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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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2
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Riddle M, McCallum R, Ojha CP, Paul TK, Gupta V, Baran DA, Prakash BV, Misra A, Mares AC, Abedin M, Kedar A, Mulukutla V, Ibrahim A, Nagarajarao H. Advances in the management of atrial fibrillation with a special focus on non-pharmacological approaches to prevent thromboembolism: a review of current recommendations. J Investig Med 2020; 68:1317-1333. [PMID: 33203786 DOI: 10.1136/jim-2020-001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/04/2022]
Abstract
Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.
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Affiliation(s)
- Malini Riddle
- Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Richard McCallum
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Chandra Prakash Ojha
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Timir Kumar Paul
- Internal Medicine, East Tennessee State University James H Quillen College of Medicine, Johnson City, Tennessee, USA
| | - Vineet Gupta
- Department of Internal Medicine, University of California San Diego, La Jolla, California, USA
| | - David Alan Baran
- Cardiovascular Diseases, Sentara Healthcare Inc, Norfolk, Virginia, USA
| | - Bharat Ved Prakash
- Department of Medicine, Texas Tech University Health Sciences Center El Paso, Transmountain Campus, El Paso, Texas, USA
| | - Amogh Misra
- Department of Biochemistry, The University of Texas at Austin, Austin, Texas, USA
| | - Adriana Camila Mares
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Moeen Abedin
- Division of Cardiology, University Medical Center of El Paso, El Paso, Texas, USA
| | - Archana Kedar
- Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | | | - Ahmed Ibrahim
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Harsha Nagarajarao
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
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Zhong L, Yin X, Xie Z. RETRACTED: Safety of radiofrequency ablation for reducing inflammatory cytokine levels and the left atrial diameter in patients with atrial fibrillation. J Int Med Res 2020; 48:300060520949760. [PMID: 38238979 PMCID: PMC7488899 DOI: 10.1177/0300060520949760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/23/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate the safety of radiofrequency ablation for reducing inflammatory cytokines and the left atrial diameter in patients with atrial fibrillation (AF). Methods A total of 200 patients with AF who were admitted to our hospital from December 2015 to April 2017 were included in this prospective analysis. Fifty patients were treated with conventional AF medication alone (AF medication group) and 50 patients received radiofrequency ablation (RFA) on the basis of conventional medication (RFA group). Results After treatment, the AF medication group showed significantly higher levels of high-sensitivity C-reactive protein, interleukin-6, carboxyterminal propeptide of type-I procollagen, procollagen type III N-terminal propeptide, and matrix metallopeptidase-9 than the RFA group. The AF medication group had a significantly lower activated partial thromboplastin time, thrombin time, and prothrombin time than the RFA group. A significantly smaller left atrial diameter was observed in both groups after treatment, but this decrease was more pronounced in the RFA group than in the AF medication group. The total treatment efficacy rate was significantly lower in the AF medication group than in the RFA group. Conclusions For patients with AF, RFA leads to a lower incidence of inflammatory responses, faster recovery of cardiac function, and good safety.
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Affiliation(s)
| | | | - Zhihong Xie
- Department of Cardiology, People’s Hospital of Ganzhou, Jiangxi, China
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Gasbarro NM, DiDomenico RJ. Frequency of "on-label" use of intravenous diltiazem for rate control in patients with acute-onset atrial fibrillation or atrial flutter. Am J Health Syst Pharm 2019; 76:214-220. [PMID: 30715182 DOI: 10.1093/ajhp/zxy033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose The study was designed to characterize "on-label" use of i.v. diltiazem in patients with acute atrial fibrillation or flutter (AFF). Methods An IRB-approved, single-center, retrospective, observational design was used. Eligible patients had acute AFF with heart rate >120 bpm and received i.v. diltiazem from June 1, 2012, to June 30, 2014. The primary outcome was frequency of on-label use of i.v. diltiazem, defined as use of at least one FDA-approved weight-based bolus dose followed by an infusion, if appropriate, in the absence of contraindications. Results A total of 300 patients were screened; 97 patients were included for analysis. I.V. diltiazem was used on-label in only 14 patients (14%). Of the 96 patients who received an initial diltiazem bolus injection, the median dose was significantly higher in patients for whom the diltiazem dose was on-label, as follows: 17.5 mg (interquartile range [IQR]), 10-20 mg vs. 10.0 mg (IQR, 10-20 mg), p < 0.02). Twenty-nine patients (35%) in the off-label group had a therapeutic response to diltiazem alone compared with 8 patients (57%) in the on-label group (p = 0.11). More patients treated with off-label diltiazem bolus injection required additional rate control medications (41% vs. 7%, p < 0.04). Conclusion In most patients, i.v. diltiazem was not used in accordance with FDA labeling. For most, i.v. diltiazem doses were lower than recommended and many of these patients required additional rate control medications to achieve a therapeutic response.
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Affiliation(s)
| | - Robert J DiDomenico
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL
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Sethi NJ, Nielsen EE, Safi S, Feinberg J, Gluud C, Jakobsen JC. Digoxin for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. PLoS One 2018. [PMID: 29518134 PMCID: PMC5843263 DOI: 10.1371/journal.pone.0193924] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background During recent years, systematic reviews of observational studies have compared digoxin to no digoxin in patients with atrial fibrillation or atrial flutter, and the results of these reviews suggested that digoxin seems to increase the risk of all-cause mortality regardless of concomitant heart failure. Our objective was to assess the benefits and harms of digoxin for atrial fibrillation and atrial flutter based on randomized clinical trials. Methods We searched CENTRAL, MEDLINE, Embase, LILACS, SCI-Expanded, BIOSIS for eligible trials comparing digoxin versus placebo, no intervention, or other medical interventions in patients with atrial fibrillation or atrial flutter in October 2016. Our primary outcomes were all-cause mortality, serious adverse events, and quality of life. Our secondary outcomes were heart failure, stroke, heart rate control, and conversion to sinus rhythm. We performed both random-effects and fixed-effect meta-analyses and chose the more conservative result as our primary result. We used Trial Sequential Analysis (TSA) to control for random errors. We used GRADE to assess the quality of the body of evidence. Results 28 trials (n = 2223 participants) were included. All were at high risk of bias and reported only short-term follow-up. When digoxin was compared with all control interventions in one analysis, we found no evidence of a difference on all-cause mortality (risk ratio (RR), 0.82; TSA-adjusted confidence interval (CI), 0.02 to 31.2; I2 = 0%); serious adverse events (RR, 1.65; TSA-adjusted CI, 0.24 to 11.5; I2 = 0%); quality of life; heart failure (RR, 1.05; TSA-adjusted CI, 0.00 to 1141.8; I2 = 51%); and stroke (RR, 2.27; TSA-adjusted CI, 0.00 to 7887.3; I2 = 17%). Our analyses on acute heart rate control (within 6 hours of treatment onset) showed firm evidence of digoxin being superior compared with placebo (mean difference (MD), -12.0 beats per minute (bpm); TSA-adjusted CI, -17.2 to -6.76; I2 = 0%) and inferior compared with beta blockers (MD, 20.7 bpm; TSA-adjusted CI, 14.2 to 27.2; I2 = 0%). Meta-analyses on acute heart rate control showed that digoxin was inferior compared with both calcium antagonists (MD, 21.0 bpm; TSA-adjusted CI, -30.3 to 72.3) and with amiodarone (MD, 14.7 bpm; TSA-adjusted CI, -0.58 to 30.0; I2 = 42%), but in both comparisons TSAs showed that we lacked information. Meta-analysis on acute conversion to sinus rhythm showed that digoxin compared with amiodarone reduced the probability of converting atrial fibrillation to sinus rhythm, but TSA showed that we lacked information (RR, 0.54; TSA-adjusted CI, 0.13 to 2.21; I2 = 0%). Conclusions The clinical effects of digoxin on all-cause mortality, serious adverse events, quality of life, heart failure, and stroke are unclear based on current evidence. Digoxin seems to be superior compared with placebo in reducing the heart rate, but inferior compared with beta blockers. The long-term effect of digoxin is unclear, as no trials reported long-term follow-up. More trials at low risk of bias and low risk of random errors assessing the clinical effects of digoxin are needed. Systematic review registration PROSPERO CRD42016052935
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Affiliation(s)
- Naqash J. Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Emil E. Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
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Afzali Moghadam M, Fadaie Dashti M, Shahsavarinia K, Mahmoodpoor A, Jamali K. A comparison of verapamil and digoxin for heart rate control in atrial fibrillation. Adv Pharm Bull 2012; 2:201-5. [PMID: 24312794 DOI: 10.5681/apb.2012.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 07/30/2012] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Atrial fibrillation (AF) is one of the most common types of sustained dysrhythmia and there are some disagreements about its treatment. The goals of AF treatment include the control of ventricular rate, the establishment of sinus rhythm and the prevention of thromboembolic events. In this study, the effect of verapamil was compared to digoxin on heart rate control in patients with AF. METHODS This descriptive study was conducted in an emergency department (ED) in Iran. Sixty patients with a new onset AF and rapid ventricular response receiving digoxin or verapamil were included and observed. RESULTS Two thirty-patient groups receiving verapamil or digoxin were evaluated. The heart rate was significantly decreased in both groups (p = 0.002); however, the cardioversion was not noticed in both of them. The best rate control in verapamil and digoxin groups was observed after 5.9 mg (46.7%) and 0.6 mg (36.7%), respectively. CONCLUSION Administration of verapamil in comparison with digoxin has no difference to control the heart rate in AF patients. It should be taken into consideration that prospective randomized studies should be conducted to identify the efficacy and select the best of these two drugs to treat AF patients.
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8
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Efficacy and Safety of Pharmacological Options for Rate Control in Atrial Fibrillation. AACN Adv Crit Care 2012; 23:120-5; quiz 126-7. [DOI: 10.1097/nci.0b013e318242fdd0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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9
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A 2-year survey of treatment of acute atrial fibrillation in an ED. Am J Emerg Med 2011; 29:534-40. [DOI: 10.1016/j.ajem.2009.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 12/14/2009] [Accepted: 12/15/2009] [Indexed: 11/21/2022] Open
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10
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European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2011; 81:1305-52. [PMID: 20956049 DOI: 10.1016/j.resuscitation.2010.08.017] [Citation(s) in RCA: 751] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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11
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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12
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Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S729-67. [PMID: 20956224 DOI: 10.1161/circulationaha.110.970988] [Citation(s) in RCA: 880] [Impact Index Per Article: 62.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.
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14
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Tamargo J, Delpón E, Caballero R. The safety of digoxin as a pharmacological treatment of atrial fibrillation. Expert Opin Drug Saf 2006; 5:453-67. [PMID: 16610972 DOI: 10.1517/14740338.5.3.453] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Digoxin has traditionally been the drug of choice for ventricular rate control in patients with chronic atrial fibrillation (AF), with or without heart failure (HF) with systolic dysfunction. In patients with permanent AF, digoxin monotherapy is ineffective to control ventricular rate during exercise, but the combination of digoxin with a beta-blocker or a non-dihydropyridine calcium channel antagonist can control heart rate both at rest and during exercise. Only a few randomised, controlled studies have evaluated the adverse effects of digoxin in patients with AF in a systematic way and side effects requiring drug withdrawal have rarely been reported. When reported, the most frequent adverse effects were cardiac arrhythmias (ventricular arrhythmias, AV block of varying degrees and sinus pauses). This evidence suggested that, in contrast to other antiarrhythmic drugs, digoxin is a safe drug in patients with AF. However, this safety profile can be erroneous due to the short follow-up of the studies and patient selection. Because patients with HF have been excluded in most studies, the safety profile of digoxin in this population has not been directly addressed. Early recognition that an arrhythmia is related to digoxin intoxication as well as recognition of concomitant medications or medical conditions that may directly alter the pharmacokinetic profile of digoxin, or indirectly alter its cardiac effects by pharmacodynamic interactions remain essential for safe and effective use of digoxin in patients with AF.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, 28040 Madrid, Spain.
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16
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2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support. Resuscitation 2006; 67:213-47. [PMID: 16324990 DOI: 10.1016/j.resuscitation.2005.09.018] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G, Baubin M, Dirks B, Wenzel V. Erweiterte Reanimationsmaßnahmen für Erwachsene (ALS). Notf Rett Med 2006; 9:38-80. [PMID: 32834772 PMCID: PMC7371819 DOI: 10.1007/s10049-006-0796-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- J. P. Nolan
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - C. D. Deakin
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - J. Soar
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - B. W. Böttiger
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - G. Smith
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - M. Baubin
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
| | - B. Dirks
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Prittwitzstraße 43, 89075 Ulm
| | - V. Wenzel
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005. Resuscitation 2005; 67 Suppl 1:S39-86. [PMID: 16321716 DOI: 10.1016/j.resuscitation.2005.10.009] [Citation(s) in RCA: 606] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Korantzopoulos P, Kolettis TM, Goudevenos JA, Siogas K. Errors and pitfalls in the non-invasive management of atrial fibrillation. Int J Cardiol 2005; 104:125-30. [PMID: 16168803 DOI: 10.1016/j.ijcard.2004.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2004] [Revised: 10/16/2004] [Accepted: 11/06/2004] [Indexed: 11/21/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice while it has a significant impact on morbidity and mortality. The errors and pitfalls in the management of AF patients are not uncommon. These include errors in detection and management of the underlying conditions that promote and perpetuate the arrhythmia, in the selection and monitoring of antithrombotic treatment, in the selection of appropriate strategy for arrhythmia management (rate or rhythm control), in the cardioversion procedure, in the prevention of recurrence after cardioversion, in the acute or chronic control of heart rate, and in the monitoring of drug toxicities. The heterogeneity of the disease along with the diversity of current treatment options mainly account for these problems. Nevertheless, deep knowledge of the evidence-based therapeutic approaches, as well as the development of individualized therapeutic strategies, can substantially improve the effective management of such patients.
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Khan IA, Nair CK, Singh N, Gowda RM, Nair RC. Acute ventricular rate control in atrial fibrillation and atrial flutter. Int J Cardiol 2005; 97:7-13. [PMID: 15336799 DOI: 10.1016/j.ijcard.2003.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2003] [Accepted: 08/11/2003] [Indexed: 10/26/2022]
Abstract
Atrioventricular node blocking agents including beta-adrenergic blockers, non-dihydropyridine calcium channel blockers and digoxin are usually effective in controlling ventricular rate in atrial fibrillation and flutter. Intravenous beta-blockers and non-dihydropyridine calcium channel blockers are equally effective in rapidly controlling the ventricular rate. The addition of digoxin to the regimen causes a favorable outcome but digoxin as a single agent is generally less effective in slowing the ventricular rate in acute setting. Clonidine, magnesium, and amiodarone have also been used for acute ventricular rate control in atrial fibrillation. Limited data suggest that combination regimens provide better ventricular rate control than any agent alone. The agent of first choice is usually individualized depending upon the clinical situation. Beta-blockers are preferable in patients with myocardial ischemia, myocardial infarction and hyperthyroidism and in post-operative state, but should be avoided in patients with bronchial asthma and chronic obstructive pulmonary disease where non-dihydropyridine calcium channel blockers are preferred. Beta-blockers are preferred drugs used for acute ventricular rate control in atrial fibrillation during pregnancy. In atrial fibrillation with Wolff-Parkinson-White syndrome, beta-blockers, calcium channel blockers and digoxin should be avoided, as these drugs are selective atrioventricular node blockers without slowing conduction through the accessory pathway, which can lead to increased transmission of impulses preferentially through the accessory pathway and precipitate ventricular fibrillation. The drug of choice for atrial fibrillation in pre-excitation syndrome is procainamide but propafenone, flecainide and disopyramide have also been used. When clinical condition is unstable or patient is hemodynamically compromised, immediate electrical cardioversion is the treatment of choice, as the best measure to control ventricular rate is by conversion to sinus rhythm. Factors precipitating rapid ventricular rate should be treated as well.
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Affiliation(s)
- Ijaz A Khan
- Division of Cardiology, Creighton University School of Medicine, 3006 Webster Street, Omaha, NE 68131 2044, USA.
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Nichol G, Huszti E, Rokosh J, Dumbrell A, McGowan J, Becker L. Impact of informed consent requirements on cardiac arrest research in the United States: exception from consent or from research? Resuscitation 2004; 62:3-23. [PMID: 15246579 DOI: 10.1016/j.resuscitation.2004.02.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2003] [Revised: 02/11/2004] [Accepted: 02/11/2004] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Research in patients with life-threatening illness such as cardiac arrest is challenging since they can not consent. The Food and Drug Administration addressed research under emergency conditions by publishing new criteria for exception from informed consent in 1996. We systematically reviewed randomized trials over a 10-year period to assess the impact of these regulations. METHODS Case-control study of published trials for cardiac arrest (cases) and atrial fibrillation (controls.) Studies were identified by using structured searches of MEDLINE and EMBASE from 1992 to 2002. Included were studies using random allocation in humans with cardiac arrest or atrial fibrillation prior to enrollment. Excluded were duplicate publications. Number of American trials, foreign trials and proportion of trials of American origin were compared by using regression analysis. Changes in cardiac arrest versus atrial fibrillation trials were calculated as risk differences. RESULTS Of 4982 identified cardiac arrest studies, 57 (1.1%) were randomized trials. The number of American cardiac arrest trials decreased by 15% (95% CI: 8, 22%) annually (P = 0.05). The proportion of cardiac arrest trials of American origin decreased by 16% (95% CI: 10, 22%) annually (P = 0.006). Of 5596 identified atrial fibrillation studies, 197 trials (3.5%) were randomized trials. The risk difference between cardiac arrest versus atrial fibrillation trials being of American origin decreased significantly (annual difference -5.8% (95% CI: -10, -0.1%), P = 0.03). INTERPRETATION Fewer American cardiac arrest trials were published during the last decade, when federal consent requirements changed. Regulatory requirements for clinical trials may inhibit improvements in care and threaten public health.
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Affiliation(s)
- G Nichol
- Clinical Epidemiology Program and Department of Medicine, University of Ottawa, ON, Canada.
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Olshansky B, Rosenfeld LE, Warner AL, Solomon AJ, O'Neill G, Sharma A, Platia E, Feld GK, Akiyama T, Brodsky MA, Greene HL. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. J Am Coll Cardiol 2004; 43:1201-8. [PMID: 15063430 DOI: 10.1016/j.jacc.2003.11.032] [Citation(s) in RCA: 229] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2003] [Revised: 10/29/2003] [Accepted: 11/20/2003] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We sought to evaluate approaches used to control rate, the effectiveness of rate control, and switches from one drug class to another in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. BACKGROUND The AFFIRM study showed that atrial fibrillation (AF) can be treated effectively with rate control and anticoagulation, but drug efficacy to control rate remains uncertain. METHODS Patients (n = 2,027) randomized to rate control in the AFFIRM study were given rate-controlling drugs by their treating physicians. Standardized rate-control efficacy criteria developed a priori included resting heart rate and 6-min walk tests and/or ambulatory electrocardiographic results. RESULTS Average follow-up was 3.5 +/- 1.3 years. Initial treatment included a beta-adrenergic blocker (beta-blocker) alone in 24%, a calcium channel blocker alone in 17%, digoxin alone in 16%, a beta-blocker and digoxin in 14%, or a calcium channel blocker and digoxin in 14% of patients. Overall rate control was achieved in 70% of patients given beta-blockers as the first drug (with or without digoxin), 54% with calcium channel blockers (with or without digoxin), and 58% with digoxin alone. Adequate overall rate control was achieved in 58% of patients with the first drug or combination. Multivariate analysis revealed an association between first drug class and several clinical variables. There were more changes to beta-blockers than to the other two-drug classes (p < 0.0001). CONCLUSIONS Rate control in AF is possible in the majority of patients with AF. Beta-blockers were the most effective drugs. To achieve the goal of adequate rate control in all patients, frequent medication changes and drug combinations were needed.
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Abstract
Conversion of atrial fibrillation and flutter to sinus rhythm results in a transient mechanical dysfunction of atrium and atrial appendage, termed atrial stunning. Atrial stunning has been reported with all modes of conversion of atrial fibrillation and flutter to sinus rhythm including both transthoracic and low energy internal electrical, pharmacological, and spontaneous cardioversion, and conversion by overdrive pacing and by radiofrequency ablation. Atrial stunning is a function of the underlying arrhythmia becoming apparent at the restoration of sinus rhythm, not the function of the mode of conversion, and does not develop after the unsuccessful attempts of cardioversion or the delivery of electric current to the heart during rhythms other than atrial fibrillation or flutter. Tachycardia-induced atrial cardiomyopathy, cytosolic calcium accumulation, and atrial hibernation are the suggested mechanisms of atrial stunning. Atrial stunning is at maximum immediately after cardioversion and improves progressively with a complete resolution within a few minutes to 4-6 weeks depending on the duration of the preceding atrial fibrillation, atrial size, and structural heart disease. Atrial stunning causes postcardioversion thromboembolism despite restoration of sinus rhythm. Duration of anticoagulation therapy after successful cardioversion should depend on the duration of atrial stunning. Lack of improvement in cardiac output and functional recovery of patients immediately after cardioversion is attributed to the atrial stunning. Verapamil, acetylstrophenathidine, isoproterenol, and dofetilide have been reported to protect from atrial stunning in animal and small human studies. Right atrium stunning is less marked and improves earlier than that of left atrium, resulting in a differential atrial stunning explaining the rare occurrence of pulmonary edema after cardioversion.
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Affiliation(s)
- Ijaz A Khan
- Divisions of Cardiology, Creighton University School of Medicine, 3006 Webster Street, Omaha, NE 68131, USA.
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Abstract
The efficacy and safety of the single oral loading dose of flecainide for cardioversion of recent-onset atrial fibrillation was examined by reviewing the trials on the subject identified through a comprehensive literature search. Most of the trials used a single dose of 300 mg for oral loading. The success rate ranged from 57 to 68% at 2-4 h and 75 to 91% at 8 h after drug administration. The conversion time ranged from 110+/-82 to 190+/-147 min, depending on the duration of observation after drug administration, which in most trials was of 8 h. Single oral loading regimen of flecainide was significantly more efficacious than placebo, and was as efficacious as the single oral loading regimen of propafenone. Both the single oral loading and the intravenous loading regimens of flecainide were equally efficacious but the intravenous regimen resulted in an earlier conversion. Adverse effects reported were mild non-cardiac side effects, reversible QRS complex widening, transient arrhythmias and left ventricular decompensation. The transient arrhythmias were chiefly at the time of conversion and included appearance of atrial flutter and sinus pauses. No life-threatening ventricular arrhythmia or death was reported. The single dose oral loading regimen of flecainide appears to be effective for cardioversion of recent-onset atrial fibrillation with a relatively rapid effect within 2-4 h, and is free of serious complications in patients without structural heart disease. Patients with substantial structural heart disease were excluded from most of the trials.
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Affiliation(s)
- Ijaz A Khan
- Divisions of Cardiology, Creighton University School of Medicine, 3006 Webster Street, Omaha, NE 68131, USA.
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Khan IA. Transient atrial mechanical dysfunction (stunning) after cardioversion of atrial fibrillation and flutter. Am Heart J 2002; 144:11-22. [PMID: 12094183 DOI: 10.1067/mhj.2002.123113] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Conversion of atrial fibrillation (AFib) and flutter (AFlt) to sinus rhythm results in a transient mechanical dysfunction of atria (atrial stunning). Methods used as a means of assessing atrial stunning, atrial stunning after conversion of atrial fibrillation/flutter, and the cause, mechanisms, determinants of the extent, and drugs affecting atrial stunning were examined. METHODS Studies on the subject, identified through a comprehensive literature search, were thoroughly evaluated. RESULTS AND CONCLUSIONS Left atrial (LA) stunning has been reported with all modes of conversion of AFib/AFlt to sinus rhythm. The incidence of LA stunning is 38% to 80%. Spontaneous echocardiographic contrast, LA appendage (LAA) flow velocities and emptying fraction, transmitral inflow velocity of atrial wave (A-wave), time-velocity integral of A-wave, and atrial filling fraction have been used as means of assessing LA stunning. The data on right atrial (RA) stunning are limited, but parallel findings have been reported in the right atrium. Atrial stunning does not develop after the unsuccessful attempts of cardioversion or on delivery of electric current to the heart without AFib/AFlt, and it is a function of the underlying AFib/AFlt manifesting at the restoration of sinus rhythm. Tachycardia-induced atrial myopathy and chronic atrial hibernation are suggested mechanisms. Duration of preceding AFib/AFlt, atrial size, and underlying heart disease are determinants of the extent of atrial stunning. Verapamil, dofetilide, and acetylstrophenathidine have been shown to attenuate or protect from atrial stunning in animal or small human studies. A comprehensive knowledge of atrial stunning would be helpful in selecting the patients for, and the duration of, anticoagulation therapy after cardioversion.
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Affiliation(s)
- Ijaz A Khan
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, USA.
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Nichol G, McAlister F, Pham B, Laupacis A, Shea B, Green M, Tang A, Wells G. Meta-analysis of randomised controlled trials of the effectiveness of antiarrhythmic agents at promoting sinus rhythm in patients with atrial fibrillation. Heart 2002; 87:535-43. [PMID: 12010934 PMCID: PMC1767130 DOI: 10.1136/heart.87.6.535] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To conduct a meta-analysis of randomised controlled trials to estimate the effectiveness of antiarrhythmic drugs at promoting sinus rhythm in patients with atrial fibrillation. DESIGN Articles were identified by using a comprehensive search of English language papers indexed in Medline from 1966 to August 2001. For the outcomes of sinus rhythm and death, a random effects model was used to model repeated assessments within a study at different time points. SETTING Emergency departments and ambulatory clinics. PATIENTS Patients with atrial fibrillation. INTERVENTIONS Antiarrhythmic agents grouped according to their Vaughan-Williams class. MAIN OUTCOME MEASURES Sinus rhythm and mortality. RESULTS 91 articles met a priori criteria for inclusion in the analysis. Median duration of follow up was one day (range 0.04-1096, mean (SD) 46 (136) days). The median proportion of patients in sinus rhythm at follow up was 55% (range 0-100%) and 32% (range 0-90%) receiving active treatment and placebo, respectively. Median survival was 99% (range 55-100%) and 99% (range 55-100%). Compared with placebo, the following drug classes were associated with increased sinus rhythm at follow up: IA (treatment difference 21.5%, 95% confidence interval (CI) 16.3% to 26.8%); IC (treatment difference 33.1%, 95% CI 23.3% to 42.9%); and III (treatment difference 17.4%, 95% CI 11.5% to 23.3%). Class IC drugs were associated with increased sinus rhythm at follow up compared with class IV drugs (treatment difference 43.2%, 95% CI 11.5% to 75.0%). There was no significant difference in mortality between any drug classes. CONCLUSIONS Class IA, IC, and III drugs are associated with increased sinus rhythm at follow up compared with placebo. It is unclear whether any antiarrhythmic drug class is associated with increased or decreased mortality.
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Affiliation(s)
- G Nichol
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.
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