ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation

下面只選出level of evidence I及IIA的

Clinical Evaluation

The initial evaluation of a patient with suspected or proved AF involves characterizing the pattern of the arrhythmia as paroxysmal or persistent, determining its cause, and defining associated cardiac and extracardiac factors pertinent to the etiology, tolerability, and history of prior management (see Table 6 titled "Clinical Evaluation in Patients with AF" in the full text guideline document).

Pharmacological Rate Control During Atrial Fibrillation (AF)

Class I

  1. Measurement of the heart rate at rest and control of the rate using pharmacological agents (either a beta blocker or nondihydropyridine calcium channel antagonist, in most cases) are recommended for patients with persistent or permanent AF. (Level of Evidence: B)
  2. In the absence of preexcitation, intravenous administration of beta blockers (esmolol, metoprolol, or propranolol) or nondihydropyridine calcium channel antagonists (verapamil, diltiazem) is recommended to slow the ventricular response to AF in the acute setting, exercising caution in patients with hypotension or heart failure (HF). (Level of Evidence: B) 若無preexcitation,可以使用b-blocker,nondihydropyridine CCB作rate control
  3. Intravenous administration of digoxin or amiodarone is recommended to control the heart rate in patients with AF and HF who do not have an accessory pathway. (Level of Evidence: B)
  4. In patients who experience symptoms related to AF during activity, the adequacy of heart rate control should be assessed during exercise, adjusting pharmacological treatment as necessary to keep the rate in the physiological range. (Level of Evidence: C)
  5. Digoxin is effective following oral administration to control the heart rate at rest in patients with AF and is indicated for patients with HF, left ventricular (LV) dysfunction, or for sedentary individuals. (Level of Evidence: C)可以使用digoxin控制心跳,特別是在有HF,LV failure的病人

Class IIa

  1. A combination of digoxin and either a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to control the heart rate both at rest and during exercise in patients with AF. The choice of medication should be individualized and the dose modulated to avoid bradycardia. (Level of Evidence: B)
  2. It is reasonable to use ablation of the atrioventricular (AV) node or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects. (Level of Evidence: B)
  3. Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C)
  4. When electrical cardioversion is not necessary in patients with AF and an accessory pathway, intravenous procainamide or ibutilide is a reasonable alternative. (Level of Evidence: C)

Preventing Thromboembolism

(For recommendations regarding antithrombotic therapy in patients with AF undergoing cardioversion, see Section below titled "Prevention of thromboembolism in patients with atrial fibrillation undergoing cardioversion")

Class I

  1. Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except those with lone AF or contraindications. (Level of Evidence: A) 除了lone AF及禁忌症,都要使用antithrombotic治療
  2. The selection of the antithrombotic agent should be based upon the absolute risks of stroke and bleeding and the relative risk and benefit for a given patient. (Level of Evidence: A)
  3. For patients without mechanical heart valves at high risk of stroke, chronic oral anticoagulant therapy with a vitamin K antagonist is recommended in a dose adjusted to achieve the target intensity international normalized ratio (INR) of 2.0 to 3.0, unless contraindicated. Factors associated with highest risk for stroke in patients with AF are prior thromboembolism (stroke, transient ischemic attack [TIA], or systemic embolism) and rheumatic mitral stenosis. (Level of Evidence: A) 治療的目標在無機械瓣膜的病人 維持INR 2-3   請記住高危險中風病患的CHAD2:congestive heart failure,hypertension,age,diabetics(2分) 另外rheumatic mitral stenosis的病人也較容易中風
  4. Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor. Such factors include age 75 years or greater, hypertension, HF, impaired LV systolic function (ejection fraction 35% or less or fractional shortening less than 25%), and diabetes mellitus. (Level of Evidence: A)
  5. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Level of Evidence: A)
  6. Aspirin, 81 to 325 mg daily, is recommended as an alternative to vitamin K antagonists in low-risk patients or in those with contraindications to oral anticoagulation. (Level of Evidence: A) 低危險病患使用aspirin即可
  7. For patients with AF who have mechanical heart valves, the target intensity of anticoagulation should be based on the type of prosthesis, maintaining an INR of at least 2.5. (Level of Evidence: B) 機械瓣膜的INR目標2.5以上
  8. Antithrombotic therapy is recommended for patients with atrial flutter as for those with AF. (Level of Evidence: C)

Class IIa

  1. For primary prevention of thromboembolism in patients with nonvalvular AF who have just 1 of the following validated risk factors, antithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable, based upon an assessment of the risk of bleeding complications, ability to safely sustain adjusted chronic anticoagulation, and patient preferences: age greater than or equal to 75 years (especially in female patients), hypertension, HF, impaired LV function, or diabetes mellitus. (Level of Evidence: A)
  2. For patients with nonvalvular AF who have 1 or more of the following less well-validated risk factors, antithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable for prevention of thromboembolism: age 65 to 74 years, female gender, or coronary artery disease (CAD). The choice of agent should be based upon the risk of bleeding complications, ability to safely sustain adjusted chronic anticoagulation, and patient preferences. (Level of Evidence: B)
  3. It is reasonable to select antithrombotic therapy using the same criteria irrespective of the pattern (i.e., paroxysmal, persistent, or permanent) of AF. (Level of Evidence: B)
  4. In patients with AF who do not have mechanical prosthetic heart valves, it is reasonable to interrupt anticoagulation for up to 1 week without substituting heparin for surgical or diagnostic procedures that carry a risk of bleeding. (Level of Evidence: C)
  5. It is reasonable to reevaluate the need for anticoagulation at regular intervals. (Level of Evidence: C)

Cardioversion of Atrial Fibrillation

Pharmacological Cardioversion of Atrial Fibrillation

Class I

Administration of flecainide, dofetilide, propafenone, or ibutilide is recommended for pharmacological cardioversion of AF. (Level of Evidence: A)

Class IIa

  1. Administration of amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A)
  2. A single oral bolus dose of propafenone or flecainide ("pill-in-the-pocket") can be administered to terminate persistent AF outside the hospital once treatment has proved safe in hospital for selected patients without sinus or AV node dysfunction, bundle-branch block, QT-interval prolongation, the Brugada syndrome, or structural heart disease. Before antiarrhythmic medication is initiated, a beta blocker or nondihydropyridine calcium channel antagonist should be given to prevent rapid AV conduction in the event atrial flutter occurs. (Level of Evidence: C)
  3. Administration of amiodarone can be beneficial on an outpatient basis in patients with paroxysmal or persistent AF when rapid restoration of sinus rhythm is not deemed necessary. (Level of Evidence: C)

Direct-Current Cardioversion of Atrial Fibrillation and Flutter

Class I

  1. When a rapid ventricular response does not respond promptly to pharmacological measures for patients with AF with ongoing myocardial ischemia, symptomatic hypotension, angina, or heart failure (HF), immediate R-wave synchronized direct-current cardioversion is recommended. (Level of Evidence: C) 當hemodynamic不穩定,即進行同步電擊
  2. Immediate direct-current cardioversion is recommended for patients with AF involving preexcitation when very rapid tachycardia or hemodynamic instability occurs. (Level of Evidence: B)
  3. Cardioversion is recommended in patients without hemodynamic instability when symptoms of AF are unacceptable to the patient. In case of early relapse of AF after cardioversion, repeated direct-current cardioversion attempts may be made following administration of antiarrhythmic medication. (Level of Evidence: C)

Class IIa

  1. Direct-current cardioversion can be useful to restore sinus rhythm as part of a long-term management strategy for patients with AF. (Level of Evidence: B)
  2. Patient preference is a reasonable consideration in the selection of infrequently repeated cardioversions for the management of symptomatic or recurrent AF. (Level of Evidence: C)

Pharmacological Enhancement of Direct-Current Cardioversion

Class IIa

  1. Pretreatment with amiodarone, flecainide, ibutilide, propafenone, or sotalol can be useful to enhance the success of direct-current cardioversion and prevent recurrent AF. (Level of Evidence: B)
  2. In patients who relapse to AF after successful cardioversion, it can be useful to repeat the procedure following prophylactic administration of antiarrhythmic medication. (Level of Evidence: C)

Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion

Class I

  1. For patients with AF of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation (INR 2.0 to 3.0) is recommended for at least 3 wk prior to and 4 wk after cardioversion, regardless of the method (electrical or pharmacological) used to restore sinus rhythm. (Level of Evidence: B) 當AF時間大於48小時或時間未明,在cardioversion前後需進行前三周後四周的抗凝血
  2. For patients with AF of more than 48-hour duration requiring immediate cardioversion because of hemodynamic instability, heparin should be administered concurrently (unless contraindicated) by an initial intravenous bolus injection followed by a continuous infusion in a dose adjusted to prolong the activated partial thromboplastin time to 1.5 to 2 times the reference control value. Thereafter, oral anticoagulation (INR 2.0 to 3.0) should be provided for at least 4 weeks, as for patients undergoing elective cardioversion. Limited data support subcutaneous administration of low-molecular-weight heparin in this indication. (Level of Evidence: C) 如果因為血行動力學不穩 要進行電擊 但AF的時間超過48小時 那可以使用heparin來進行抗凝血 APTT:1.5-2倍為目標
  3. For patients with AF of less than 48-hours duration associated with hemodynamic instability (angina pectoris, myocardial infarction [MI], shock, or pulmonary edema), cardioversion should be performed immediately without delay for prior initiation of anticoagulation. (Level of Evidence: C)

Class IIa

  1. During the 48 hours after onset of AF, the need for anticoagulation before and after cardioversion may be based on the patient's risk of thromboembolism. (Level of Evidence: C)
  2. As an alternative to anticoagulation prior to cardioversion of AF, it is reasonable to perform transesophageal echocardiography (TEE) in search of thrombus in the left atrium (LA) or left atrial appendage (LAA). (Level of Evidence: B) 
    1. For patients with no identifiable throbus, cardioversion is reasonable immediately after anticoagulation with unfractionated heparin (e.g., initiate by intravenous bolus injection and an infusion continued at a dose adjusted to prolong the activated partial thromboplastin time to 1.5 to 2 times the control value until oral anticoagulation has been established with vitamin K antagonist (e.g., warfarin) as evidenced by an INR equal to or greater than 2.0). (Level of Evidence: B)

      Thereafter, oral anticoagulation (INR 2.0 to 3.0) is reasonable for a total anticoagulation period of at least 4 weeks, as for patients undergoing elective cardioversion. (Level of Evidence: B)

      Limited data are available to support the subcutaneous administration of a low molecular-weight heparin in this indication. (Level of Evidence: C)

    1. For patients in whom thrombus is identified by TEE, oral anticoagulation (INR 2.0 to 3.0) is reasonable for at least 3 weeks prior to and 4 weeks after restoration of sinus rhythm, and a longer period of anticoagulation may be appropriate even after apparently successful cardioversion, because the risk of thromboembolism often remains elevated in such cases. (Level of Evidence: C)
  1. For patients with atrial flutter undergoing cardioversion, anticoagulation can be beneficial according to the recommendations as for patients with AF. (Level of Evidence: C)

Maintenance of Sinus Rhythm

Class I

Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C)

Class IIa

  1. Pharmacological therapy can be useful in patients with AF to maintain sinus rhythm and prevent tachycardia-induced cardiomyopathy. (Level of Evidence: C)
  2. Infrequent, well-tolerated recurrence of AF is reasonable as a successful outcome of antiarrhythmic drug therapy. (Level of Evidence: C)
  3. Outpatient initiation of antiarrhythmic drug therapy is reasonable in patients with AF who have no associated heart disease when the agent is well tolerated. (Level of Evidence: C)
  4. In patients with lone AF without structural heart disease, initiation of propafenone or flecainide can be beneficial on an outpatient basis in patients with paroxysmal AF who are in sinus rhythm at the time of drug initiation. (Level of Evidence: B)
  5. Sotalol can be beneficial in outpatients in sinus rhythm with little or no heart disease, prone to paroxysmal AF, if the baseline uncorrected QT interval is less than 460 ms, serum electrolytes are normal, and risk factors associated with class III drug–related proarrhythmia are not present. (Level of Evidence: C)
  6. Catheter ablation is a reasonable alternative to pharmacological therapy to prevent recurrent AF in symptomatic patients with little or no LA enlargement. (Level of Evidence: C)

Special Considerations

Postoperative Atrial Fibrillation

Class I

  1. Unless contraindicated, treatment with an oral beta blocker to prevent postoperative AF is recommended for patients undergoing cardiac surgery. (Level of Evidence: A)
  2. Administration of AV nodal blocking agents is recommended to achieve rate control in patients who develop postoperative AF. (Level of Evidence: B)

Class IIa

  1. Preoperative administration of amiodarone reduces the incidence of AF in patients undergoing cardiac surgery and represents appropriate prophylactic therapy for patients at high risk for postoperative AF. (Level of Evidence: A)
  2. It is reasonable to restore sinus rhythm by pharmacological cardioversion with ibutilide or direct-current cardioversion in patients who develop postoperative AF as advised for nonsurgical patients. (Level of Evidence: B)
  3. It is reasonable to administer antiarrhythmic medications in an attempt to maintain sinus rhythm in patients with recurrent or refractory postoperative AF, as recommended for other patients who develop AF. (Level of Evidence: B)
  4. It is reasonable to administer antithrombotic medication in patients who develop postoperative AF, as recommended for nonsurgical patients. (Level of Evidence: B)

Acute Myocardial Infarction (MI)

Class I

  1. Direct-current cardioversion is recommended for patients with severe hemodynamic compromise or intractable ischemia, or when adequate rate control cannot be achieved with pharmacological agents in patients with acute MI and AF. (Level of Evidence: C)
  2. Intravenous administration of amiodarone is recommended to slow a rapid ventricular response to AF and improve LV function in patients with acute MI. (Level of Evidence: C)
  3. Intravenous beta blockers and nondihydropyridine calcium antagonists are recommended to slow a rapid ventricular response to AF in patients with acute MI who do not display clinical LV dysfunction, bronchospasm, or AV block. (Level of Evidence: C)
  4. For patients with AF and acute MI, administration of unfractionated heparin by either continuous intravenous infusion or intermittent subcutaneous injection is recommended in a dose sufficient to prolong the activated partial thromboplastin time to 1.5 to 2 times the control value, unless contraindications to anticoagulation exist. (Level of Evidence: C)

Class IIa

Intravenous administration of digitalis is reasonable to slow a rapid ventricular response and improve LV function in patients with acute MI and AF associated with severe LV dysfunction and HF. (Level of Evidence: C)

Management of Atrial Fibrillation Associated With the Wolff-Parkinson-White (WPW) Preexcitation Syndrome

Class I

  1. Catheter ablation of the accessory pathway is recommended in symptomatic patients with AF who have WPW syndrome, particularly those with syncope due to rapid heart rate or those with a short bypass tract refractory period. (Level of Evidence: B)
  2. Immediate direct-current cardioversion is recommended to prevent ventricular fibrillation in patients with a short anterograde bypass tract refractory period in whom AF occurs with a rapid ventricular response associated with hemodynamic instability. (Level of Evidence: B)
  3. Intravenous procainamide or ibutilide is recommended to restore sinus rhythm in patients with WPW in whom AF occurs without hemodynamic instability in association with a wide QRS complex on the electrocardiogram (ECG) (greater than or equal to 120-ms duration) or with a rapid preexcited ventricular response. (Level of Evidence: C)

Class IIa

Intravenous flecainide or direct-current cardioversion is reasonable when very rapid ventricular rates occur in patients with AF involving conduction over an accessory pathway. (Level of Evidence: B)

Hyperthyroidism

Class I

  1. Administration of a beta blocker is recommended to control the rate of ventricular response in patients with AF complicating thyrotoxicosis, unless contraindicated. (Level of Evidence: B)
  2. In circumstances when a beta blocker cannot be used, administration of a nondihydropyridine calcium channel antagonist (diltiazem or verapamil) is recommended to control the ventricular rate in patients with AF and thyrotoxicosis. (Level of Evidence: B)
  3. In patients with AF associated with thyrotoxicosis, oral anticoagulation (INR 2.0 to 3.0) is recommended to prevent thromboembolism, as recommended for AF patients with other risk factors for stroke. (Level of Evidence: C)
  4. Once a euthyroid state is restored, recommendations for antithrombotic prophylaxis are the same as for patients without hyperthyroidism. (Level of Evidence: C)

Management of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy (HCM)

Class I

Oral anticoagulation (INR 2.0 to 3.0) is recommended in patients with HCM who develop AF, as for other patients at high risk of thromboembolism. (Level of Evidence: B)

Class IIa

Antiarrhythmic medications can be useful to prevent recurrent AF in patients with HCM. Available data are insufficient to recommend one agent over another in this situation, but (a) disopyramide combined with a beta blocker or nondihydropyridine calcium channel antagonist or (b) amiodarone alone is generally preferred. (Level of Evidence: C)

Management of Atrial Fibrillation in Patients With Pulmonary Disease

Class I

  1. Correction of hypoxemia and acidosis is the recommended primary therapeutic measure for patients who develop AF during an acute pulmonary illness or exacerbation of chronic pulmonary disease. (Level of Evidence: C)
  2. A nondihydropyridine calcium channel antagonist (diltiazem or verapamil) is recommended to control the ventricular rate in patients with obstructive pulmonary disease who develop AF. (Level of Evidence: C)
  3. Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of AF. (Level of Evidence: C)

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