ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation—Executive Summary
2006; Lippincott Williams & Wilkins; Volume: 114; Issue: 7 Linguagem: Inglês
10.1161/circulationaha.106.177031
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—Executive Summary 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 Fibrillation—Executive SummaryA 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 , Lars E. RydénLars E. Rydén , David S. CannomDavid S. Cannom , Harry J. CrijnsHarry J. Crijns , Anne B. CurtisAnne B. Curtis , Kenneth A. EllenbogenKenneth A. Ellenbogen , Jonathan L. HalperinJonathan L. Halperin , Jean-Yves Le HeuzeyJean-Yves Le Heuzey , G. Neal KayG. Neal Kay , James E. LoweJames E. Lowe , S. Bertil OlssonS. Bertil Olsson , Eric N. PrystowskyEric N. Prystowsky , Juan Luis TamargoJuan Luis Tamargo , Samuel WannSamuel Wann , ACC/AHA TASK FORCE MEMBERS , Sidney C. SmithJrSidney C. SmithJr , Alice K. JacobsAlice K. Jacobs , Cynthia D. AdamsCynthia D. Adams , Jeffery L. AndersonJeffery L. Anderson , Elliott M. AntmanElliott M. Antman , Jonathan L. HalperinJonathan L. Halperin , Sharon Ann HuntSharon Ann Hunt , Rick NishimuraRick Nishimura , Joseph P. OrnatoJoseph P. Ornato , Richard L. PageRichard L. Page , Barbara RiegelBarbara Riegel , ESC COMMITTEE FOR PRACTICE GUIDELINES , Silvia G. PrioriSilvia G. Priori , Jean-Jacques BlancJean-Jacques Blanc , Andrzej BudajAndrzej Budaj , A. John CammA. John Camm , Veronica DeanVeronica Dean , Jaap W. DeckersJaap W. Deckers , Catherine DespresCatherine Despres , Kenneth DicksteinKenneth Dickstein , John LekakisJohn Lekakis , Keith McGregorKeith McGregor , Marco MetraMarco Metra , Joao MoraisJoao Morais , Ady OsterspeyAdy Osterspey , Juan Luis TamargoJuan Luis Tamargo and José Luis ZamoranoJosé Luis Zamorano Originally published2 Aug 2006https://doi.org/10.1161/CIRCULATIONAHA.106.177031Circulation. 2006;114:700–752is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 2, 2006: Previous Version 1 TABLE OF CONTENTSPreamble…702 I. Introduction…702 A. Organization of Committee and Evidence Review…702 Classification of Recommendations…704 Level of Evidence…704 B. Changes Since the Initial Publication of These Guidelines in 2001…704 C. Recommendations for Management of Patients With Atrial Fibrillation…704Recommendations…704 Pharmacological Rate Control During Atrial Fibrillation…704 Preventing Thromboembolism…705 Cardioversion of Atrial Fibrillation…706 a. Pharmacological Cardioversion…706 b. Direct-Current Cardioversion…707 c. Pharmacological Enhancement of Direct-Current Cardioversion…707 d. Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Cardioversion…707 Maintenance of Sinus Rhythm…708 Special Considerations…708 a. Postoperative Atrial Fibrillation…708 b. Acute Myocardial Infarction…709 c. Management of Atrial Fibrillation Associated With the Wolff-Parkinson-White (WPW) Preexcitation Syndrome…709 d. Hyperthyroidism…709 e. Management of Atrial Fibrillation During Pregnancy…709 f. Management of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy (HCM)…710 g. Management of Atrial Fibrillation in Patients With Pulmonary Disease…710 II. Definition…710 A. Atrial Fibrillation…710 B. Related Arrhythmias…710 III. Classification…711 IV. Epidemiology and Prognosis…711 A. Prevalence…712 B. Incidence…712 C. Prognosis…712 V. Pathophysiological Mechanisms…712 A. Atrial Factors…712 Atrial Pathology as a Cause of Atrial Fibrillation…712 Mechanisms of Atrial Fibrillation…712 Atrial Electrical Remodeling…713 Other Factors Contributing to Atrial Fibrillation…713 B. Atrioventricular Conduction…713 General Aspects…713 Atrioventricular Conduction in Preexcitation Syndromes…714 C. Myocardial and Hemodynamic Consequences of Atrial Fibrillation…714 D. Thromboembolism…714 Pathophysiology of Thrombus Formation…714 Clinical Implications…715 VI. Causes, Associated Conditions, Clinical Manifestations, and Quality of Life…715 A. Causes and Associated Conditions…715 Reversible Causes of Atrial Fibrillation…715 Atrial Fibrillation Without Associated Heart Disease…715 Medical Conditions Associated With Atrial Fibrillation…715 Atrial Fibrillation With Associated Heart Disease…715 Familial Atrial Fibrillation…716 Autonomic Influences in Atrial Fibrillation…716 B. Clinical Manifestations…716 C. Quality of Life…716 VII. Clinical Evaluation…716 A. Basic Evaluation of the Patient With Atrial Fibrillation…716 Clinical History and Physical Examination…716 Investigations…716 VIII. Management…718 A. Strategic Objectives…718 B. Pharmacological and Nonpharmacological Treatment Options…718 Heart Rate Control Versus Rhythm Control…718 a. Pharmacological Rate Control During Atrial Fibrillation…720 b. Regulation of Atrioventricular Nodal Conduction by Pacing…720 c. Atrioventricular Nodal Ablation…720 Preventing Thromboembolism…722 a. Risk Stratification…722 b. Antithrombotic Strategies for Prevention of Ischemic Stroke and Systemic Embolism…723 c. Nonpharmacological Approaches to Prevention of Thromboembolism…725 Cardioversion of Atrial Fibrillation…726 a. Pharmacological Cardioversion…727 Pharmacological Agents to Maintain Sinus Rhythm…727 a. Agents With Proven Efficacy to Maintain Sinus Rhythm…727 b. Out-of-Hospital Initiation of Antiarrhythmic Drugs in Patients With Atrial Fibrillation…728 Direct-Current Cardioversion of Atrial Fibrillation and Atrial Flutter…731 a. Technical and Procedural Aspects…731 b. Risks and Complications of Direct-Current Cardioversion of Atrial Fibrillation…732 c. Pharmacological Enhancement of Direct-Current Cardioversion…732 d. Prevention of Thromboembolism in Patients With Atrial Fibrillation Undergoing Conversion…732 Maintenance of Sinus Rhythm…734 a. Pharmacological Therapy…734 b. Predictors of Recurrent Atrial Fibrillation…734 c. General Approach to Antiarrhythmic Drug Therapy…734 d. Selection of Antiarrhythmic Agents in Patients With Cardiac Diseases…735 Nonpharmacological Therapy for Atrial Fibrillation…735 a. Surgical Ablation…735 b. Catheter Ablation…736 c. Suppression of Atrial Fibrillation Through Pacing…737 d. Internal Atrial Defibrillators…737 C. Primary Prevention…737 IX. Proposed Management Strategies…737 A. Overview of Algorithms for Management of Patients With Atrial Fibrillation…738 Newly Discovered Atrial Fibrillation…738 Recurrent Paroxysmal Atrial Fibrillation…738 Recurrent Persistent Atrial Fibrillation…739 Permanent Atrial Fibrillation…739Appendix I…740Appendix II…741Appendix III…743References…745PreambleIt 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 to 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 his or her tenure, he or she is 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 on 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, issue of the Journal of the American College of Cardiology, August 15, 2006, issue of Circulation, and August 16, 2006, issue of the European Heart Journal. The full-text guidelines are e-published in the same issues of the Journal of the American College of Cardiology and Circulation and published in September 9, 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 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 GuidelinesI. IntroductionA. 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 representatives of the ACC, AHA, ESC, the European Heart Rhythm Association (EHRA), and the Heart Rhythm Society (HRS). The document was reviewed by reviewers nominated by these organizations and will be reviewed annually by the Task Force and considered current unless the Task Force revises or withdraws it from distribution.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 using the PubMed/MEDLINE and Cochrane Library databases. Searches focused on English-language sources and studies in human subjects. Articles related to animal experimentation were cited when important to understanding concepts pertinent to patient management.Classification 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.B. Changes Since the Initial Publication of These Guidelines in 2001The Writing Committee considered evidence published since 2001 and drafted revised recommendations to incorporate results from major clinical trials such as those that compared rhythm control and rate control approaches to long-term management. The text has been reorganized to reflect the implications for patient care, beginning with recognition of AF and its pathogenesis and the general priorities of rate control, prevention of thromboembolism, and methods available for use in selected patients to correct the arrhythmia and maintain normal sinus rhythm. Advances in catheter-based ablation technologies are incorporated in expanded sections and recommendations, with the recognition that such vital details as patient selection, optimum catheter positioning, absolute rates of treatment success, and the frequency of complications remain incompletely defined. Sections on drug therapy have been confined to human studies with compounds approved for clinical use in North America and/or Europe. As data on the management of patients prone to AF in special circumstances are more robust, recommendations are based on a higher level of evidence than in the first edition of these guidelines. Every effort was made to maintain consistency with other ACC/AHA and ESC practice guidelines.C. Recommendations for Management of Patients With Atrial FibrillationClassification 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. The reader is referred to the full-text guidelines for a complete description of the rationale and evidence supporting these recommendations. 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-careRecommendationsPharmacological Rate Control During Atrial Fibrillation Class I 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) 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) 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) 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) 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) Class IIa 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) It is reasonable to use ablation of the AV node or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects. (Level of Evidence: B) 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) 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) Class IIb When the ventricular rate cannot be adequately controlled both at rest and during exercise in patients with AF using a beta blocker, nondihydropyridine calcium channel antagonist, or digoxin, alone or in combination, oral amiodarone may be administered to control the heart rate. (Level of Evidence: C) Intravenous procainamide, disopyramide, ibutilide, or amiodarone may be considered for hemodynamically stable patients with AF involving conduction over an accessory pathway. (Level of Evidence: B) When the rate cannot be controlled with pharmacological agents or tachycardia-mediated cardiomyopathy is suspected, catheter-directed ablation of the AV node may be considered in patients with AF to control the heart rate. (Level of Evidence: C) Class III Digitalis should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal AF. (Level of Evidence: B) Catheter ablation of the AV node should not be attempted without a prior trial of medication to control the ventricular rate in patients with AF. (Level of Evidence: C) In patients with decompensated HF and AF, intravenous administration of a nondihydropyridine calcium channel antagonist may exacerbate hemodynamic compromise and is not recommended. (Level of Evidence: C) Intravenous administration of digitalis glycosides or nondihydropyridine calcium channel antagonists to patients with AF and a preexcitation syndrome may paradoxically accelerate the ventricular response and is not recommended. (Level of Evidence: C)Preventing Thromboembolism (For recommendations regarding antithrombotic therapy in patients with AF undergoing cardioversion, see Section I.C.3.d.) Class I Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except those with lone AF or contraindications. (Level of Evidence: A) 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) 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) Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor. Such factors include age 75 y 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) INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable. (Level of Evidence: A) Aspirin, 81–325 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) 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) Antithrombotic therapy is recommended for patients with atrial flutter as for those with AF. (Level of Evidence: C) Class IIa 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 y (especially in female patients), hypertension, HF, impaired LV function, or diabetes mellitus. (Level of Evidence: A) 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 y, female gender, or CAD. The choice of agent should be based upon the risk of bleeding complicat
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