Excerpt

The guideline covers aspects of diagnosis and the management of atrial fibrillation (AF) in a number of different circumstances. It covers paroxysmal, persistent and permanent AF, considers AF developing after surgical procedures, and offers advice on haemodynamically unstable AF. Many of the recommendations relate to control of AF and the important decision of whether to attempt to restore sinus rhythm or concentrate on control of the heart rate. In a linked set of recommendations, the importance of considering anticoagulation in all these patients is emphasised. This is sometimes neglected in clinical practice, but anticoagulation is of enormous potential benefit because of its role in stroke prevention, and one of the key recommendations in the guideline is that the risk of thromboembolism should be formally assessed. A simple clinical model that includes advice on appropriate prophylaxis is suggested for this purpose. Other key recommendations cover the use of the electrocardiogram in diagnosis, and the preference in most patients for beta-blockers or rate-limiting calcium antagonists over digoxin for rate control.

Contents

• Members of the Guideline Development Group
• Preface
• Abbreviations
• Development of the Guideline
  • 1. Introduction
    • 1.1 Definition
    • 1.2 Classification
    • 1.3 Epidemiology
    • 1.4 Prognosis
    • 1.5 Guideline structure
    • 1.6 How to use this guideline
  • 2. Methodology
    • 2.1 About the guideline
    • 2.2 Guideline development
    • 2.3 Disclaimer
    • 2.4 Funding
  • 3. Key messages of the guideline
    • 3.1 Priorities for implementation
    • 3.2 AF care pathway
    • 3.3 Treatment strategy decision tree
    • 3.4 Audit criteria
    • 3.5 Areas for future research
• The Guideline
  • 4. Identification and diagnosis
    • 4.1 Presenting symptoms/pulse palpitation
    • 4.2 Electrocardiography
    • 4.3 Ambulatory ECG recording
    • 4.4 Echocardiography
  • 5. Cardioversion
    • 5.1 Electrical versus pharmacological cardioversion
    • 5.2 Pharmacological cardioversion
    • 5.3 Electrical cardioversion with concomitant antiarrhythmic drugs
    • 5.4 Transoesophageal echocardiography-guided cardioversion
    • 5.5 Cardioversion treatment algorithm
  • 6. Treatment for persistent AF
    • 6.1 Rate control versus rhythm control
    • 6.2 Rhythm control for persistent AF
    • 6.3 Antithrombotic therapy for persistent AF
    • 6.4 Rhythm-control treatment algorithm for persistent AF
  • 7. Treatment for permanent AF
    • 7.1 Rate control for permanent AF
    • 7.2 Antithrombotic therapy for permanent AF
    • 7.3 Rate-control treatment algorithm for permanent AF
  • 8. Treatment for paroxysmal AF
    • 8.1 Rhythm control for paroxysmal AF
    • 8.2 Treatment strategy for paroxysmal AF
    • 8.3 Antithrombotic therapy for paroxysmal AF
    • 8.4 Rhythm-control treatment algorithm for paroxysmal AF
  • 9. Treatment for acute-onset AF
    • 9.1 Acute AF in haemodynamically unstable patients
    • 9.2 Antithrombotic therapy for acute-onset AF
    • 9.3 Haemodynamically unstable AF treatment algorithm
  • 10. Postoperative AF
    • 10.1 Drug prophylaxis for postoperative AF
    • 10.2 Treatment for postoperative AF
  • 11. Antithrombotic therapy
    • 11.1 Initiating antithrombotic therapy
    • 11.2 Antithrombotic therapy in acute stroke patients
    • 11.3 Antithrombotic therapy following a stroke or TIA
    • 11.4 Antithrombotic therapy for asymptomatic AF
    • 11.5 Risks of long-term anticoagulation
    • 11.6 Risk factors for stroke and thromboembolism
    • 11.7 Stroke risk stratification algorithm
    • 11.8 The cost effectiveness of oral anticoagulation as thromboprophylaxis
  • 12. Monitoring and referral
    • 12.1 Anticoagulation self-monitoring
    • 12.2 Follow-up post cardioversion
    • 12.3 Referral
• Appendices
  • Appendix A Health economics modelling
  • Appendix B Stroke risk stratification models
  • Appendix C Clinical questions and search strategies
  • Appendix D Drug classification and licensing
  • Appendix E Glossary of terms
  • Appendix F Stakeholders
  • Appendix G Scope
• References
• Evidence Tables
  • Section 4 Evidence Tables
  • Section 5 Evidence Tables
  • Section 6 Evidence Tables
  • Section 7 Evidence Tables
  • Section 8 Evidence Tables
  • Section 9 Evidence Tables
  • Section 10 Evidence Tables
  • Section 11 Evidence Tables
  • Section 12 Evidence Tables

Acknowledgements: The Guideline Development Group would like to thank the following people for their valuable input during the development of this guideline: Mr Steven Barnes, Mrs Susan Clifford, Mr Rob Grant, Dr Bernard Higgins, Ms Jane Ingham, Ms Ester Klaeijsen, Dr Ian Lockhart, Ms Louise Martin, Ms Jill Parnham.

Mission statement: The Royal College of Physicians plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

The National Collaborating Centre for Chronic Conditions: The National Collaborating Centre for Chronic Conditions (NCC-CC) is a collaborative, multi-professional centre undertaking commissions to develop clinical guidance for the NHS in England and Wales. The NCC-CC was established in 2001. It is an independent body, housed within Clinical Standards Department at the Royal College of Physicians of London. The NCC-CC is funded by the National Institute for Health and Clinical Excellence (NICE) to undertake commissions for national clinical guidelines on an annual rolling programme.

Suggested citation:

National Collaborating Centre for Chronic Conditions. Atrial fibrillation: national clinical guideline for management in primary and secondary care. London: Royal College of Physicians, 2006.