Additionally, these patients still require anticoagulation, and the side effects of anti-arrhythmic drugs might offset the benefits of sinus rhythm. Therefore, rate control is an appropriate strategy. The stroke rate and side-effect risks with anti-arrhythmics are considerably lower in younger patients or those with paroxysmal lone AF, and so a rhythm-control strategy in these groups is reasonable.
Stroke rate in AF increases with known high-risk factors (prior thromboembolism or rheumatic mitral stenosis) and moderate-risk factors (heart failure, hypertension, age over 75, and diabetes). Less validated risk factors include female gender, age 65-74, thyrotoxicosis, and the presence of coronary artery disease.
There are well-defined recommendations for how to anticoagulate specific subgroups that pose clinical challenges not directly addressed in studies, but the guidelines do assist with:
- Patients who have a stroke with a therapeutic INR: Rather than adding antiplatelet agents, INR goal can be raised to 3-3.5;
- Patients >75 years old who are at a high risk for bleeding: A target INR of 2.0 (target range 1.6-2.5) seems reasonable;1 and
- Patients with stable coronary artery disease and AF: Warfarin anticoagulation alone should provide satisfactory antithrombotic prophylaxis against cerebrovascular and coronary atheroembolic events.1
Decisions involving perioperative management of anticoagulation in patients with AF frequently arise. Per the guidelines, in patients with nonvalvular AF, anticoagulation can be stopped for up to one week without bridging for surgical or diagnostic procedures, but bridging should be considered in high-risk patients.
Hospitalists are likely to manage AF, whether alone or in conjunction with cardiology consultation. These new comprehensive guidelines deal with rate control, rhythm control, and prevention of thromboembolism. Hospitalists should take particular interest in the guidelines regarding lenient rate control, dronedarone for rhythm control, and dabigatran as a new alternative for anticoagulation in appropriate populations.
Drs. Farrell and Carbo are hospitalists at Beth Israel Deaconess Medical Center in Boston.
- Fuster V, Rydén LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2011;57(11):e101-98.
- Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Heart Rhythm. 2011;8(1):157-76.
- Wann LS, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2011;57(11):1330-7.