Transcript Atrial Fibrillation - Annals of Internal Medicine

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© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
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© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
in the clinic
Atrial Fibrillation
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Who is at risk for atrial fibrillation?
 Most common, clinically significant cardiac arrhythmia
 Occurs in <1% 60-65y; 8%-10% >80y
 Higher prevalence men than women, whites than blacks
 Risk for AF  w/ presence & severity of underlying HF
and valvular disease.
Definition of Atrial Fibrillation (AF):
When diffuse, chaotic electrical activity in atria
suppresses/replaces normal sinus mechanism,
leads to deterioration of mechanical function
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What symptoms and signs should
cause clinicians to suspect AF?
Symptoms
 Palpitations
 Shortness of breath
 Exercise intolerance
 Chest pain
 Malaise
Result from 
 Elevated ventricular rate (either at
rest or exaggerated by exercise)
 Irregular ventricular rate
 Loss atrial contrib to cardiac output
Signs on physical exam
 Faster-than-expected heart
rate (varies greatly from pt to pt)
 “Irregularly irregular” time
between heart sounds on
auscultation
 Peripheral pulses that vary
irregularly in rate & amplitude
 Symptoms greatest at AF
onset (paroxysmal episode)
 Diminish over time, esp
when arrhythmia persistent
 Many pts asymptomatic, esp
elderly  silent AF (some have
severe symptoms with other
AF episodes)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Is a single electrocardiogram sufficient
to diagnose or exclude atrial fibrillation?
 Single ECG sufficient to Dx  if recorded during arrhythmia
ECG of AF
w/ rapid
ventricular
rate
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Is a single electrocardiogram sufficient
to diagnose or exclude atrial fibrillation?
 Single ECG showing normal rhythm does not exclude
Dx because AF often is paroxysmal
 With daily symptoms, 24- or 48-h continuous Holter
monitoring usually is sufficient to make Dx
 With less-frequent symptoms, monitor longer with ECG
loop recorder
 Must turn on recorder when symptoms begin, so it is
not useful if arrhythmias are asymptomatic or if pt
doesn’t recognize symptoms
 With very infrequent episodes may take yrs to confirm
Dx (if symptoms nonspecific and long periods between
episodes)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Is a single electrocardiogram sufficient
to diagnose or exclude atrial fibrillation?
 Newer event monitors, implanted pacemakers & defibcardioverters with atrial leads record symptomatic &
asymptomatic AF
 Other new devices continuously record heart rhythms
for ≥1 mo
 Wirelessly send data to central monitoring station
for automated interpretation and Dx
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What is the role of history and physical
examination in patients with AF?
 Determine duration symptoms
 Identify potential underlying causes
 Cardiac causes
 Noncardiac causes
 Hypertension
 Pulmonary disease
 HF
 Hyperthyroidism
 Cardiac surgery
 Use of adrenergic drugs
(e.g., for pulmonary
disease) or other stim’ts
 Murmurs indicating
stenotic or
regurgitant valvular
disease
 Other indications
structural heart
disease
 Alcohol use
 Family Hx might identify 1stdegree relatives with AF and
may someday have therapeutic
implications
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What other electrocardiographic
arrhythmias can be confused with AF?
 Sinus rhythm with frequent
premature atrial contractions
 Atrial flutter
 Atrial tachycardia
Key ECG findings of AF
 Absence of P waves
 Presence of irregular
ventricular rhythm without a
recurring pattern
When irregular rhythm
present but Dx of AF
uncertain
 Examine long
recordings from
multiple leads
 Look for partially
obscured P waves in
deformed T waves
and ST segments
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What other electrocardiographic
arrhythmias can be confused with AF?
 ECG of irregular rhythm that might be AF, but P waves
& other features ID sinus rhythm with frequent
premature atrial contractions
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What other electrocardiographic
arrhythmias can be confused with AF?
 ECG of irregular rhythm that might be AF, but “sawtooth” P waves & varying ventricular response (2:1 to
4:1 AV conduction) identify atrial flutter
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
How should clinicians classify AF?
 Paroxysmal: Episodes spontaneously terminate < 7d
 Persistent: Episodes last >7d and require intervention
to restore sinus rhythm
 Permanent: Interventions to restore sinus rhythm
have either failed or have not been attempted
 Same pt may be classified into different categories at
different times. Classify to current or most common
pattern
 Distinctions predict responses to Tx (antiarrhythmic
drug Tx less likely to succeed as pattern goes from
paroxysmal to persistent to permanent)
 Pts in all 3 categories require anticoagulation
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What lab studies should clinicians obtain
in patients newly diagnosed with AF?
 Serum electrolytes and TSH (for possible causes)
 Renal & hepatic function blood tests (to guide selection
of drug Tx)
 Stool Hemoccult test (before starting anticoagulation)
 Transthoracic ECHO (to measure left atrial size and
assess for valvular heart disease, pericardial disease, and
LV hypertrophy)
 Transesophageal ECHO (excludes atrial clot and is
indicated when transthoracic images are inadequate or
cardioversion is planned in a pt therapeutically
anticoagulated <3 wks)
 Additional tests as necessary for possible PE, AMI, or HF
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What underlying conditions should
clinicians look for in patients with AF?
 Structural heart disease causes 80% of AF
 Particularly hypertensive heart disease
 Also CAD, valvular heart disease, or cardiomyopathy
 Atrial fibrosis often occurs with structural heart disease
 May be central to arrhythmia's pathogenesis
 AF in absence of heart disease is “Lone” AF
 Some experts restrict Lone AF to pts <60y because it
is hard to exclude structural heart disease in older pts
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What underlying conditions should
clinicians look for in patients with AF?
Illnesses associated with AF
 AMI
 Pulmonary embolism
 Thyrotoxicosis
 After major surgery
(AF occurs in ≈40% after
cardiac/thoracic surgery)
 During severe illness
 Obesity and sleep apnea
 May occur without
predisposing conditions,
typically in men 40-50y with
symptoms at night, at rest,
following vigorous exercise, or
with alcohol use
 Other forms of AF without
underlying conditions occur
during waking hrs and are
preceded by emotional stress or
exercise
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Diagnosis… Atrial fibrillation is the most common clinically
significant cardiac arrhythmia, and its prevalence increases with
advancing age. Typical symptoms include palpitations, shortness
of breath, and exercise intolerance. However, some patients report
only general malaise, and many patients are asymptomatic.
Electrocardiogram recordings during episodes are the only way to
confirm the diagnosis. If the diagnosis is suspected and the ECG
is normal, longer monitoring with a loop recorder or a Holter
monitor can be helpful. The initial assessment should include
laboratory tests for electrolytes, thyroid-stimulating hormone, and
renal and hepatic function to rule out underlying disorders or
contraindications to therapies. An echocardiogram should be
done to look for structural heart disease.
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What are the complications of atrial
fibrillation, and how can therapy
decrease the risk for these events?
 Symptoms (sometimes disabling)
 Usually caused by rapid ventricular rates or irregular
ventricular response
 Loss of atrial contribution to ventricular filling (atrial
kick) is well tolerated except by pts with ventricular
hypertrophy
 Thromboembolism (stroke most common)
 In nonvalvular AF, the annual risk of arterial
thromboembolism is 5% (higher in pts >75y)
 Atrial thrombi cause 75% strokes in AF
 Cardiomyopathy (prevent by treating tachycardia of AF)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
When should clinicians consider immediate
cardioversion in patients with AF?
 When duration of arrhythmia is <48h (e.g., hospitalized pt
on cardiac monitoring)
 May be appropriate in selected pts with
 Decompensated HF
 Severe angina or
acute infarction
 Most pts with AF don’t
require immediate
cardioversion
 Hypotension
 High risk for acute stroke
 In patients with extremely rapid AV conduction
mediated by the accessory pathway in Wolff-ParkinsonWhite syndrome
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Which patients with AF should
clinicians consider hospitalizing?
 Uncertain or unstable underlying arrhythmia
 Acute MI, altered mental status, decompensated
HF, or hypotension
 Intolerable symptoms despite hemodynamic
stability
 Elective cardioversion (if monitored outpatient
setting unavailable)
 Acute anticoagulation for very high stroke risk high
 Telemetry monitoring when initiating some drugs
 For procedures such as cardiac catheterization,
electrophysiologic studies, pacemakers,
implantable defibrillators, or catheter or surgical
ablation
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Should clinicians attempt rate control or
rhythm control?
 Traditionally clinicians preferred rhythm control to rate
control
 Recently high-quality clinical trials have found that
rhythm control doesn’t improve mortality, stroke,
hospitalization, or QOL compared with rate control
 Rate control easier to accomplish, prevents exposure to
the potential adverse effects of antiarrhythmic agents
 Rhythm control is useful in select pts with severe
symptoms (before or after rate control failure) or
younger pts without structural heart disease
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rate control in patients with rapid AF?
 Consider drugs to control ventricular rate in all pts with
AF even those being treated for rhythm control
 Traditional target heart rate has been 60-80 beats/min
at rest and 90-115 beats/min during mod exercise
(criteria varies by age)
 Recent data found no advantage of a target of ≤80
beats/min compared to a target of ≤110 beats/min
(Van Gelder et al, 2009)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rate control in patients with rapid AF?
ß-Blockers: 1st-line Tx to  AV nodal conduction
 Metoprolol
 Propranolol
 Esmolol
 Pindolol
 Atenolol
 Nadolol
 Convenient IV admin in NPO
pts, rapid onset action,
 Inexpensive, commonly avail
dependable AV nodal blockade
 Short-acting,
titratable on or off
Side effects: Bradycardia,
 Side
effects:
w/
very
rapid Bradycardia,
half-life
hypotension,
heart block,
hypotension,
heartless
block,
 Less
bradycardia,
bronchospasm,
worsening CHF
 Side
bronchospasm
effects: Bradycardia,
(less
bronchospasm;
less frequently
propensity for

Lower
incidence
of
crossing
than
heart
ß-blockers),
block,
 hypotension,
Doesn’t
cross
blood-brain
heartnonselective
block
than
other
ß-blockers
blood–brain
barrier,
fewer
CNS
worsening
bronchospasm
of CHF
(less
frequent)
barrier, fewer
CNS
side
effects
 side
Side effects
effects: Bradycardia,
 Occasionally
inconsistent
Side
effects: Bradycardia,
hypotension,
heart block effect
 Side
effects: Bradycardia,
in
high-catecholamine
states
hypotension,
heart block
hypotension, heart block
 Available in oral form only
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rate control in patients with rapid AF?
Nondihydropyridine calcium-channel antagonists (1st-line
Tx to  AV nodal conduction)
 Verapamil
 Consistent AV nodal blockade
 Diltiazem
 Side effects: Hypotension, heart block,
direct myocardial depression
 Do not use in Wolff-Parkinson-White
 Cardiac glycoside syndrome
digoxin
 Useful for rate control only with  LV systolic function
 Side effects: Heart block and arrhythmias; dosage
adjustment required in renal impairment
 Not useful for rate control during exercise or
conversion of AF/aflutter to NSR
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rate control in patients with rapid AF?
 Dronedarone
 Recently approved, modestly effective, fewer side
effects than amiodarone
 Amiodarone
 Blocks AV node, not recommended as 1st-line
monotherapy for rate control because of associated
toxicities
 Occasionally used to  ventricular response if other
agents fail
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
Rhythm control is no longer the preferred strategy
based on trials comparing rate vs. rhythm control
 Consider rhythm control in younger patients and patients
with highly symptomatic AF because trials did not include
these groups
 Experienced clinicians may prefer rhythm control with
cardioversion for 1st episode symptomatic AF in younger
patients because many such patients maintain sinus
rhythm without drugs
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
 Direct electrical current to convert to NSR indicated if
hemodynamically unstable
 Antiarrhythmic drugs:
- conversion rate < direct electrical current in
hemodynamically stable pts
+ deep sedation or general anesthesia not required
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
 Either direct electrical or antiarrhythmic drug
cardioversion:
 AF >48h or undetermined duration: establish rate control &
anticoagulation before elective cardioversion
 INR 2.0 – 3.0 for > 3 weeks prior and > 4 weeks after cardioversion
 Alternative- Transesophageal Echo:
  No clot: heparin for 48 hr prior to cardioversion & warfarin for 4 wks
after
  Clot present: anticoagulation for 4 weeks; most confirm thrombus
resolution with repeat TEE before cardioversion
 Serum K level should be >4.0 mmol/L, serum Mg level >1.0
mmol/L, and ionized Ca levels >0.5 mmol/L
 Conduct cardioversion in monitored hospital setting
 Because antiarrhythmic drugs generally have equal efficacy,
except for amiodarone, choose a drug by side effects
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
Class Ia antiarrhythmic drugs prolong conduction & slow
repolarization by blocking inward Na+ flux
 Procainamide not recommended because of frequent side
effects (hypotension, nausea, vomiting, lupus-like syndrome,
QT prolongation, arrhythmia)
 Quinidine gluconate not recommded because of frequent
side effects (proarrhythmia, nausea, vomiting, diarrhea, QT
prolongation)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
 Disopyramide: Use in pts with hypertension & normal LV
function
 Adverse effects include QT prolongation, torsades de
pointes, and heart block
 Rarely used in current era
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
Class Ic antiarrhythmic drugs block Na+ channels
 Flecainide is effective in paroxysmal AF with structurally
normal hearts
 Adverse effects include atrial flutter and atrial tachycardia
with rapid ventricular response; also VT, and VF in diseased
hearts
 Do not use in pts with structurally abnormal hearts
 Propafenone is effective in paroxysmal and sustained AF
 Adverse effects include atrial flutter or atrial tachycardia with
rapid ventricular response
 Do not use in pts with structurally abnormal hearts
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
Antiarrhythmic drugs (class III)
 Ibutilide prolongs action potential duration (and atrial and
ventricular refractoriness)
 Effective in acute & rapid conversion of AF to NSR
 Adverse effects include torsades de pointes and QT
prolongation
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
 Amiodarone blocks Na+ channels
 Safest agent for use in pts with structural heart disease, good
efficacy maintaining NSR chronically; can be used in Wolff–
Parkinson-White syndrome
 Adverse effects include bradycardia, QT prolongation,
hyperthyroidism, lung toxicity, blue discoloration of skin
 Sotalol is a nonselective ß - and 1ß -blocking agent that
prolongs action potential duration
 Similar in efficacy to quinidine but with fewer adverse effects
and better rate control. Initiate on telemetry
 Adverse effects include fatigue, depression, bradycardia,
torsades de pointes, and CHF
 ß-blocking properties, but some inotropic activity; lethal
arrhythmias possible; adjust dose in pts with renal insufficiency
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What strategies should clinicians consider
for rhythm control in patients with AF?
 Dofetilide prolongs refractoriness without slowing conduction
 More effective than quinidine in conversion to and
maintenance of NSR; initiate on telemetry
 Adverse effetcs include QT prolongation and, torsades de
pointes
 Dose strictly according to renal function, body size, & age;
contraindicated in pts with creatinine clearance <20 mL/min
 Dronedarone is similar to amiodarone—blocks sodium,
potassium, and calcium channels—but without iodine
 Adverse effects include GI intolerance
 Contraindicated for decompensated CHD; less efficacious but
better tolerated than amiodarone
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
When should clinicians use antiarrhythmic
drugs to prevent the recurrence of AF?
 Have only modest effects prolonging time to recurrence
The Canadian Trial of Atrial Fibrillation randomly
assigned 403 patients to amiodarone, sotalol, or
propafenone and found that after mean followup of 16 mos, recurrence of AF was 35% for
amiodarone Tx compared w/ 63% for sotalol or
propafenone Tx (NEJM, 2000)
 Some nonantiarrhythmic drugs (ACE-inhibitors, statins)
reduce the incidence of AF in pts with HF presumably
because of antifibrotic effects
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
When is anticoagulation indicated for
patients with atrial fibrillation?
 When thromboembolism risk exceeds the risk for
anticoagulation-associated bleeding
 For example, a >65y pt with AF and no other risk
factors has ≈1% risk for thromboembolism, which
approximates the risk for major bleeding on warfarin
when the INR is between 2.0-3.0
 Same indications for anticoagulation in pts with
paroxysmal, persistent, & permanent AF
 Use CHADS2 score (Cardiac Failure, Hypertension, Age,
Diabetes, and Stroke [Doubled]) to identify which pts
with AF warrant anticoag Tx
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
When is anticoagulation indicated for
patients with atrial fibrillation?
CHADS2 Risk Criteria
Score
Past stroke or TIA 2
Age >75 y
1
Hypertension
1
Diabetes mellitus
1
Heart failure
1
Reproduced from
ACC/AHA/ESC 2006
Guidelines for the
Management of Patients
with Atrial Fibrillation 2006
(PMID: 16908781) with
permission from the AHA.
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
When is anticoagulation indicated for
patients with atrial fibrillation?
 Consider long-term anticoagulation in pts with
 High risk for recurrent AF
 Asymptomatic AF
 Intracardiac thrombus
 Known risk factors for thromboembolism (age ≥75y, recent
HF, LV dysfunction, diabetes mellitus, hypertension,
previous thromboembolism)
 Many clinicians use cutoff of 65 rather than 75 yrs to
initiate warfarin Tx when pt also has CAD
 Genetic tests can identify pts who require different
warfarin dosing, but the tests are not recommended
because they have not been shown to improve pt
outcomes
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What anticoagulation regimens should
clinicians use in patients with AF?
 Warfarin is the preferred drug. Adjust the dose to an INR of 2.03.0 (2.5-3.5 for patients with prosthetic valves)
 Aspirin is an alternative to warfarin when there are
contraindications to warfarin; no previous stroke or transient
ischemic attack; no hypertension, diabetes, or HF, and the
patient is < 75
 Aspirin + clopidogrel together prevent more strokes than
aspirin alone but are not as effective as warfarin and have a
bleeding risk that is equivalent to warfarin
 Dabigatran recently has been approved by the FDA to prevent
stroke and systemic embolism in pts with AF & creatinine
clearance ≥30 mL/min
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
When should clinicians consider
nondrug therapies for patients with AF?
 AV nodal catheter ablation inactivates parts of the
atrium where AF begins
 
Occlusion
Use when
ofdrug
the left
Tx atrial
doesn’t
appendage
achieve rate
to prevent
controlstrokes
(usually because of drug intolerance in the elderly or in
pts
Prevents
recurrent
symptomatic
AF inlimits
highly
selected
with advanced
HF
or COPD, which
β-blocker
patients,
ideally young, otherwise healthy person without
use)
structural
Selected heart
high-risk
pts not
candidates
for oral
disease
& with
paroxysmal
AF

Highly
effective
but
requires
pacemaker
insertion, can
anticoagulation therapy
lead
Maytobeprogressive
reasonableLV
when
antiarrhythmic drug Tx fails in
dysfunction
highly
Additional
studies needed
verify the safety
&
symptomatic
pts withtoparoxysmal
AF
 Pacing therapy
without
AV nodal ablation has little
effectiveness
of these
devices
effect on burden of AF (but may help with paroxysmal AF
and symptomatic bradycardia, a side effect drug Tx)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
How should clinicians monitor patients
with atrial fibrillation?
 Regular follow-up to
 Determine effectiveness of Tx
 Monitor warfarin anticoagulation
 Check if symptoms adequately controlled (ask about
palpitations, easy fatigability, dyspnea on exertion)
 If on amiodarone, check liver and thyroid function
every 6 months and order chest x-ray annually
(otherwise routine tests for drug side effects
unnecessary)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
Treatment… Atrial fibrillation treatment goals include reducing the
frequency and severity of symptoms, preventing stroke, and
preventing tachycardia-related cardiomyopathy. Selection of
patients for anticoagulation with aspirin or warfarin should be
based on the CHADS2 score. Focus treatment first on rate control
by using beta-blockers or calcium-channel antagonists aiming for
a resting rate between 60 and 110 beats per minute. Rhythm
control may be reasonable in patients who do not respond to rate
control. Atrial ablation and atrioventricular nodal ablation therapy
may be appropriate for selected patients with highly symptomatic
AF despite drug therapy.
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.
What do professional organizations
recommend with regard to the
management of patients with AF?
 American College of Physicians & American Academy
of Family Physicians guideline on AF mgmt (2003)
 American Heart Association & American College of
Cardiology guideline on AF mgmt (2006)
 European Society of Cardiology guideline on AF mgmt
(2010)
© Copyright Annals of Internal Medicine, 2010
Ann Int Med. 153 (11): ITC6-1.