ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation
2006; Lippincott Williams & Wilkins; Volume: 114; Issue: 7 Linguagem: Inglês
10.1161/circulationaha.106.177292
ISSN1524-4539
AutoresValentı́n Fuster, Lars Rydén, David S. Cannom, Harry J.G.M. Crijns, Anne B. Curtis, Kenneth A. Ellenbogen, Jonathan L. Halperin, Jean-Yves Le Heuzey, G. Neal Kay, James E. Lowe, Sandra Olsson, Eric N. Prystowsky, Juan Tamargo, Samuel Wann, Sidney C. Smith, Alice K. Jacobs, Cynthia D. Adams, Jeffery L. Anderson, Elliott M. Antman, Jonathan L. Halperin, Sharon A. Hunt, Rick A. Nishimura, Joseph P. Ornato, Richard L. Page, Bárbara Riegel, Silvia G. Priori, Jean‐Jacques Blanc, Andrzej Budaj, A. John Camm, Verónica Dean, Jaap W. Deckers, Catherine Despres, Kenneth Dickstein, John Lekakis, Keith McGregor, Marco Metra, João Morais, A. Osterspey, Juan Tamargo, José Luis Zamorano,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculationVol. 114, No. 7ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial FibrillationA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society Valentin Fuster, WRITING COMMITTEE:, MD, PhD, FACC, FAHA, FESC, Co-Chair, Lars E. Rydén, MD, PhD, FACC, FESC, FAHA, Co-Chair, David 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, Jean-Yves Le Heuzey, MD, FESC, G. Neal Kay, MD, FACC, James E. Lowe, MD, FACC, S. Bertil Olsson, MD, PhD, FESC, Eric N. Prystowsky, MD, FACC, Juan Luis Tamargo, MD, FESC, Samuel Wann, MD, FACC, FESC, ACC/AHA TASK FORCE MEMBERS Sidney C. SmithJr, MD, FACC, FAHA, FESC, Chair, Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair, Cynthia D. Adams, MSN, APRN-BC, FAHA, Jeffery L. Anderson, MD, FACC, FAHA, Elliott M. Antman, MD, FACC, FAHA, Jonathan L. Halperin, MD, FACC, FAHA, Sharon Ann Hunt, MD, FACC, FAHA, Rick Nishimura, MD, FACC, FAHA, Joseph P. Ornato, MD, FACC, FAHA, Richard L. Page, MD, FACC, FAHA, Barbara Riegel, DNSc, RN, FAHA, ESC COMMITTEE FOR PRACTICE GUIDELINES Silvia G. Priori, MD, PhD, FESC, Chair, Jean-Jacques Blanc, MD, FESC, France, Andrzej Budaj, MD, FESC, Poland, A. John Camm, MD, FESC, FACC, FAHA, United Kingdom, Veronica Dean, France, Jaap W. Deckers, MD, FESC, The Netherlands, Catherine Despres, France, Kenneth Dickstein, MD, PhD, FESC, Norway, John Lekakis, MD, FESC, Greece, Keith McGregor, PhD, France, Marco Metra, MD, Italy, Joao Morais, MD, FESC, Portugal, Ady Osterspey, MD, Germany, Juan Luis Tamargo, MD, FESC, Spain and José Luis Zamorano, MD, FESC, Spain Valentin FusterValentin Fuster Search for more papers by this author , Lars E. RydénLars E. Rydén Search for more papers by this author , David S. CannomDavid S. Cannom Search for more papers by this author , Harry J. CrijnsHarry J. Crijns Search for more papers by this author , Anne B. CurtisAnne B. Curtis Search for more papers by this author , Kenneth A. EllenbogenKenneth A. Ellenbogen Search for more papers by this author , Jonathan L. HalperinJonathan L. Halperin Search for more papers by this author , Jean-Yves Le HeuzeyJean-Yves Le Heuzey Search for more papers by this author , G. Neal KayG. Neal Kay Search for more papers by this author , James E. LoweJames E. Lowe Search for more papers by this author , S. Bertil OlssonS. Bertil Olsson Search for more papers by this author , Eric N. PrystowskyEric N. Prystowsky Search for more papers by this author , Juan Luis TamargoJuan Luis Tamargo Search for more papers by this author , Samuel WannSamuel Wann Search for more papers by this author , ACC/AHA TASK FORCE MEMBERS Search for more papers by this author , Sidney C. SmithJrSidney C. SmithJr Search for more papers by this author , Alice K. JacobsAlice K. Jacobs Search for more papers by this author , Cynthia D. AdamsCynthia D. Adams Search for more papers by this author , Jeffery L. AndersonJeffery L. Anderson Search for more papers by this author , Elliott M. AntmanElliott M. Antman Search for more papers by this author , Jonathan L. HalperinJonathan L. Halperin Search for more papers by this author , Sharon Ann HuntSharon Ann Hunt Search for more papers by this author , Rick NishimuraRick Nishimura Search for more papers by this author , Joseph P. OrnatoJoseph P. Ornato Search for more papers by this author , Richard L. PageRichard L. Page Search for more papers by this author , Barbara RiegelBarbara Riegel Search for more papers by this author , ESC COMMITTEE FOR PRACTICE GUIDELINES Search for more papers by this author , Silvia G. PrioriSilvia G. Priori Search for more papers by this author , Jean-Jacques BlancJean-Jacques Blanc Search for more papers by this author , Andrzej BudajAndrzej Budaj Search for more papers by this author , A. John CammA. John Camm Search for more papers by this author , Veronica DeanVeronica Dean Search for more papers by this author , Jaap W. DeckersJaap W. Deckers Search for more papers by this author , Catherine DespresCatherine Despres Search for more papers by this author , Kenneth DicksteinKenneth Dickstein Search for more papers by this author , John LekakisJohn Lekakis Search for more papers by this author , Keith McGregorKeith McGregor Search for more papers by this author , Marco MetraMarco Metra Search for more papers by this author , Joao MoraisJoao Morais Search for more papers by this author , Ady OsterspeyAdy Osterspey Search for more papers by this author , Juan Luis TamargoJuan Luis Tamargo Search for more papers by this author and José Luis ZamoranoJosé Luis Zamorano Search for more papers by this author Originally published15 Aug 2006https://doi.org/10.1161/CIRCULATIONAHA.106.177292Circulation. 2006;114:e257–e354is corrected byCorrectionTABLE OF CONTENTSPreamble…e2601. Introduction…e261 1.1. Organization of Committee and Evidence Review…e261 1.2. Contents of These Guidelines…e261 1.3. Changes Since the Initial Publication of These Guidelines in 2001…e2632. Definition…e263 2.1. Atrial Fibrillation…e263 2.2. Related Arrhythmias…e2633. Classification…e2634. Epidemiology and Prognosis…e265 4.1. Prevalence…e266 4.2. Incidence…e266 4.3. Prognosis…e2675. Pathophysiological Mechanisms…e268 5.1. Atrial Factors…e268 5.1.1. Atrial Pathology as a Cause of Atrial Fibrillation…e268 5.1.1.1. Pathological Changes Caused by Atrial Fibrillation…e268 5.1.2. Mechanisms of Atrial Fibrillation…e269 5.1.2.1. Automatic Focus Theory…e269 5.1.2.2. Multiple-Wavelet Hypothesis…e269 5.1.3. Atrial Electrical Remodeling…e270 5.1.4. Counteracting Atrial Electrical Remodeling…e271 5.1.5. Other Factors Contributing to Atrial Fibrillation…e271 5.2. Atrioventricular Conduction…e272 5.2.1. General Aspects…e272 5.2.2. Atrioventricular Conduction in Patients With Preexcitation Syndromes…e272 5.3. Myocardial and Hemodynamic Consequences of Atrial Fibrillation…e272 5.4. Thromboembolism…e273 5.4.1. Pathophysiology of Thrombus Formation…e273 5.4.2. Clinical Implications…e2746. Causes, Associated Conditions, Clinical Manifestations, and Quality of Life…e274 6.1. Causes and Associated Conditions…e274 6.1.1. Reversible Causes of Atrial Fibrillation…e274 6.1.2. Atrial Fibrillation Without Associated Heart Disease…e274 6.1.3. Medical Conditions Associated With Atrial Fibrillation…e274 6.1.4. Atrial Fibrillation With Associated Heart Disease…e275 6.1.5. Familial (Genetic) Atrial Fibrillation…e275 6.1.6. Autonomic Influences in Atrial Fibrillation…e275 6.2. Clinical Manifestations…e275 6.3. Quality of Life…e2767. Clinical Evaluation…e276 7.1. Basic Evaluation of the Patient With Atrial Fibrillation…e276 7.1.1. Clinical History and Physical Examination…e276 7.1.2. Investigations…e276 7.2. Additional Investigation of Selected Patients With Atrial Fibrillation…e278 7.2.1. Electrocardiogram Monitoring and Exercise Testing…e278 7.2.2. Transesophageal Echocardiography…e278 7.2.3. Electrophysiological Study…e2788. Management…e278 8.1. Pharmacological and Nonpharmacological Therapeutic Options…e279 8.1.1. Pharmacological Therapy…e279 8.1.1.1. Drugs Modulating the Renin- Angiotensin-Aldosterone System…e279 8.1.1.2. HMG CoA-Reductase Inhibitors (Statins)…e280 8.1.2. Heart Rate Control Versus Rhythm Control…e280 8.1.2.1. Distinguishing Short-Term and Long-Term Treatment Goals…e280 8.1.2.2. Clinical Trials Comparing Rate Control and Rhythm Control…e280 8.1.2.3. Effect on Symptoms and Quality of Life…e280 8.1.2.4. Effects on Heart Failure…e281 8.1.2.5. Effects on Thromboembolic Complications…e281 8.1.2.6. Effects on Mortality and Hospitalization…e282 8.1.2.7. Implications of the Rhythm-Control Versus Rate-Control Studies…e282 8.1.3. Rate Control During Atrial Fibrillation…e282 8.1.3.1. Pharmacological Rate Control During Atrial Fibrillation…e283 8.1.3.1.1. Beta Blockers…e284 8.1.3.1.2. Nondihydropyridine Calcium Channel Antagonists…e285 8.1.3.1.3. Digoxin…e285 8.1.3.1.4. Antiarrhythmic Agents…e285 8.1.3.1.5. Combination Therapy…e285 8.1.3.1.6. Special Considerations in Patients With the Wolff- Parkinson-White (WPW) Syndrome…e286 8.1.3.2. Pharmacological Therapy to Control Heart Rate in Patients With Both Atrial Fibrillation and Atrial Flutter…e286 8.1.3.3. Regulation of Atrioventricular Nodal Conduction by Pacing…e286 8.1.3.4. AV Nodal Ablation…e286 8.1.4. Preventing Thromboembolism…e287 8.1.4.1. Risk Stratification…e288 8.1.4.1.1. Epidemiological Data…e288 8.1.4.1.2. Echocardiography and Risk Stratification…e289 8.1.4.1.3. Therapeutic Implications…e290 8.1.4.2. Antithrombotic Strategies for Prevention of Ischemic Stroke and Systemic Embolism…e292 8.1.4.2.1. Anticoagulation With Vitamin K Antagonist Agents…e292 8.1.4.2.2. Aspirin for Antithrombotic Therapy in Patients With Atrial Fibrillation…e294 8.1.4.2.3. Other Antiplatelet Agents for Antithrombotic Therapy in Patients With Atrial Fibrillation…e295 8.1.4.2.4. Combining Anticoagulant and Platelet-Inhibitor Therapy…e296 8.1.4.2.5. Emerging and Investigational Antithrombotic Agents…e297 8.1.4.2.6. Interruption of Anticoagulation for Diagnostic or Therapeutic Procedures…e298 8.1.4.3. Nonpharmacological Approaches to Prevention of Thromboembolism…e298 8.1.5. Cardioversion of Atrial Fibrillation…e298 8.1.5.1. Basis for Cardioversion of Atrial Fibrillation…e298 8.1.5.2. Methods of Cardioversion…e299 8.1.5.3. Pharmacological Cardioversion…e299 8.1.5.4. Agents With Proven Efficacy for Cardioversion of Atrial Fibrillation…e300 8.1.5.4.1. Amiodarone…e300 8.1.5.4.2. Dofetilide…e300 8.1.5.4.3. Flecainide…e300 8.1.5.4.4. Ibutilide…e302 8.1.5.4.5. Propafenone…e302 8.1.5.5. Less Effective or Incompletely Studied Agents for Cardioversion of Atrial Fibrillation…e303 8.1.5.5.1. Quinidine…e303 8.1.5.5.2. Procainamide…e303 8.1.5.5.3. Beta Blockers…e304 8.1.5.5.4. Nondihydropyridine Calcium Channel Antagonists (Verapamil and Diltiazem)…e304 8.1.5.5.5. Digoxin…e304 8.1.5.5.6. Disopyramide…e304 8.1.5.5.7. Sotalol…e304 8.1.6. Pharmacological Agents to Maintain Sinus Rhythm…e304 8.1.6.1. Agents With Proven Efficacy to Maintain Sinus Rhythm…e304 8.1.6.1.1. Amiodarone…e304 8.1.6.1.2. Beta Blockers…e305 8.1.6.1.3. Dofetilide…e305 8.1.6.1.4. Disopyramide…e306 8.1.6.1.5. Flecainide…e306 8.1.6.1.6. Propafenone…e306 8.1.6.1.7. Sotalol…e306 8.1.6.2. Drugs With Unproven Efficacy or No Longer Recommended…e307 8.1.6.2.1. Digoxin…e307 8.1.6.2.2. Procainamide…e307 8.1.6.2.3. Quinidine…e307 8.1.6.2.4. Verapamil and Diltiazem…e307 8.1.7. Out-of-Hospital Initiation of Antiarrhythmic Drugs in Patients With Atrial Fibrillation…e307 8.1.8. Drugs Under Development…e309 8.1.8.1. Atrioselective Agents…e310 8.1.8.2. Nonselective Ion Channel–Blocking Drugs…e310 8.2. Direct-Current Cardioversion of Atrial Fibrillation and Flutter…e310 8.2.1. Terminology…e310 8.2.2. Technical Aspects…e310 8.2.3. Procedural Aspects…e311 8.2.4. Direct-Current Cardioversion in Patients With Implanted Pacemakers and Defibrillators…e311 8.2.5. Risks and Complications of Direct-Current Cardioversion of Atrial Fibrillation…e312 8.2.6. Pharmacological Enhancement of Direct-Current Cardioversion…e312 8.2.6.1. Amiodarone…e313 8.2.6.2. Beta-Adrenergic Antagonists…e313 8.2.6.3. Nondihydropyridine Calcium Channel Antagonists…e313 8.2.6.4. Quinidine…e314 8.2.6.5. Type IC Antiarrhythmic Agents…e314 8.2.6.6. Type III Antiarrhythmic Agents…e314 8.2.7. Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion…e314 8.3. Maintenance of Sinus Rhythm…e315 8.3.1. Pharmacological Therapy…e316 8.3.1.1. Goals of Treatment…e316 8.3.1.2. Endpoints in Antiarrhythmic Drug Studies…e316 8.3.1.3. Predictors of Recurrent AF…e317 8.3.2. General Approach to Antiarrhythmic Drug Therapy…e317 8.3.3. Selection of Antiarrhythmic Agents in Patients With Cardiac Diseases…e317 8.3.3.1. Heart Failure…e317 8.3.3.2. Coronary Artery Disease…e318 8.3.3.3. Hypertensive Heart Disease…e318 8.3.4. Nonpharmacological Therapy for Atrial Fibrillation…e319 8.3.4.1. Surgical Ablation…e319 8.3.4.2. Catheter Ablation…e319 8.3.4.2.1. Complications of Catheter- Based Ablation…e320 8.3.4.2.2. Future Directions in Catheter-Based Ablation Therapy for Atrial Fibrillation…e320 8.3.4.3. Suppression of Atrial Fibrillation Through Pacing…e320 8.3.4.4. Internal Atrial Defibrillators…e321 8.4. Special Considerations…e321 8.4.1. Postoperative AF…e321 8.4.1.1. Clinical and Pathophysiological Correlates…e322 8.4.1.2. Prevention of Postoperative AF…e322 8.4.1.3. Treatment of Postoperative AF…e323 8.4.2. Acute Myocardial Infarction…e323 8.4.3. Wolff-Parkinson White (WPW) Preexcitation Syndromes…e324 8.4.4. Hyperthyroidism…e325 8.4.5. Pregnancy…e325 8.4.6. Hypertrophic Cardiomyopathy…e326 8.4.7. Pulmonary Diseases…e327 8.5. Primary Prevention…e3279. Proposed Management Strategies…e327 9.1. Overview of Algorithms for Management of Patients With Atrial Fibrillation…e327 9.1.1. Newly Discovered Atrial Fibrillation…e328 9.1.2. Recurrent Paroxysmal Atrial Fibrillation…e328 9.1.3. Recurrent Persistent Atrial Fibrillation…e328 9.1.4. Permanent Atrial Fibrillation…e329APPENDIX I…e330APPENDIX II…e331APPENDIX III…e333References…e335PreambleIt is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines, whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. The Task Force is pleased to have this guideline developed in conjunction with the European Society of Cardiology (ESC). Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop or update written recommendations for clinical practice.Experts in the subject under consideration have been selected from all 3 organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular tests or therapies are considered as well as frequency of follow-up and cost-effectiveness. When available, information from studies on cost will be considered; however, review of data on efficacy and clinical outcomes will constitute the primary basis for preparing recommendations in these guidelines.The ACC/AHA Task Force on Practice Guidelines and the ESC Committee for Practice Guidelines make every effort to avoid any actual, potential, or perceived conflict of interest that might arise as a result of an outside relationship or personal interest of the writing committee. Specifically, all members of the Writing Committee and peer reviewers of the document are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. Writing committee members are also strongly encouraged to declare a previous relationship with industry that might be perceived as relevant to guideline development. If a writing committee member develops a new relationship with industry during their tenure, they are required to notify guideline staff in writing. The continued participation of the writing committee member will be reviewed. These statements are reviewed by the parent Task Force, reported orally to all members of the writing committee at each meeting, and updated and reviewed by the writing committee as changes occur. Please refer to the methodology manuals for further description of the policies used in guideline development, including relationships with industry, available online at the ACC, AHA, and ESC World Wide Web sites (http://www.acc.org/clinical/manual/manual_introltr.htm, http://circ.ahajournals.org/manual/, and http://www.escardio.org/knowledge/guidelines/Rules/). Please see Appendix I for author relationships with industry and Appendix II for peer reviewer relationships with industry that are pertinent to these guidelines.These practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases and conditions. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. These guideline recommendations reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence and are intended to improve patient care. If these guidelines are used as the basis for regulatory/payer decisions, the ultimate goal is quality of care and serving the patient’s best interests. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient. There are circumstances in which deviations from these guidelines are appropriate.The guidelines will be reviewed annually by the ACC/AHA Task Force on Practice Guidelines and the ESC Committee for Practice Guidelines and will be considered current unless they are updated, revised, or sunsetted and withdrawn from distribution. The executive summary and recommendations are published in the August 15, 2006, issues of the Journal of the American College of Cardiology and Circulation and the August 16, 2006, issue of the European Heart Journal. The full-text guidelines are published in the August 15, 2006, issues of the Journal of the American College of Cardiology and Circulation and the September 2006 issue of Europace, as well as posted on the ACC (www.acc.org), AHA (www.americanheart.org), and ESC (www.escardio.org) World Wide Web sites. Copies of the full-text guidelines and the executive summary are available from all 3 organizations.Sidney C. Smith Jr, MD, FACC, FAHA, FESC, Chair, ACC/AHA Task Force on Practice GuidelinesSilvia G. Priori, MD, PhD, FESC, Chair, ESC Committee for Practice Guidelines1. Introduction1.1. Organization of Committee and Evidence ReviewAtrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance, increasing in prevalence with age. AF is often associated with structural heart disease, although 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 optimum management of this frequent and complex arrhythmia.The committee was composed of members representing the ACC, AHA, and ESC, as well as the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS). This document was reviewed by 2 official reviewers nominated by the ACC, 2 official reviewers nominated by the AHA, and 2 official reviewers nominated by the ESC, as well as by the ACCF Clinical Electrophysiology Committee, the AHA ECG and Arrhythmias Committee, the AHA Stroke Review Committee, EHRA, HRS, and numerous additional content 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 the EHRA and the HRS.The ACC/AHA/ESC Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation conducted a comprehensive review of the relevant literature from 2001 to 2006. Literature searches were conducted in the following databases: PubMed/MEDLINE and the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Registry). Searches focused on English-language sources and studies in human subjects. Articles related to animal experimentation were cited when the information was important to understanding pathophysiological concepts pertinent to patient management and comparable data were not available from human studies. Major search terms included atrial fibrillation, age, atrial remodeling, atrioventricular conduction, atrioventricular node, cardioversion, classification, clinical trial, complications, concealed conduction, cost-effectiveness, defibrillator, demographics, epidemiology, experimental, heart failure (HF), hemodynamics, human, hyperthyroidism, hypothyroidism, meta-analysis, myocardial infarction, pharmacology, postoperative, pregnancy, pulmonary disease, quality of life, rate control, rhythm control, risks, sinus rhythm, symptoms, andtachycardia-mediated cardiomyopathy.The complete list of search terms is beyond the scope of this section.Classification of Recommendations and Level of Evidence are expressed in the ACC/AHA/ESC format as follows and described in Table 1. Recommendations are evidence based and derived primarily from published data. TABLE 1. Applying Classification of Recommendations and Level of Evidence†Size of Treatment Effect*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.Estimate of Certainty (Precision) of Treatment EffectClass IClass IIaClass IIbClass IIIBenefit >>> RiskBenefit >> RiskBenefit ≥ RiskRisk ≥ BenefitAdditional studies with focused objectives neededAdditional studies with broad objectives needed; additional registry data would be helpfulNo additional studies neededProcedure/treatment SHOULD be performed/administeredIT IS REASONABLE to perform procedure/administer treatmentProcedure/treatment MAY BE CONSIDEREDProcedure/treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFULLevel A• Recommendation that procedure or treatment is useful/effective• Recommendation in favor of treatment or procedure being useful/effective• Recommendation’s usefulness/efficacy less well established• Recommendation that procedure or treatment is not useful/effective and may be harmfulMultiple (3 to 5) population risk strata evaluated*General consistency of direction and magnitude of effect• Sufficient evidence from multiple randomized trials or meta-analyses• Some conflicting evidence from multiple randomized trials or meta-analyses• Greater conflicting evidence from multiple randomized trials or meta-analyses• Sufficient evidence from multiple randomized trials or meta-analysesLevel B• Recommendation that procedure or treatment is useful/effective• Recommendation in favor of treatment or procedure being useful/effective• Recommendation’s usefulness/efficacy less well established• Recommendation that procedure or treatment is not useful/effective and may be harmfulLimited (2 to 3) population risk strata evaluated*• Limited evidence from single randomized trial or nonrandomized studies• Some conflicting evidence from single randomized trial or nonrandomized studies• Greater conflicting evidence from single randomized trial or nonrandomized studies• Limited evidence from single randomized trial or nonrandomized studiesLevel C• Recommendation that procedure or treatment is useful/effective• Recommendation in favor of treatment or procedure being useful/effective• Recommendation’s usefulness/efficacy less well established• Recommendation that procedure or treatment is not useful/effective and may be harmfulVery limited (1 to 2) population risk strata evaluated*• Only expert opinion, case studies, or standard-of-care• Only diverging expert opinion, case studies, or standard-of-care• Only diverging expert opinion, case studies, or standard-of-care• Only expert opinion, case studies, or standard-of-careClassification of RecommendationsClass I: Conditions for which there is evidence and/or general agreement that a given procedure/therapy is beneficial, useful, and effective.Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy. ○ Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. ○ Class IIb: Usefulness/efficacy is less well established by evidence/opinion.Class III: Conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful or effective and in some cases may be harmful.Level of EvidenceThe weight of evidence was ranked from highest (A) to lowest (C), as follows:Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies.Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care.1.2. Contents of These GuidelinesThese guidelines first present a comprehensive review of the latest information about the definition, classification, epidemiology, pathophysiological mechanisms, and clinical characteristics of AF. The management of this complex and potentially dangerous arrhythmia is then reviewed. This includes prevention of AF, control of heart rate, prevention of thromboembolism, and conversion to and maintenance of sinus rhythm. The treatment algorithms include pharmacological and nonpharmacological antiarrhythmic approaches, as well as antithrombotic strategies most appropriate for particular clinical conditions. 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 may include some drugs and devices that do not have the approval of all government regulatory agencies. Additional information may be obtained from the package inserts when the drug or device has been approved for the stated indication.Because atrial flutter can precede or coexist with AF, special consideration is given to this arrhythmia in each section. There are important differences in the mechanisms of AF and atrial flutter, and the body of evidence av
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