Atrial Fibrillation Study
Please note that I have practiced medicine over 45 years now and
have known for some time that the new game of cardioversion was NOT
in my Atrial Fibrillation patient's best interest. Also I have world
famous patients betting their LIFE that I am right and have not used
the unsafe rhythm control drugs. I take my patients off those drugs
routinely citing this and other mainstream published studies PROVING
that RATE control is ENOUGH!!
Since none of these patients on Beyond Chelation Improved and
Endokinase have ever thrown a clot, it seems that we have a very
safe and effective alternative program for all these patients with
Atrial Fibrillation, which becomes very common in patients over 50.
These patients can be interested in learning that there was up to an
80% reduction in sudden death in males JUST from the increased
intake of OMEGA 3 oil capsules, which is a foundation for the Beyond
Chelation program I have developed over 18 years ago!
Garry F. Gordon, MD,DO,MD(H)
ACP and AAFP Issue Joint Clinical Guidelines for Management of AF in
the Primary Care Setting
January 5, 2004 - Rate control with chronic anticoagulation therapy,
not rhythm control, is the recommended strategy for treating adult
patients with new onset atrial fibrillation (AF) in the primary care
setting, according to new clinical practice guidelines issued by a
joint commission of the American College of Physicians (ACP) and the
American Academy of Family Physicians (AAFP).[1] The guidelines,
published in a recent issue of the Annals of Internal Medicine, are
based on a systematic evidence-based review[2] that examined the
efficacy of rate control vs rhythm control, anticoagulation therapy,
electrical vs pharmacologic cardioversion, and the role of
transesophageal echocardiography (TEE) to guide pharmacologic
therapy.
"It has been the generally accepted practice to do everything we
can to get patients with atrial fibrillation back into sinus rhythm and
to try to keep them there," said AAFP spokesman Michael LeFevre,
MD, Department of Family and Community Medicine, University of Missouri-Columbia.
"The best evidence now shows that approach to be wrong for most patients.
Our focus should be on rate control and stroke prevention."
Guidelines include 6 overall recommendations
During the course of an18-month collaboration, the AAFP and the ACP drafted
the following 6 recommendations for the management of the adult patient
with first-detected AF:
1. Rate control with chronic anticoagulation is the recommended strategy
for most AF patients.
2. Patients with AF should receive chronic anticoagulation with adjusted-dose
warfarin.
3. Atenolol, metoprolol, diltiazem, and verapamil are recommended for
rate control during exercise and while at rest.
4. Electrical and pharmacologic conversions are "appropriate options"
for patients electing acute cardioversion.
5. The use of TEE with short-term prior anticoagulation followed by early
acute cardioversion with postcardioversion anticoagulation is appropriate.
6. Most patients should not be placed on rhythm maintenance therapy "since
the risks outweigh the benefits." The guidelines do not pertain to
patients with postoperative or post myocardial infarction, AF, class IV
heart failure, or valvular disease or to patients already taking antiarrhythmic
drugs.
Recommendation 1: Rate control with chronic anticoagulation best for
most AF patients
Using data from the Atrial Fibrillation Follow-up Investigation of
Rhythm Management (AFFIRM) trial,[3] the Rate Control versus
Electrical cardioversion for persistent atrial fibrillation (RACE)
trial,[4] the Pharmacological Intervention in Atrial Fibrillation
(PIAF) trial,[5] and the preliminary results of the Strategies of
Treatment of Atrial Fibrillation (STAF), the joint commission sought
to answer "[o]ne of the fundamental questions in the management of
AF...whether to attempt cardioversion." They determined that none
of
these trials conclusively demonstrated that a rhythm control
strategy significantly improved mortality or morbidity more so than
rate control. In some cases, such as that noted in the AFFIRM trial,
a rhythm control strategy actually increased the risk of death in
older patients, patients with coronary disease, and those without
congestive heart failure and resulted in more hospitalizations than
in the rate control group.
Of note, in the STAF trial, only 40% of patients receiving rhythm
control (pre- and postanticoagulation therapy and antiarrhythmic
maintenance) were in sinus rhythm at 1 year. In addition, all of the
primary endpoints (ie, death, stroke, transient ischemic attack,
cardiopulmonary resuscitation, and thromboembolism) occurred in
patients in AF, a result that has fueled speculation as to what the
outcome might have been had anticoagulation been used indefinitely
in the rhythm control group.
Recommendation 2: Most AF patients should receive chronic
anticoagulation with adjusted-dose warfarin
"Warfarin is a hard drug to use, because it does have risks and
requires vigilance in monitoring," Dr. LeFevre said. "Unfortunately,
nobody feels better because they take warfarin."
However, currently in standard practice, warfarin represents the
gold standard therapy for patients with AF. But the authors
concluded that AF patients should receive chronic anticoagulation
therapy with adjusted-dose warfarin unless stroke risk is low or
contraindication to warfarin use has been identified.
Their conclusion was based on a metaanalysis of primary prevention
studies to determine pooled efficacy (rate of stroke) and safety
(hemorrhage) of warfarin or aspirin, compared with placebo, which
showed that both warfarin and aspirin were more efficacious than
placebo for stroke prevention and, in fact, stroke occurred less
often in patients receiving warfarin than in those receiving
aspirin. These benefits, however, were also accompanied by an
observed increased risk of major bleeding with warfarin, compared
with placebo (evidence of bleeding risk for aspirin vs placebo was
inconclusive).
"[Nonetheless] the studies are clear that for most patients with
atrial fibrillation, the benefits [of warfarin] outweigh the risks,"
Dr. LeFevre said.
Recommendation 3: Atenolol, metoprolol, diltiazem, and verapamil
recommended for rate control during exercise and at rest
The third recommendation was based on 54 trials that assessed 17
different agents for rate control in AF during exercise and at rest.
The committee specifically focused on the studies that evaluated
digoxin, calcium channel blockers, and beta blockers.
They found that the calcium channel blockers diltiazem and verapamil
were more effective than placebo or digoxin in reducing ventricular
rate both during exercise and at rest, and improvement was noted
during exercise and at rest with the beta blockers atenolol and
metoprolol. They also found that in studies assessing digoxin vs
placebo, comparisons were inconsistent, especially during exercise.
Based on the data, the authors recommended the use of atenolol,
metoprolol, diltiazem, and verapamil for rate control during
exercise. They also added that "digoxin is only effective for rate
control at rest and therefore should only be used as a second-line
agent for rate control in atrial fibrillation."
Recommendation 4: Electrical and pharmacologic conversion
are "appropriate options" for patients electing acute cardioversion
The efficacy of traditional monophasic direct current cardioversion
is between 80% and 85% and that of biphasic cardioversion is more
than 90%, yet no trial data exist comparing the efficacy of
electrical vs pharmacologic conversion. The authors pointed out,
however, that long-term maintenance of sinus rhythm is "moderate
to
low" for both methods.
According to the authors, 7 of 8 randomized trials studying
antiarrhythmic treatment before electrical cardioversion vs
electrical conversion alone found no increased efficacy with
quinidine, propafenone, and sotalol. Although ibutilide showed
increased efficacy in 1 trial, it was also associated with risk of
inducing ventricular arrhythmia.
The authors pointed out that strong evidence supports the efficacy
of ibutilide, flecainide, dofetilide, propafenone, and amiodarone
for acute pharmacologic conversion, whereas moderate evidence
supports the efficacy of quinidine.
Because the risk of thromboembolism does not differ between
electrical and pharmacologic conversion, patient preference should
be taken into account.
Recommendation 5: Transesophageal echocardiography deemed an
appropriate management strategy
Both TEE -- a procedure used to stratify patients for risk of
thromboembolism -- and delayed cardioversion with pre- and
postanticoagulation therapy are acceptable strategies for patients
electing cardioversion, according to the authors. Their conclusion
was based on the findings from the Assessment of Cardioversion Using
Transesophageal Echocardiography (ACUTE) study,[6] a randomized
clinical trial that compared TTE-guided cardioversion with the
conventional strategy of pre- and postanticoagulation therapy. The
study found that there were no differences in the incidence of
stroke, transient ischemic attack, or peripheral embolism between
the 2 approaches. In addition, patients receiving TTE had a higher
initial success rate, and more bleeding events occurred in patients
receiving conventional therapy. At 8 weeks, however, maintenance of
sinus rhythm was similar in the 2 groups.
"The choice between the 2 strategies should be based on patient
preference and clinical situation, including contraindications to
transesophageal echocardiography or availability of this
technology," the authors wrote.
Recommendation 6: Risks associated with rhythm maintenance therapy
outweigh benefits for most patients
The authors stressed that adverse side effects, especially the risk
of torsades de pointes and other ventricular arrhythmias, should be
considered in deciding whether to use maintenance therapy in
patients converted to sinus rhythm from AF.
For most patients, the risks of maintenance therapy outweigh the
benefits, according to the authors, but for those in whom quality of
life has been sufficiently compromised, agents recommended for
rhythm maintenance include amiodarone, disopyramide, propafenone,
and sotalol.
Guidelines aimed at family physicians may lead to simplified and
cost-effective management of AF
"Advances in knowledge don't always lead to easier care, but in this
circumstance, the recommended approach [guidelines for internists
and family physicians] is actually simpler than the previous
approach," Dr. LeFevre said. "There will still be individuals
who
are quite symptomatic from atrial fibrillation who need to have a
focus on rhythm control. Many of these will require the expertise
and skills of a cardiologist."
Dr. LeFevre also pointed out that because the incidence of AF is
directly related to age, the problem will become more prevalent with
the aging of the Baby Boomers.
"We can certainly hope that advances in science will provide us
safer, easier methods of anticoagulation and stroke prevention, as
that is now a significant cost and inconvenience," Dr. LeFevre
said. "Simplified management will be more cost effective."
References
1. Snow V, Weiss K, LeFevre M, et al. Management of newly
detected atrial fibrillation: A clinical practice guideline from the
American Academy of Family Physicians and the American College of
Physicians. Ann Intern Med. 2003;139:1009-1017.
2. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management of
atrial fibrillation: Review of the evidence for the role of
pharmacologic therapy, electrical cardioversion, and
echocardiography. Ann Intern Med. 2003;139:1018-1033.
3. The Atrial Fibrillation Follow-up Investigation of Rhythm
Management (AFFIRM) Investigators. A comparison of rate control and
rhythm control in patients with atrial fibrillation. N Engl J Med.
2002;347:1825-1833.
4. Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of
rate control and rhythm control in patients with recurrent
persistent atrial fibrillation. N Engl J Med. 2002;347:1834-1840.
5. Hohnloser SH, Kuck K-H, Lilenthal J, for the PIAF
Investigators. Rhythm or rate control in atrial fibrillation --
Pharmacological Intervention in Atrial Fibrillation (PIAF): A
randomized trial. Lancet. 2000;356:1789-1794.
6. Klein AL, Grimm RA, Murray RA, et al. Use of transesophageal
echocardiography to guide cardioversion in patients with atrial
fibrillation. N Engl J Med. 2001;344:1411-1420.
By Staff Writer, Medscape CRM
Reviewer: Albert A. Del Negro, MD
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