1st February 2007
Institute for Clinical Systems Improvement
Summary,

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)

• To increase the percentage of patients age 18 years and older who are accurately diagnosed with A Fib
• To improve the consistency of anticoagulation in patients with paroxysmal, persistent or permanent atrial fibrillation/atrial flutter (A Fib/Flutter)
• To improve rate control in patients with permanent A Fib
• To increase the percentage of patients with A Fib/Flutter who receive patient education

TARGET POPULATION

Adults with first detected episode and recurrent (paroxysmal, persistent or permanent) atrial fibrillation (A Fib) and atrial flutter (A Flutter)

INTERVENTIONS AND PRACTICES CONSIDERED

Diagnosis

1. 12-lead electrocardiogram (ECG)
2. Assessment for hemodynamic stability
3. Echocardiography
4. Chest x-ray
5. Computed tomography (CT) of chest
6. Coronary/pulmonary angiography
7. Thyroid function tests
8. Cardiology or electrophysiology consult as needed
9. Evaluation for potentially reversible causes of atrial fibrillation (A Fib), comorbidities, risk factors for bleeding, risk factors for thromboembolism, and other special situations such as recent surgery, acute myocardial infarction, preexcitation, hypertrophic cardiomyopathy, pulmonary diseases, hyperthyroidism, or pregnancy

Management/Treatment

1. Electrical (DC) cardioversion
2. Antiarrhythmic/chemical cardioversion
3. Patient education regarding A Fib disease process, symptoms, treatment options, risks, drug interactions
4. Rate control agents: atenolol (Tenormin); metoprolol (Lopressor); propranolol (Inderal); esmolol (Brevibloc); verapamil; diltiazem (Cardizem); digoxin (Lanoxin); digoxin in combination with calcium channel blocker or beta-blocker
5. Antiarrhythmic agents: quinidine; procainamide; disopyramide (Norpace), flecainide (Tambocor), propafenone (Rythmol), amiodarone (Cordarone), sotalol (Betapace), ibutilide (Corvert), dofetilide (Tikosyn)
6. Acute and/or chronic anticoagulation: warfarin and unfractionated heparin (UFH)
7. Coronary bypass or valve replacement/repair
8. Catheter based ablative therapies such as HIS-bundle ablation and permanent pacemaker implantation; atrial flutter ablation; and pulmonary vein isolation for atrial fibrillation suppression
9. Cardiac pacing, such as single- or dual-site atrial pacing and implantable cardioverter defibrillator
10. Surgical maze procedure
11. Monitoring for recurrence (self-monitoring and adjunctive monitoring)

MAJOR OUTCOMES CONSIDERED

• Rates of cardioversion
• Symptom control
• Rate and rhythm control
• Rates of recurrence of atrial fibrillation (A Fib) or flutter
• Adverse effects of treatments
• Risk of thromboembolic complications or stroke or fatal bleeding