Two Largest Primary Care Medical Organizations Release Joint Clinical Guidelines To Manage Common Heart Condition

LEAWOOD, Kan. – The American Academy of Family Physicians and the American College of Physicians today released joint guidelines to manage new onset atrial fibrillation, a common arrhythmia (irregular heartbeat) that occurs most often in older adults.

According to the new guidelines, control of heart rate (not heart rhythm) with chronic anticoagulation medication is the recommended strategy for the majority of patients with atrial fibrillation. The guidelines identify drugs recommended for controlling heart rate during exercise and at rest. The guidelines and the background paper on which they are based are published in the Dec. 16, 2003, issue of Annals of Internal Medicine, published by ACP.

Atrial fibrillation is an abnormal heart rhythm in which the upper heart chambers (atria) contract rapidly, pumping blood inefficiently. The condition is rarely fatal, but, if uncontrolled, can cause stroke when blood clots formed in the atria travel to the brain.

Standard treatments have attempted to convert the heart to normal rhythm, either with medications or electricity, and often use long-term medication to try to maintain the normal rhythm.

“The generally accepted practice has been to do everything we can to get patients back into sinus rhythm and to try to keep them there,” said Michael LeFevre, MD, MSPH, family physician and co-chair of the Joint AAFP-ACP Panel on Atrial Fibrillation. “The best available research showed that the preferred approach for most patients with atrial fibrillation should be to focus on control of heart rate and stroke prevention with blood thinners, rather than attempt to restore sinus rhythm. Controlling rhythm was not better than controlling rate in reducing complications and death, and the side effects of medications to keep patients in normal rhythm may be greater than their benefits.”

"We are proposing that a major goal of treatment should be to control the individual’s heart rate and relieve the discomfort of symptoms associated with atrial fibrillation," said Kevin B. Weiss, MD, MPH, chair of ACP’s Clinical Efficacy Assessment Subcommittee and co-chair of the AAFP-ACP panel. "Prior to this evidence review, experts have primarily focused on restoring the heart’s natural rhythm. This recent systematic review of the literature presents strong enough evidence for both the ACP and AAFP to agree on guidelines focusing on control of heart rate (with anticoagulation) as the best strategy for most patients."

Atrial fibrillation is the most common arrhythmia. Common signs are fluttering sensation in the chest, lightheadedness, shortness of breath or chest pain. However, some people with atrial fibrillation have no symptoms.

Atrial fibrillation is not the same as ventricular fibrillation, the authors warn. Ventricular fibrillation — irregular beat of the lower chambers of the heart, which pump blood to the lungs for oxygen refueling and to the rest of the body — is much more serious. Irregular ventricular rhythms must be immediately converted into normal rhythm or the heart collapses, resulting in sudden cardiac death. The conversion is done with an electrical defibrillator that shocks the heart.

The guidelines are the result of an 18-month collaboration between the two organizations to develop evidence-based recommendations on the best way to treat atrial fibrillation. ACP and AAFP have collaborated previously on a guideline on the prevention and management of migraines, published in Annals of Internal Medicine on Nov. 19, 2002. They are working on two more collaborative guidelines. Both AAFP and ACP support clinical guidelines based on scientifically reviewed evidence instead of on the opinion of an expert panel.

The AAFP represents more than 94,300 family physicians and medical students nationwide. Family physicians are trained to provide comprehensive health care for people of all ages and serve as the patient’s advocate in the health-care system. Almost 200 million office visits are made to family physicians each year — 75 million more visits than to any other medical specialists.

ACP is the nation’s largest medical specialty organization and the second-largest physician group. Its membership includes more than 115,000 internal medicine physicians and medical students. Internists are specialists in the prevention, detection and treatment of illnesses that primarily affect adults.