Skip to main content
NCBI home page
The Western Journal of Medicine logoLink to The Western Journal of Medicine
. 1995 Apr;162(4):331–339.

Treatment of nonvalvular atrial fibrillation.

G D Stettin 1
PMCID: PMC1022771  PMID: 7747499

Abstract

Nonvalvular atrial fibrillation is an increasingly common condition. It may cause disabling symptoms and is an important risk factor for stroke. The goals of treatment include the relief and prevention of rate- and rhythm-related symptoms and the prevention of stroke and systemic emboli. Three principal treatments should be considered: pharmacologic rate control, cardioversion and antiarrhythmic therapy to restore and maintain sinus rhythm, and prophylactic anticoagulation or antiplatelet therapy to reduce the risk of stroke. The risks and benefits of each of these therapies have been reviewed. Symptoms, if present, can often be managed safely with rate-directed therapy alone. Until issues regarding safety and long-term efficacy are resolved, cardioversion and antiarrhythmic therapy should be limited to those patients whose symptoms cannot otherwise be controlled. The benefits of warfarin anticoagulation for the primary and secondary prevention of stroke in nonvalvular atrial fibrillation have been demonstrated convincingly by several randomized clinical trials. These benefits must be weighed against the real risk of major hemorrhage. For patients at low risk of stroke, the use of aspirin may be an acceptable alternative to warfarin sodium therapy.

Full text

PDF
331

Images in this article

332Image
on p.332
332Image
on p.332
333Image
on p.333
335Image
on p.335
336Image
on p.336
337Image
on p.337

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Anderson J. L., Gilbert E. M., Alpert B. L., Henthorn R. W., Waldo A. L., Bhandari A. K., Hawkinson R. W., Pritchett E. L. Prevention of symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy. A multicenter, double-blind, crossover study of flecainide and placebo with transtelephonic monitoring. Flecainide Supraventricular Tachycardia Study Group. Circulation. 1989 Dec;80(6):1557–1570. doi: 10.1161/01.cir.80.6.1557. [DOI] [PubMed] [Google Scholar]
  2. Arnold A. Z., Mick M. J., Mazurek R. P., Loop F. D., Trohman R. G. Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter. J Am Coll Cardiol. 1992 Mar 15;19(4):851–855. doi: 10.1016/0735-1097(92)90530-z. [DOI] [PubMed] [Google Scholar]
  3. Beasley R., Smith D. A., McHaffie D. J. Exercise heart rates at different serum digoxin concentrations in patients with atrial fibrillation. Br Med J (Clin Res Ed) 1985 Jan 5;290(6461):9–11. doi: 10.1136/bmj.290.6461.9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bianconi L., Boccadamo R., Pappalardo A., Gentili C., Pistolese M. Effectiveness of intravenous propafenone for conversion of atrial fibrillation and flutter of recent onset. Am J Cardiol. 1989 Aug 1;64(5):335–338. doi: 10.1016/0002-9149(89)90530-4. [DOI] [PubMed] [Google Scholar]
  5. Bjerkelund C. J., Orning O. M. The efficacy of anticoagulant therapy in preventing embolism related to D.C. electrical conversion of atrial fibrillation. Am J Cardiol. 1969 Feb;23(2):208–216. doi: 10.1016/0002-9149(69)90068-x. [DOI] [PubMed] [Google Scholar]
  6. Bogousslavsky J., Van Melle G., Regli F., Kappenberger L. Pathogenesis of anterior circulation stroke in patients with nonvalvular atrial fibrillation: the Lausanne Stroke Registry. Neurology. 1990 Jul;40(7):1046–1050. doi: 10.1212/wnl.40.7.1046. [DOI] [PubMed] [Google Scholar]
  7. Brand F. N., Abbott R. D., Kannel W. B., Wolf P. A. Characteristics and prognosis of lone atrial fibrillation. 30-year follow-up in the Framingham Study. JAMA. 1985 Dec 27;254(24):3449–3453. [PubMed] [Google Scholar]
  8. Caplan L. R., Hier D. B., D'Cruz I. Cerebral embolism in the Michael Reese Stroke Registry. Stroke. 1983 Jul-Aug;14(4):530–536. doi: 10.1161/01.str.14.4.530. [DOI] [PubMed] [Google Scholar]
  9. Connolly S. J., Laupacis A., Gent M., Roberts R. S., Cairns J. A., Joyner C. Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J Am Coll Cardiol. 1991 Aug;18(2):349–355. doi: 10.1016/0735-1097(91)90585-w. [DOI] [PubMed] [Google Scholar]
  10. Coplen S. E., Antman E. M., Berlin J. A., Hewitt P., Chalmers T. C. Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized control trials. Circulation. 1990 Oct;82(4):1106–1116. doi: 10.1161/01.cir.82.4.1106. [DOI] [PubMed] [Google Scholar]
  11. Dunn M., Alexander J., de Silva R., Hildner F. Antithrombotic therapy in atrial fibrillation. Chest. 1986 Feb;89(2 Suppl):68S–74S. doi: 10.1378/chest.89.2_supplement.68s. [DOI] [PubMed] [Google Scholar]
  12. Echt D. S., Liebson P. R., Mitchell L. B., Peters R. W., Obias-Manno D., Barker A. H., Arensberg D., Baker A., Friedman L., Greene H. L. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med. 1991 Mar 21;324(12):781–788. doi: 10.1056/NEJM199103213241201. [DOI] [PubMed] [Google Scholar]
  13. Ezekowitz M. D., Bridgers S. L., James K. E., Carliner N. H., Colling C. L., Gornick C. C., Krause-Steinrauf H., Kurtzke J. F., Nazarian S. M., Radford M. J. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators. N Engl J Med. 1992 Nov 12;327(20):1406–1412. doi: 10.1056/NEJM199211123272002. [DOI] [PubMed] [Google Scholar]
  14. Falk R. H., Knowlton A. A., Bernard S. A., Gotlieb N. E., Battinelli N. J. Digoxin for converting recent-onset atrial fibrillation to sinus rhythm. A randomized, double-blinded trial. Ann Intern Med. 1987 Apr;106(4):503–506. doi: 10.7326/0003-4819-106-4-503. [DOI] [PubMed] [Google Scholar]
  15. Flaker G. C., Blackshear J. L., McBride R., Kronmal R. A., Halperin J. L., Hart R. G. Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators. J Am Coll Cardiol. 1992 Sep;20(3):527–532. doi: 10.1016/0735-1097(92)90003-6. [DOI] [PubMed] [Google Scholar]
  16. Friedman G. D., Loveland D. B., Ehrlich S. P., Jr Relationship of stroke to other cardiovascular disease. Circulation. 1968 Sep;38(3):533–541. doi: 10.1161/01.cir.38.3.533. [DOI] [PubMed] [Google Scholar]
  17. Goldman S., Probst P., Selzer A., Cohn K. Inefficacy of "therapeutic" serum levels of digoxin in controlling the ventricular rate in atrial fibrillation. Am J Cardiol. 1975 May;35(5):651–655. doi: 10.1016/0002-9149(75)90051-x. [DOI] [PubMed] [Google Scholar]
  18. Gosselink A. T., Crijns H. J., Van Gelder I. C., Hillige H., Wiesfeld A. C., Lie K. I. Low-dose amiodarone for maintenance of sinus rhythm after cardioversion of atrial fibrillation or flutter. JAMA. 1992 Jun 24;267(24):3289–3293. [PubMed] [Google Scholar]
  19. Halperin J. L., Hart R. G. Atrial fibrillation and stroke: new ideas, persisting dilemmas. Stroke. 1988 Aug;19(8):937–941. doi: 10.1161/01.str.19.8.937. [DOI] [PubMed] [Google Scholar]
  20. Hart R. G., Coull B. M., Hart D. Early recurrent embolism associated with nonvalvular atrial fibrillation: a retrospective study. Stroke. 1983 Sep-Oct;14(5):688–693. doi: 10.1161/01.str.14.5.688. [DOI] [PubMed] [Google Scholar]
  21. Hinton R. C., Kistler J. P., Fallon J. T., Friedlich A. L., Fisher C. M. Influence of etiology of atrial fibrillation on incidence of systemic embolism. Am J Cardiol. 1977 Oct;40(4):509–513. doi: 10.1016/0002-9149(77)90064-9. [DOI] [PubMed] [Google Scholar]
  22. Juul-Möller S., Edvardsson N., Rehnqvist-Ahlberg N. Sotalol versus quinidine for the maintenance of sinus rhythm after direct current conversion of atrial fibrillation. Circulation. 1990 Dec;82(6):1932–1939. doi: 10.1161/01.cir.82.6.1932. [DOI] [PubMed] [Google Scholar]
  23. Kannel W. B., Abbott R. D., Savage D. D., McNamara P. M. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med. 1982 Apr 29;306(17):1018–1022. doi: 10.1056/NEJM198204293061703. [DOI] [PubMed] [Google Scholar]
  24. Karlson B. W., Torstensson I., Abjörn C., Jansson S. O., Peterson L. E. Disopyramide in the maintenance of sinus rhythm after electroconversion of atrial fibrillation. A placebo-controlled one-year follow-up study. Eur Heart J. 1988 Mar;9(3):284–290. doi: 10.1093/oxfordjournals.eurheartj.a062498. [DOI] [PubMed] [Google Scholar]
  25. Kopecky S. L., Gersh B. J., McGoon M. D., Whisnant J. P., Holmes D. R., Jr, Ilstrup D. M., Frye R. L. The natural history of lone atrial fibrillation. A population-based study over three decades. N Engl J Med. 1987 Sep 10;317(11):669–674. doi: 10.1056/NEJM198709103171104. [DOI] [PubMed] [Google Scholar]
  26. Lancaster T. R., Singer D. E., Sheehan M. A., Oertel L. B., Maraventano S. W., Hughes R. A., Kistler J. P. The impact of long-term warfarin therapy on quality of life. Evidence from a randomized trial. Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. Arch Intern Med. 1991 Oct;151(10):1944–1949. [PubMed] [Google Scholar]
  27. Lewis R. V., McMurray J., McDevitt D. G. Effects of atenolol, verapamil, and xamoterol on heart rate and exercise tolerance in digitalised patients with chronic atrial fibrillation. J Cardiovasc Pharmacol. 1989 Jan;13(1):1–6. doi: 10.1097/00005344-198901000-00002. [DOI] [PubMed] [Google Scholar]
  28. Manning W. J., Leeman D. E., Gotch P. J., Come P. C. Pulsed Doppler evaluation of atrial mechanical function after electrical cardioversion of atrial fibrillation. J Am Coll Cardiol. 1989 Mar 1;13(3):617–623. doi: 10.1016/0735-1097(89)90602-5. [DOI] [PubMed] [Google Scholar]
  29. Mohr J. P., Caplan L. R., Melski J. W., Goldstein R. J., Duncan G. W., Kistler J. P., Pessin M. S., Bleich H. L. The Harvard Cooperative Stroke Registry: a prospective registry. Neurology. 1978 Aug;28(8):754–762. doi: 10.1212/wnl.28.8.754. [DOI] [PubMed] [Google Scholar]
  30. Petersen P., Boysen G., Godtfredsen J., Andersen E. D., Andersen B. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study. Lancet. 1989 Jan 28;1(8631):175–179. doi: 10.1016/s0140-6736(89)91200-2. [DOI] [PubMed] [Google Scholar]
  31. Pomfret S. M., Beasley C. R., Challenor V., Holgate S. T. Relative efficacy of oral verapamil and digoxin alone and in combination for the treatment of patients with chronic atrial fibrillation. Clin Sci (Lond) 1988 Apr;74(4):351–357. doi: 10.1042/cs0740351. [DOI] [PubMed] [Google Scholar]
  32. Reimold S. C., Cantillon C. O., Friedman P. L., Antman E. M. Propafenone versus sotalol for suppression of recurrent symptomatic atrial fibrillation. Am J Cardiol. 1993 Mar 1;71(7):558–563. doi: 10.1016/0002-9149(93)90511-a. [DOI] [PubMed] [Google Scholar]
  33. Sherman D. G., Goldman L., Whiting R. B., Jurgensen K., Kaste M., Easton J. D. Thromboembolism in patients with atrial fibrillation. Arch Neurol. 1984 Jul;41(7):708–710. doi: 10.1001/archneur.1984.04050180030011. [DOI] [PubMed] [Google Scholar]
  34. Van Gelder I. C., Crijns H. J., Van Gilst W. H., Hamer H. P., Lie K. I. Decrease of right and left atrial sizes after direct-current electrical cardioversion in chronic atrial fibrillation. Am J Cardiol. 1991 Jan 1;67(1):93–95. doi: 10.1016/0002-9149(91)90108-w. [DOI] [PubMed] [Google Scholar]
  35. Van Gelder I. C., Crijns H. J., Van Gilst W. H., Verwer R., Lie K. I. Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Am J Cardiol. 1991 Jul 1;68(1):41–46. doi: 10.1016/0002-9149(91)90707-r. [DOI] [PubMed] [Google Scholar]
  36. Vitolo E., Tronci M., Larovere M. T., Rumolo R., Morabito A. Amiodarone versus quinidine in the prophylaxis of atrial fibrillation. Acta Cardiol. 1981;36(6):431–444. [PubMed] [Google Scholar]
  37. Weinberg D. M., Mancini J. Anticoagulation for cardioversion of atrial fibrillation. Am J Cardiol. 1989 Mar 15;63(11):745–746. doi: 10.1016/0002-9149(89)90264-6. [DOI] [PubMed] [Google Scholar]
  38. Wolf P. A., Abbott R. D., Kannel W. B. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991 Aug;22(8):983–988. doi: 10.1161/01.str.22.8.983. [DOI] [PubMed] [Google Scholar]
  39. Wolf P. A., Abbott R. D., Kannel W. B. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987 Sep;147(9):1561–1564. [PubMed] [Google Scholar]
  40. Wolf P. A., Dawber T. R., Thomas H. E., Jr, Kannel W. B. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology. 1978 Oct;28(10):973–977. doi: 10.1212/wnl.28.10.973. [DOI] [PubMed] [Google Scholar]
  41. Wong C. K., Lau C. P., Leung W. H., Cheng C. H. Usefulness of labetalol in chronic atrial fibrillation. Am J Cardiol. 1990 Nov 15;66(17):1212–1215. doi: 10.1016/0002-9149(90)91102-c. [DOI] [PubMed] [Google Scholar]

Articles from Western Journal of Medicine are provided here courtesy of BMJ Publishing Group

RESOURCES