
3. Classification
Various classification systems have been proposed for AF.
OneisbasedontheECGpresentation.2–4Anotherisbasedon
epicardial6 or endocavitary recordings or non-contact map-
pingofatrialelectricalactivity.Severalclinicalclassification
schemeshavealsobeenproposed,butnonefullyaccountsfor
allaspectsofAF.7–10Tobeclinicallyuseful,aclassification
systemmustbebasedonasufficientnumberoffeaturesand
carry specific therapeutic implications.
Assorted labels have been used to describe the pattern of
AF, including acute, chronic, paroxysmal, intermittent, con-
stant, persistent, and permanent, but the vagaries of defini-
tions make it difficult to compare studies of AF or the
effectiveness of therapeutic strategies based on these desig- Figure3.Patternsofatrialfibrillation(AF).1,Episodesthatgen-
nations. Although the pattern of the arrhythmia can change erallylast7dorless(mostlessthan24h);2,episodesthat
usuallylastlongerthan7d;3,cardioversionfailedornot
over time, it may be of clinical value to characterize the
attempted;and4,bothparoxysmalandpersistentAFmaybe
arrhythmia at a given moment. The classification scheme recurrent.
e278 Circulation March 15, 2011
alsoincludescasesoflong-standingAF(eg,greaterthan1y),
usuallyleadingtopermanentAF,inwhichcardioversionhas
failed or has not been attempted.
Thesecategoriesarenotmutuallyexclusiveinaparticular
patient, who may have several episodes of paroxysmal AF
and occasional persistent AF, or the reverse. Regarding
paroxysmal and persistent AF, it is practical to categorize a
given patient by the most frequent presentation. The defini-
tion of permanent AF is often arbitrary. The duration of AF
refersbothtoindividualepisodesandtohowlongthepatient
has been affected by the arrhythmia. Thus, a patient with
paroxysmalAFmayhaveepisodesthatlastsecondstohours
occurring repeatedly for years.
Figure4.Estimatedage-specificprevalenceofatrialfibrillation
Episodes of AF briefer than 30 s may be important in
(AF)basedon4population-basedsurveys.Prevalence,age,
certain clinical situations involving symptomatic patients, distribution,andgenderofpatientswithAFanalysisandimpli-
pre-excitationorinassessingtheeffectivenessoftherapeutic cations.ModifiedwithpermissionfromFeinbergWM,Blacks-
hearJL,LaupacisA,etal.Prevalence,agedistribution,and
interventions.ThisterminologyappliestoepisodesofAFthat
genderofpatientswithatrialfibrillation.Analysisandimplica-
lastmorethan30swithoutareversiblecause.SecondaryAF tions.ArchInternMed1995;155:469–73.19Copyright©1995,
thatoccursinthesettingofacutemyocardialinfarction(MI), AmericanMedicalAssociation.Allrightsreserved.
cardiac surgery, pericarditis, myocarditis, hyperthyroidism,
pulmonary embolism, pneumonia, or other acute pulmonary of work (6%), and paramedical procedures (2%). Globally,
disease is considered separately. In these settings, AF is not the annual cost per patient is close to €3000 (approximately
theprimaryproblem,andtreatmentoftheunderlyingdisorder U.S. $3600).16 Considering the prevalence of AF, the total
concurrently with management of the episode of AF usually societal burden is huge, for example, about €13.5 billion
terminates the arrhythmia without recurrence. Conversely, (approximately U.S. $15.7 billion) in the European Union.
because AF is common, it may occur independently of a
concurrentdisorderlikewell-controlledhypothyroidism,and 4.1. Prevalence
thenthegeneralprinciplesformanagementofthearrhythmia TheestimatedprevalenceofAFis0.4%to1%inthegeneral
apply. population, increasing with age.18,19 Cross-sectional studies
The term “lone AF” has been variously defined but havefoundalowerprevalenceinthosebelowtheageof60y,
generally applies to young individuals (under 60 y of age) increasing to 8% in those older than 80 y (Fig. 4).20–22 The
without clinical or echocardiographic evidence of cardiopul- age-adjustedprevalenceofAFishigherinmen,22,23inwhom
monary disease, including hypertension.11 These patients the prevalence has more than doubled from the 1970s to the
haveafavorableprognosiswithrespecttothromboembolism 1990s, while the prevalence in women has remained un-
andmortality.Overtime,patientsmaymoveoutofthelone changed.24 The median age of AF patients is about 75 y.
AF category due to aging or development of cardiac abnor- Approximately70%arebetween65and85yold.Theoverall
malitiessuchasenlargementoftheleftatrium(LA.Then,the number of men and women with AF is about equal, but
risksofthromboembolismandmortalityriseaccordingly.By approximately 60% of AF patients over 75 y are female.
convention, the term “nonvalvular AF” is restricted to cases Basedonlimiteddata,theage-adjustedriskofdevelopingAF
in which the rhythm disturbance occurs in the absence of inblacksseemslessthanhalfthatinwhites.18,25,26AFisless
rheumatic mitral valve disease, a prosthetic heart valve, or common among African-American than Caucasian patients
mitral valve repair. with heart failure (HF).
In population-based studies, patients with no history of
4. Epidemiology and Prognosis cardiopulmonary disease account for fewer than 12% of all
AF is the most common arrhythmia in clinical practice, cases of AF.11,22,27,28 In some series, however, the observed
accountingforapproximatelyone-thirdofhospitalizationsfor proportion of lone AF was over 30%.29,30
cardiac rhythm disturbances. Most data regarding the epide- These differences may depend on selection bias when
miology, prognosis, and quality of life in AF have been recruiting patients seen in clinical practice compared with
obtainedintheUnitedStatesandwesternEurope.Ithasbeen population-based observations. In the Euro Heart Survey on
estimatedthat2.2millionpeopleinAmericaand4.5million AF,31theprevalenceofidiopathicAFamountedto10%,with
in the European Union have paroxysmal or persistent AF.12 anexpectedhighestvalueof15%inparoxysmalAF,14%in
During the past 20 y, there has been a 66% increase in first-detected AF, 10% in persistent AF, and only 4% in
hospital admissions for AF13–15 due to a combination of permanent AF. Essential hypertension, ischemic heart dis-
factorsincludingtheagingofthepopulation,arisingpreva- ease, HF (Table 2), valvular heart disease, and diabetes are
lence of chronic heart disease, and more frequent diagnosis the most prominent conditions associated with AF.14
through use of ambulatory monitoring devices. AF is an
extremelycostlypublichealthproblem,16,17withhospitaliza- 4.2. Incidence
tions as the primary cost driver (52%), followed by drugs In prospective studies, the incidence of AF increases from
(23%), consultations (9%), further investigations (8%), loss less than 0.1% per year in those under 40 y old to exceed