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Introduction 

Introduction
Chapter:
Introduction
Author(s):

A. John Camm

DOI:
10.1093/med/9780198784906.003.0494_update_001

Update:

Updated text referring to guidelines

Updated figure

Updated on 1 October 2020. The previous version of this content can be found here.
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date: 18 April 2021

This chapter provides the background information and detailed discussion of the data for the following current ESC Guidelines on: Introduction atrial fibrillation - https://doi.org/10.1093/eurheartj/ehaa612

Summary

Although a condition associated with a fully irregular pulse has been known to physicians for centuries, it was only towards the end of the nineteenth century and the beginning of the twentieth century that some mechanistic understanding of the arrhythmia was gained from the jugular venous and arterial pulse recordings (polysomnography) made by Mackenzie and the electrocardiograms recorded by Einthoven and Lewis. It was apparent that atrial contraction was absent, that the normal atrial activation (P wave) was replaced by a higher-frequency atrial fibrillatory wave, and that the QRS complexes were usually narrow and consistent with a normal supraventricular origin.

The link between atrial fibrillation and disease has been unclear. On the one hand, there were patients with overt heart disease, such as rheumatic or ischaemic, who seemed to develop atrial fibrillation because of the heart disease, others where the atrial fibrillation appeared to be a result of toxicity from thyroid overactivity, drugs (recreational, illegal or prescription) or alcoholic binges, and finally there was a large group of usually older people who had the disease without any obvious underlying cause. The latter group of patients often had minimal symptoms and no treatment appeared to be warranted. In fact, so usual was this state of affairs that medical students prior to about 1970 were assured that atrial fibrillation in the elderly was an acceptable alternative to normal sinus rhythm. The link between the arrhythmia and stroke, heart failure, sudden death, all-cause death, and increased hospitalization rates had not been established. Therefore, treatment consisted mostly of digoxin for occasional symptomatic elderly patients to reduce the heart rate when it was faster than was comfortable.

For those, usually younger, patients with highly symptomatic recurrences, antiarrhythmic therapy with quinidine was a possibility, and rate control with glycosides, or with propranolol by the late 1960s, were used. Anticoagulation started when cardioversion was introduced following Russian and North American discoveries, but continuous thromboprophylactic anticoagulation with vitamin K antagonist therapy did not become popular until the late 1980s. Even when positive clinical trials documented the very substantial value of anticoagulation, it remained difficult to persuade physicians to use these drugs, predominantly because of haemorrhagic complications. Only recently, with the advent of the non-vitamin K antagonist (or direct) oral anticoagulants has the anticoagulation rate of at-risk patients exceeded 75%.

IntroductionThe first full guideline for the management of atrial fibrillation did not emerge until 2001. The document was jointly prepared by the European and American professional societies and was an enormously well-cited and much used document. It was followed by a revision in 2006 and again the publication proved very valuable. In 2010, the European Society of Cardiology produced its own guideline which was updated in 2012, and fully rewritten in 2016. The latest ESC Guideline was produced in 2020. The American Heart Association, the American College of Cardiology, and the Heart Rhythm Society, published a joint guideline, followed by several updates, in 2011. These documents have greatly influenced the global management of atrial fibrillation and have spurred a dramatic growth of guideline-related publications (Figure 41.1.1a). A new rewrite was published in 2014 and an update was released in 2019, such is the pace of progress on the investigation and management of this condition (Figure 41.1.1b).

 Figure 41.1.1 (a) All publications on atrial fibrillation. (b) Guideline-related publications on atrial fibrillation.

Figure 41.1.1 (a) All publications on atrial fibrillation. (b) Guideline-related publications on atrial fibrillation.

Further reading

Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P, ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation – developed with the special contribution of the European Heart Rhythm Association. Europace 2012;14:1385–413.Find this resource:

European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH, ESC Committee for Practice Guidelines. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace 2010;12:1360–420. Erratum in: Europace 2011;13:1058.Find this resource:

Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, American College of Cardiology, American Heart Association, European Society of Cardiology, North American Society of Pacing and Electrophysiology. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. 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 and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 2001;22:1852–923.Find this resource:

Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL, American College of Cardiology, American Heart Association Task Force, European Society of Cardiology Committee for Practice Guidelines, European Heart Rhythm Association, Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: 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 (Writing Committee to Revise the2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace 2006;8:651–745. Erratum in: Europace 2007;9:856.Find this resource:

January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW, American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:2246–80.Find this resource:

Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GY, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893–962.Find this resource:

Wann LS, Curtis AB, Ellenbogen KA, Estes NA 3rd, Ezekowitz MD, Jackman WM, January CT, Lowe JE, Page RL, Slotwiner DJ, Stevenson WG, Tracy CM, Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Heuzey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 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. Heart Rhythm 2011;8:e1–8.Find this resource:

Wann LS, Curtis AB, January CT, Ellenbogen KA, Lowe JE, Estes NA 3rd, Page RL, Ezekowitz MD, Slotwiner DJ, Jackman WM, Stevenson WG, Tracy CM. 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;8:157–76.Find this resource: