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A report of the American College of Cardiology, American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for practice guidelines.

The REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation (RecordAF) is the first worldwide, 1-year observational, longitudinal study of the management of paroxysmal/persistent atrial fibrillation (AF) in recently diagnosed patients. The study was conducted at 532 sites in 21 countries across Europe, America, and Asia; recruitment was completed in April 2008. The primary objectives were to prospectively assess the therapeutic success and clinical outcomes in rhythm- and rate-control strategies. The study design and patient baseline data are reported. A total of 5,814 patients with AF were registered, and 5,604 were eligible for evaluation. Rhythm- and rate-control strategies were applied to 55% and 45% of patients, respectively, at study inclusion. Rhythm-control patients mainly received class III agents (45%) or beta blockers (51%), except for sotalol, and rate-control patients mainly received beta blockers (72%), except for sotalol, or cardiac glycosides (34%). Patients receiving a rhythm-control strategy were younger, had a lower resting heart rate, were more frequently symptomatic, and were more likely to have recently diagnosed AF or paroxysmal AF compared to patients receiving a rate-control strategy. A rate-control strategy was more common in patients with a history of heart failure or valvular heart disease and persistent AF. Rate-control patients more often had previous electrocardiographic evidence of AF and were not in sinus rhythm at inclusion (p0.01 for both end points). Patients were followed at 6 and 12 months, and changes in therapeutic strategy and clinical outcomes were recorded. In conclusion, the RecordAF study results will provide a global perspective on current AF treatment strategies.

Background— Improving health-related quality of life (HRQoL) is an important treatment goal in the management of patients with atrial fibrillation (AF). Uncertainty exists as to whether patients’ HRQoL differ when treated with medical rhythm control or rate control. We compared HRQoL between patients treated with rhythm control or rate control in a large observational registry of patients with recent-onset AF. Methods and Results— In the Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation (RECORD-AF), 2439 patients with recent onset (P P =0.01; propensity score-adjusted difference: −0.71 point; 95% confidence interval, −1.31 to −0.11; P =0.02). Conclusions— In this observational cohort of recent-onset AF patients, treatment with medical rhythm- or rate control over 1 year was associated with an improvement in HRQoL. The magnitude of HRQoL improvement was minimally higher in patients treated with rhythm control than rate control. However, the overall degree of improvement was not large, and its clinical significance was uncertain.

Atrial fibrillation (AF) poses a major global public health challenge because it is increasing in prevalence and is associated with an increased risk of stroke, dementia, heart failure, and death.1–3 In response to the many challenges posed by AF, the American Heart Association (AHA) convened a conference in Washington, DC, on June 12–13, 2010, that included patients, nurses, physicians, and healthcare policy makers and regulators. In addition, basic, translational, population, outcomes, and clinical scientists participated (Appendix). The 22 presentations and 6 panel discussions were organized into 4 sessions: (1) Mechanisms of AF: Basic and Translational Science and Genetics; (2) Epidemiology, Outcomes, Cost, AF, and Stroke Prevention; (3) Meeting the Clinical Challenges in AF; and (4) Redefining the Therapeutic Goals of AF (Appendix). The focus of the present report is to provide an overview of the key concepts presented and the core recommendations made by the summit participants. Attempts to develop safe and effective pharmacological therapy for AF have focused on atrium-selective drugs that take advantage of electrophysiological differences between the atrium and ventricle.4–7 Heterogeneous abbreviation of the effective refractory period within the atrium provides the electric substrate for development of AF. The reduced effective refractory period results from abbreviation of the atrial action potential duration, which is caused by a decrease in the calcium channel current ( ICa ) and an increase in the potassium channel current ( IK1 ) and the constitutively active acetylcholine-sensitive current (CA IKACh ).4–7 Maintenance of AF is facilitated by structural remodeling and additional abbreviation of the effective refractory period. The principal goal of pharmacological therapy is therefore to augment the effective refractory period. Distinctions in the ion channel currents between the atrium and ventricle open the possibility for development of atrium-specific and -selective drugs for rhythm …

Sidney C. Smith, Jr, MD, FACC, FAHA, FESC, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair; Cynthia D. Adams, MSN, APRN-BC, FAHA; Jeffery L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA[‡][1]; Jonathan L. Halperin, MD, FACC, FAHA; Sharon Ann Hunt, MD, FACC, FAHA; Rick Nishimura

Ventricular arrhythmia (VA) in structurally normal hearts can be broadly considered under non-life-threatening monomorphic and life-threatening polymorphic rhythms. Monomorphic VA is classified on the basis of site of origin in the heart, and the most common areas are the ventricular outflow tracts and left ventricular fascicles. The morphology of the QRS complexes on electrocardiogram is an excellent tool to identify the site of origin of the rhythm. Although these arrhythmias are common and generally carry an excellent prognosis, rare sudden death events have been reported. Very frequent ventricular ectopy may also result in a cardiomyopathy in a minority of patients. Suppression of VA may be achieved using calcium-channel blockers, beta-adrenergic blockers, and class I or III antiarrhythmic drugs. Radiofrequency ablation has emerged as an excellent option to eliminate these arrhythmias, although certain foci including aortic cusps and epicardium may be technically challenging. Polymorphic ventricular tachycardia (VT) is rare and generally occurs in patients with genetic ion channel disorders including long QT syndrome, Brugada syndrome, catecholaminergic polymorphic VT, and short QT syndrome. Unlike monomorphic VT, these arrhythmic syndromes are associated with sudden death. While the cardiac gross morphology is normal, suggesting a structurally normal heart, abnormalities exist at the molecular level and predispose them to arrhythmias. Another fascinating area, idiopathic ventricular fibrillation and early repolarization syndrome, are undergoing research for a genetic basis.

“Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.... Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession” (1). Cardiovascular specialists support the fundamental principles of primacy of patient welfare, patient autonomy, and the promotion of social justice. For the purposes of this document, “self-referral” occurs when a physician recommends a patient intervention from which the physician may benefit personally. Such recommendations usually facilitate the provision of efficient, effective, and high-quality care, but may also afford the potential for abuse. As former JACC Editor-in-Chief William Parmley stated so clearly: “At issue is the question of intent; if the intent is to provide excellent medical care, the practice is laudable. If the intent is to subjugate medical decision-making, then the practice is unethical” (2). Those few physicians who are publicized for violating our trust do not reflect the rank and file of cardiovascular specialists. The cardiovascular specialist's primary duty is to the patient. His or her role is to promote patient welfare in an increasingly complex health care environment, one that has been made even more complex by the anti-kickback statutes and Stark laws (see the following sections). Having entered into a physician-patient relationship, physicians must counsel their patients regardless of individual financial or medical care delivery system considerations or other factors, such as socio-economic status, race, gender, or sexual orientation (3). The physician's clinical judgment must not be influenced by financial incentives from a fee-for-service system or disincentives from a capitated care system. Recommendations should be made based only on medical merit (4,5). Physicians must …

This document is a compilation of the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) practice guideline recommendations for atrial fibrillation (AF) from the “ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation),”* the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)”† and the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran).”‡ Updated and new recommendations from 2011 are noted and outdated recommendations have been removed. No new evidence was reviewed, and no recommendations included herein are original to this document. The ACCF/AHA Task Force on Practice Guidelines chooses to republish the recommendations in this format to provide the complete set of practice guideline recommendations in a single resource. ### 1.1. Pharmacological and Nonpharmacological Therapeutic Options #### 1.1.1. Rate Control During AF Class I 1. Measurement of the heart rate at rest and control of the rate using …

Discrimination between long RP tachycardias can be difficult but is essential when ablative therapy is contemplated. After diagnosis by EP study, we administered adenosine (Ad) 12 mg to pts during atrial (AT, n = 24) or atypical AV node (ATYP, n = 7) tachycardia (tc). Tc cycle length (CL) and component intervals were measured before and after Ad. Ad caused termination (term) in all AT without prior AV node block. In tc without substantial CL variability, first change (δ) in Cl after Ad was located in either H-H or A-A intervals. For cycles between δ and term in atrium (a) or ventricle (v), presence of CL oscillation (Osc) and net change of A-A were assessed and intervals were examined for Pearson rlinear correlation patterns. 1. Before Ad age (y) sex (m, f) CL (ms) A-H (ms) H-A (ms) AT 43 ± 17 2, 22 425 ± 94 82 ± 52 332 ± 107 ATYP 38 ± 20 3, 4 387 ± 107 113 ± 70 289 ± 86 p: ns l0.005 ns ns ns 2. After Ad δ(kk)(A-A, H-H) Osc(kk)(n) term(kk)[0,5-6](a, v) δ to term(kk)(cycles) net ΔAA(kk)(ms) AT 17 0 15 10 14 3.9 ± 14 2 ± 29 ATYP 2 2 6 2 5 3.5 ± 1.7 25 ± 24 p: ns ns ns ns ns ns ns 3. A-Avs A-H A-Avs H-A (term a) (term v) (term a) (term v) No. of Correlations AT 6/10 2/14 4/10 13/14 with p l 0.05 for r ATYP 1/2 1/5 2/2 3/5 P(AT vs ATYP): ns ns ns ns AT pts were predominantly female. Othervvise, AT and ATYP were not separated by tc CL or intervals before Ad, or by dynamic relationships of intervals analysed by linear correlation. Thus, Ad is not a useful pharmacologic probe for differentiation of AT from ATYP when tc terminates without prior AVnode block.