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Clinical Practice Guideline on Management of Newly Detected Atrial Fibrillation

A newly developed set of recommendations is now available to help clinicians address critical treatment questions for adult patients with first-time detected atrial fibrillation.

In a collaborative effort between the Joint Panel of the American Academy of Family Physicians and the American College of Physicians with the Johns Hopkins Evidence-based Practice Center, Vincenza Snow, MD, and colleagues systematically reviewed the current available evidence on treatment of newly detected atrial fibrillation in adults and developed 6 recommendations to aid clinical decision-making. Each recommendation is accompanied by a grade denoting quality of the evidence on which the recommendation is made and the strength of the recommendation. For example, the strongest recommendations are based on data from randomised trials without important limitations that provide clear risk-benefit information.

For the majority of patients in this group, rate control with chronic anticoagulation with adjusted-dose warfarin is the recommended strategy based on consistent clinical data that fail to show superior results with aggressive rhythm control over rate control in reducing morbidity and mortality. This is not recommended for patients at low risk of stroke or in whom warfarin is contraindicated.

Atenolol, metoprolol, diltiazem, and verapamil are recommended for their demonstrated efficacy in rate control during exercise and at rest, whereas digoxin should only be used as second-line agent because of its efficacy for rate control only while at rest.

Both direct-current and pharmacological cardioversion are appropriate options for patients undergoing acute cardioversion to obtain sinus rhythm. For these patients, transoesophageal echocardiography with short-term prior anticoagulation followed by early cardioversion with postcardioversion anticoagulation as well as delayed cardioversion with pre- and postanticoagulation are both appropriate strategies.

Finally, rhythm maintenance therapy is not recommended for most patients who convert to sinus rhythm, except if AF compromises the quality of life. For these patients, choice of agent for maintenance therapy depends on risk factors based on patient characteristics.
Ann Intern Med. 2003 Dec 16;139:12:1009-1017. "Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians"

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