Appendix:analytical report of level of evidence, related primary studies, strength of recommendation within each guideline and provisional GRADE based recommendation made by the working group
Question 1.When do you choose rate control or rhythm control strategy?
Question 1a.In haemodynamically unstable patients affected by acute-onset non-valvularatrial fibrillation is rhythm control preferable to a rate-control strategy?CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
electrical cardioversion / electrical cardioversion / electrical cardioversion / electrical cardioversion
Page: 40
References: No references
GRADE :Strong Recommendation,
Low-Quality Evidence / Page: 52
References: No references
COR/LOE: IB/IC / Page: 2395 eur heart j 2010:
References: No references
COR/LOE: IC / GRADE : Strong Recommendation,
Low-Quality Evidence
Outcome: survival
GRADE :Strong Recommendation,
Low-Quality Evidence / GRADE : Strong Recommendation,
Low-Quality Evidence / GRADE : Strong Recommendation,
Low-Quality Evidence
Question 1b.In haemodynamically stable patients affected by acute-onset (less than 48 hours) non-valvularatrial fibrillation for which patients rhythm control is preferable to a rate-control strategy?
CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
No recommendation, left to patients and physicians preferences / Persistent symptoms associated with AF remain themost compelling indication for a rhythm-control strategy. Other factors that may favor attempts at rhythmcontrol include difficulty in achieving adequate rate control, younger patient age, tachycardia-mediatedcardiomyopathy, first episode of AF, AF that is precipitated by an acute illness, and patient preference. / Rate control should be the initial approach in elderly patients with AF and minor symptoms (EHRA score 1)
1 Rhythm control is recommended inpatients with symptomatic (EHRAscore >2) AF despite adequate ratecontrol.
2 Rhythm control in patients with AFand AF-related heart failure shouldbe considered for improvement ofsymptoms.
3 Rhythm control as an initialapproach should be consideredin young symptomatic patients inwhom catheter ablation treatmenthas not been ruled out.
4 Rhythm control should beconsidered in patients with AFsecondary to a trigger or substratethat has been corrected (e.g.ischaemia, hyperthyroidism). / No agreement
No evidence
Outcomes: survival, hospitalization, stroke reduction, incidence of heart failure and quality of life
Disparity in evidence of recommendation (ESC IB)
Page: 39 (Management of AF in ED 2010)
References: Not Applicable
COR/LOE: Not Applicable / Page: 51
References:
-95. Olshansky B, Rosenfeld LE, Warner AL, et al. The Atrial Fibrillation Follow-up Investigation of RhythmManagement (AFFIRM) study: approaches to control rate in atrial fibrillation. J Am CollCardiol. 2004;43:1201-8. -306 Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of rate control and rhythm control in patients withrecurrent persistent atrial fibrillation. N Engl J Med. 2002;347:1834-40.
-129. Singh BN, Singh SN, Reda DJ, et al. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med.2005;352:1861-72.
COR/LOE: IC / Page: 1398
References:
-86AFFIRM Investigators. A comparison of rate control and rhythm control inpatients with atrial fibrillation. N Engl J Med 2002;347:1825–1833.
-87. Van Gelder IC,. A comparison of ratecontrol and rhythm control in patients with recurrent persistent atrial fibrillation.N Engl J Med 2002;347:1834–1840.
-90 Roy D, Rhythm control versus rate control for atrial fibrillationand heart failure. N Engl J Med 2008;358:2667–2677
COR/LOE: IA
Page: 2398
1 References:
-3 Kirchhof P. Outcome parameters for trials in atrial fibrillation: executive summary. Recommendations from a consensus conference organized by the German Atrial Fibrillation Competence NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eur Heart J 2007;28:2803–2817.
-46 Singh BN, Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005;352:1861–1872.
-93 Hsu LF . Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 2004;351:2373–2383.
-94 Khan MN . Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med 2008;359:1778–1785.
96 Wilber DJ. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA 2010;303:333–340.
COR/LOE: IB
2References:
-97 Talajic M. Maintenance of sinus rhythm and survival in patients with heart failure and atrial fibrillation. J Am CollCardiol 2010;55: 1796–1802.
3 COR/LOE: IIaB
References:Not Applicable
COR/LOE: IIaC
4 References: Not applicable
COR/LOE: IIaC
GRADE : Not applicable / GRADE: strong recommendation, low quality of evidence / GRADE :strong recommendation, moderate quality of evidence
Question 1c.In haemodynamically unstable patients affected by acute-onset non-valvularatrial fibrillation and WPW syndrome is rhythm control preferable to a rate-control strategy?
CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
Rhythm Control Strategy
(Urgent electrical cardioversion / Rhythm Control Strategy
(Urgent electrical cardioversion) / Not covered by the guidelines / Urgent electrical cardioversion
(ESC not covered)
Outcomes: Survival
Page: 43
References: No references
GRADE: Strong Recommendation,
Low-Quality Evidence / Page: 52, 76
References: No references
COR/LOE: IC / Page:
References: Not applicable
COR/LOE: Not applicable / GRADE : Strong Recommendation, Low-Quality Evidence
GRADE :Strong Recommendation, Low-Quality Evidence / GRADE : Strong Recommendation, Low-Quality Evidence / GRADE : Not applicable
Question 1d.In haemodynamically stable patients affected by acute-onset non-valvularatrial fibrillation and WPW syndrome is rhythm control preferable to a rate-control strategy?
CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
Rhythm Control Strategy (Pharmacological cardioversion with Ibutilide or Procainamide) / Rhythm Control Strategy (Pharmacological cardioversion with Ibutilide or Procainamide) / Not covered by the guidelines / Rhythm Control Strategy (Pharmacological cardioversion with Ibutilide or Procainamide) (ESC not covered)
Outcomes: survival, hospitalization, stroke reduction, incidence of heart failure and quality of life
Page: 43
References: No references
GRADE: Strong Recommendation,
Low-Quality Evidence / Page: 52, 76
References: 64
COR/LOE: IC
-64 Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. 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 develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am CollCardiol. 2003;42:1493-531 / Page:
References: Not applicable
COR/LOE: Not applicable / GRADE : strong recommendation, low quality of evidence
GRADE : strong recommendation, low quality of evidence / GRADE : strong recommendation, low quality of evidence / GRADE : Not applicable
Question 2. When do you choose electrical or pharmacological cardioversion?
Question 2a. In haemodynamically unstable patients affected by acute-onset non-valvularatrial fibrillation is electrical cardioversion preferable to pharmacological cardioversion?CCS 2010 / AHA 2014 / ESC 2010 / Agreement
Electrical cardioversion / Electrical cardioversion when no prompt reaction to pharmacologic therapies / Electrical cardioversion when no prompt reaction to pharmacologic therapies / Electrical cardioversion
Outcomes: Survival
Page: 40
References: No references
GRADE: Strong recommendation, Low-quality evidence / Page: 52
References: No references
COR/LOE: IC / Page: 2395
References: No references
COR/LOE: IC / GRADE : strong recommendation, low quality of evidence
GRADE: Strong recommendation, Low-quality evidence / GRADE: Strong recommendation, Low-quality evidence / GRADE: Strong recommendation, Low-quality evidence
Question 2b. In haemodynamically unstable patients affected by acute-onset non-valvularatrial fibrillation and WPW is electrical cardioversion preferable to pharmacological cardioversion??
CCS 2010 / AHA 2014 / ESC 2010 / Agreement
Electrical cardioversion. / Electrical cardioversion.
/ Electrical cardioversion. / Electrical cardioversion
Outcomes: Survival
Page: 43
References: No references
GRADE: Strong Recommendation, Low-Quality Evidence / Page: 52,76
References: No references
COR/LOE IC / Page: 2395
References: 82
-82 Gulamhusein S, Ko P, Carruthers SG, Klein GJ. Acceleration of the ventricular response during atrial fibrillation in the Wolff–Parkinson–White syndrome after verapamil. Circulation 1982;65:348–354.
COR/LOE: IB / GRADE : strong recommendation, low quality of evidence
GRADE: Strong Recommendation, Low-Quality Evidence / GRADE: Strong Recommendation, Low-Quality Evidence / GRADE: Strong Recommendation, Low-Quality Evidence
Question 2c. In haemodynamically stable patients affected by acute-onset (less than 48 hours) non-valvularatrial fibrillation is electrical cardioversion preferable to pharmacological cardioversion?
CCS 2010 / AHA 2014 / ESC 2010 / Agreement
Synchronized electrical cardioversion or pharmacologic cardioversion may be used when a decision is made to cardiovert patients in the emergency department.
Individual considerations of the patient and treating physician are recognized in making specific decisions about method of cardioversion. / 1. DCC is recommended for AF or atrial flutter to restore sinus rhythm. If unsuccessful, repeat cardioversion attempts may be made.
2. Electrical cardioversion is recommended for AF with rapid ventricular response that does not respond to pharmacological therapies. / Elective DCC should be considered in order to initiate a long-term rhythm control management strategy for patients with AF. / No agreement
Page: 41
Ref: No references
GRADE: Strong Recommendation, Low Quality Evidence / 1. Page: 53
Ref:
-320Oral H, Souza JJ, Michaud GF, Knight BP, Goyal R, Strickberger SA, Morady F. Facilitating transthoraciccardioversion of atrial fibrillation with ibutilidepretreatment. N Engl J Med 1999;340:1849-1854.
COR/LOE: IB
2. Page: 53
Ref: no references
COR/LOE: IC / Page: 2395
Ref:
-46 Singh BN, Singh SN, Reda DJ, Tang XC, Lopez B, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis HD Jr, Raisch DW, Ezekowitz MD. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005;352:1861-1872.
-78 Kirchhof P, Eckardt L, Loh P, Weber K, Fischer RJ, Seidl KH, Böcker D, Breithardt G, Haverkamp W, Borggrefe M. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial. Lancet 2002;360:1275-1279.
-83 Fetsch T, Bauer P, Engberding R, Koch HP, Lukl J, Meinertz T, Oeff M, Seipel L, Trappe HJ, Treese N, Breithardt G. Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial. Eur Heart J 2004;25:1385-1394.
COR/LOE: IIa B
GRADE: Strong Recommendation, Low Quality Evidence / GRADE: Strong Recommendation, Low Quality Evidence / GRADE: Strong Recommendation, Low Quality Evidence
Question 2d. In haemodynamically stable patients affected by acute-onset non-valvularatrial fibrillation and WPW syndrome is electrical cardioversion preferable to pharmacological cardioversion?
CCS 2010 / AHA 2014 / ESC 2010 / Agreement
Pharmacologic Cardioversion (Procainamide or Ibutilide)
Amiodarone should be used with caution in the case of preexcited AF as several case reports have described the occurrence of VF after intravenous administration. / Pharmacologic Cardioversion (Procainamide or Ibutilide)
Intravenous procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate is recommended for patients with pre-excited AF and rapid ventricular response.
/ Not Covered / Pharmacologic Cardioversion
Outcome: Survival
Page: 43
Ref: No references
GRADE: Strong Recommendation, Low-Quality Evidence / Page: 76-77
Ref:
-64Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS et al.. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. 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 develop guidelines for the management of patients with supraventricular arrhythmias). J Am CollCardiol 2003;42:1493-1531.
COR/LOE: IC / Page: Not Applicable
Ref: Not Applicable
COR/LOE: Not Applicable / GRADEStrong Recommendation, Low-Quality Evidence
GRADE: Strong Recommendation, Low-Quality Evidence / GRADE: Strong Recommendation, Low-Quality Evidence / GRADE:Not applicable
Question 3: In case of pharmacologicalcardioversion which drug would you use?
Question 3a. In haemodinamically stable patients affected by acute-onset (less than 48 hours) non-valvularatrial fibrillation and no structural heart disease which drug preferable for pharmacological cardioversion?CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
Flecainide, procainamide, propafenone, ibutilide / Flecainide, propafenone, dofetilide, and ibutilide / Propafenone, flecainide, ibutilide / Flecainide and propafenone.
Less consensus regarding ibutilide Outcome: restoring sinus rhythm
Page: 41
References:
-13. Page RL. Newly diagnosed atrial fibrillation. N Engl J Med 2004;351:2408-16.
-15. Taylor DM, Aggarwall A, Carter M, Garewal D, Hunt D. Management ofnew onset atrial fibrillation in previously well patients less than 60 years ofage. Emerg Med Austral 2005;17:4-10.
-16. Raghavan AV, Decker WW, Meloy TD. Management of atrial fibrillationin the emergency department. Emerg Med Clin N Am 2005;23:1127-39.
-36. ACLS Guidelines: Part 7.3: Management of symptomatic bradycardia and tachycardia. Circulation 2005;112:IV-67-IV-77.
-37. Nichol G, McAlister FA, Pham B, et al. Meta-analysis of randomized controlled trials of the effectiveness of antiarrhythmic agents at promoting sinus rhythm in patients with atrial fibrillation. Heart 2002;87:535-43.
GRADE: Strong recommendation, high quality of evidence / Page: 53
References:
-321. Alboni P, Botto GL, Baldi N, et al. Outpatient treatment of recent-onset atrial fibrillation with the “pill-in-the-pocket” approach. N Engl J Med 2004;351:2384–91.
-322. Ellenbogen KA, Clemo HF, Stambler BS, et al. Efficacy of ibutilide for termination of atrial fibrillation and flutter. Am J Cardiol 1996;78:42–5.
-323. Khan IA. Single oral loading dose of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation. J Am CollCardiol 2001;37:542–7.
-324. Patsilinakos S, Christou A, Kafkas N, et al. Effect of high doses of magnesium on converting ibutilide to a safe and more effective agent. Am J Cardiol 2010;106:673–6.
-325. Singh S, Zoble RG, Yellen L, et al. Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) study. Circulation 2000;102:2385–90.
-326. Stambler BS, Wood MA, Ellenbogen KA, et al.Efficacy and safety of repeated intravenous doses ofibutilide for rapid conversion of atrial flutter or fibrillation.Ibutilide Repeat Dose Study Investigators. Circulation1996;94:1613–21.
COR/LOE: I/A / Page: 2394
References: 71-73
-71. Reisinger J, Gatterer E, LangW, Vanicek T, Eisserer G, Bachleitner T, Niemeth C, Aicher F, Grander W, Heinze G, Kuhn P, Siostrzonek P. Flecainide versus ibutilide for immediate cardioversion of atrial fibrillation of recent onset. Eur Heart J 2004;25:1318–1324.
-72. Khan IA. Single oral loading dose of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation. J Am CollCardiol 2001;37:542–547.
-73. Martinez-Marcos FJ, Garcia-Garmendia JL, Ortega-Carpio A, Fernandez-Gomez JM, Santos JM, Camacho C. Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Am J Cardiol 2000;86:950–953.
COR/LOE: I/A (propafenone and fleicanide)
IIb/A (ibutilide) / GRADE: weak recommendation, low quality of evidence
GRADE :weak recommendation, low quality of evidence / GRADE :weak recommendation, low quality of evidence / GRADE :weak recommendation, low quality of evidence
Question 3b. In haemodinamically stable patients affected by acute-onset (less than 48 hours) non-valvularatrial fibrillation and structural heart disease which drug is preferable for pharmacological cardioversion?
CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
Ibutilide, Procainamide / Ibutilide, Dofetilide, Amiodarone / Amiodarone / No agreement
Page: 41
References: -13. Page RL. Newly diagnosed atrial fibrillation. N Engl J Med 2004;351:2408-16.
-15. Taylor DM, Aggarwall A, Carter M, Garewal D, Hunt D. Management of new onset atrial fibrillation in previously well patients less than 60 years of age. Emerg Med Austral 2005;17:4-10.
-16. Raghavan AV, Decker WW, Meloy TD. Management of atrial fibrillation in the emergency department. Emerg Med Clin N Am 2005;23:1127-39.
-36. ACLS Guidelines: Part 7.3: Management of symptomatic bradycardia and tachycardia. Circulation 2005;112:IV-67-IV-77.
-37. Nichol G, McAlister FA, Pham B, et al. Meta-analysis of randomized controlled trials of the effectiveness of antiarrhythmic agents at promoting sinus rhythm in patients with atrial fibrillation. Heart 2002;87:535-43.
GRADE: strong recommendation, high quality of evidence / Page: 53
References:
-322. Ellenbogen KA, Clemo HF, Stambler BS, et al. Efficacy of ibutilide for termination of atrial fibrillation and flutter. Am J Cardiol 1996;78:42–5.
-324. Patsilinakos S, Christou A, Kafkas N, et al. Effect of high doses of magnesium on converting ibutilide to a safe and more effective agent. Am J Cardiol 2010;106:673–6.
-325. Singh S, Zoble RG, Yellen L, et al. Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) study. Circulation 2000;102:2385–90.
-326. Stambler BS, Wood MA, Ellenbogen KA, et al. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation 1996;94:1613–21.
-328. Letelier LM, Udol K, Ena J, et al. Effectiveness of amiodarone for conversion of atrial fibrillation to sinus rhythm: a meta-analysis. Arch Intern Med 2003;163:777–85.
-329. Pedersen OD, Bagger H, Keller N, et al. Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: a Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND) Substudy. Circulation 2001;104:292–6.
COR/LOE: I/A (dofetilide, ibutilide) IIa/A (amiodarone) / Page: 2394
References: 74-76
-74. Chevalier P, Durand-Dubief A, Burri H, Cucherat M, Kirkorian G, Touboul P. Amiodarone versus placebo and class Ic drugs for cardioversion of recent-onset atrial fibrillation: a meta-analysis. J Am CollCardiol 2003;41:255–262.
-75. Vardas PE, Kochiadakis GE, Igoumenidis NE, Tsatsakis AM, Simantirakis EN, Chlouverakis GI. Amiodarone as a first-choice drug for restoring sinus rhythm in patients with atrial fibrillation: a randomized, controlled study. Chest 2000;117:1538–1545.
-76. Bianconi L, Castro A, Dinelli M, Alboni P, Pappalardo A, Richiardi E, Santini M. Comparison of intravenously administered dofetilide versus amiodarone in the acute termination of atrial fibrillation and flutter. A multicentre, randomized, double-blind, placebo-controlled study. Eur Heart J 2000;21:1265–1273
COR/LOE: I/A
GRADE: weak recommendation, low quality of evidence / GRADE: weak recommendation, low quality of evidence / GRADE: weak recommendation, low quality of evidence
Question 3c. In haemodinamically stable patients affected by paroxysmal non-valvularatrial fibrillation and no structural heart disease would you recommend the pill in the pocket approach with flecainide or propafenone?
CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
Pill-in-the-pocket / Pill-in-the-pocket / Pill-in-the-pocket / Pill-in-the-pocket approach is a feasible, safe and effective strategy Outcome: emergency room visits, hospitalization, quality of life
Page: 55
References: 59
GRADE: Weak recommendation, low quality of evidence / Page: 53
References:
-321. Alboni P, Botto GL, Baldi N, et al. Outpatient treatment of recent-onset atrial fibrillation with the “pill-in-the-pocket” approach. N Engl J Med 2004;351:2384–91.
COR/LOE: IIA/B / Page: 2394-2395
References:
-67. Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L, Marchi P, Calzolari M, Solano A, Baroffio R, Gaggioli G. Outpatient treatment of recent-onset atrial fibrillation with the ‘pill-in-the-pocket’ approach. N Engl J Med 2004;351:2384–2391
COR/LOE: IIA/B / GRADE: Weak recommendation, low quality of evidence
GRADE: Weak recommendation, low quality of evidence / GRADE: Weak recommendation, low quality of evidence / GRADE: Weak recommendation, low quality of evidence
Question 4: In case of rate control strategy which drug would you use?
Question 4a.In patients affected by acute-onset non-valvularatrial fibrillation and no hypotension or heart failure which therapy would you recommend in order to obtain rate control?CCS 2010 / AHA 2014 / ESC 2010-2012 / Agreement
Beta blockers or non-dihydropyridine calcium channel antagonists / Beta blockers or non-dihydropyridine calcium channel antagonists / Beta blockers or non-dihydropyridine calcium channel antagonists / Beta blockers or non-dihydropyridine calcium channel antagonists