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,

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ACC/AHA/ESC 2006 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 (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society

Atrial fibrillation (AF), the most common sustained cardiac rhythm disturbance, is increasing in prevalence as the population ages. Although it is often associated with heart disease, AF occurs in many patients with no detectable disease. Hemodynamic impairment and thromboembolic events result in significant morbidity, mortality, and cost. Accordingly, the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) created a committee of experts to establish guidelines for management of this arrhythmia.

The committee was composed of 8 members representing the ACC and AHA, 4 representing the ESC, 1 from the North American Society of Pacing and Electrophysiology (NASPE), and a representative of the Johns Hopkins University Evidence-Based Practice Center representing the Agency for Healthcare Research and Quality’s report on Atrial Fibrillation in the Elderly. This document was reviewed by 3 official reviewers nominated by the ACC, 3 nominated by the AHA, and 3 nominated by the ESC, as well as by the ACC Clinical Electrophysiology Committee, the AHA ECG and Arrhythmia Committee, NASPE, and 25 reviewers nominated by the writing committee. The document was approved for publication by the governing bodies of the ACC, AHA, and ESC and officially endorsed by NASPE. These guidelines will be reviewed annually by the task force and will be considered current unless the task force revises or withdraws them from distribution.

The committee conducted a comprehensive review of the literature from 1980 to June 2000 relevant to AF using the following databases: PubMed/Medline, EMBASE, the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Registry), and Best Evidence. Searches were limited to English language sources and to human subjects.

### A. Atrial Fibrillation

AF is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function. On the electrocardiogram (ECG), AF …

/pdf/acc-aha-esc-guidelines-for-the-management-of-patients-with-4281694a2b.pdf

ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: 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 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

https://smhs.gwu.edu/medicine/sites/medicine/files/GuidelinesforManagementofPatientsWithAtrialFibrillation.pdf

ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation--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 Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation)

For new or updated text, view the 2011 Focused Update and the 2011 Focused Update on Dabigatran. Text supporting unchanged recommendations has not been updated. 

It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines, whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. The Task Force is pleased to have this guideline developed in conjunction with the European Society of Cardiology (ESC). Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop or update written recommendations for clinical practice.

Experts in the subject under consideration have been selected from all 3 organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular …

2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society

The tachycardia-bradycardia syndrome consists of paroxysmal atrial fibrillation, flutter or tachycardia followed by sinoatrial block or sinus arrest resulting in Stokes-Adams attacks. Detailed histologie findings of the conduction system of 2 patients with this entity correlated well with the clinical observation of cardiac rhythm disturbances in the sinus node, atria and atrioventricular (A-V) junction. Eight other patients with the syndrome were studied clinically. The mechanisms (as revealed by the electrocardiogram) producing the bradycardia phase include depression of pacemaker function (arrest) or of conduction (exit block) of the sinus impulse, or both, plus depression of A-V junctional impulse formation. Proper therapy usually requires electrical pacing in conjunction with administration of digitalis or propranolol, or both. Our findings suggest that the term “sick sinus syndrome” is an inaccurate and inappropriate synonym for the tachycardia-bradycardia syndrome.

Tachycardia-bradycardia syndrome (so-called “sick sinus syndrome”): Pathology, mechanisms and treatment

The ventricular response in atrial fibrillation is determined by the long refractory period of the AV junction. Since an atrial impulse is always available for transmission to the ventricles, a regular ventricular rhythm would be expected, the rate of which would reflect the duration of a stable junctional refractory phase. The irregularity of the ventricular action associated with atrial fibrillation, therefore, indicates changes of refractoriness of the AV junctional tissues from cycle to cycle. This can best be attributed to varying degrees of penetration of "blocked" atrial impulses into parts of the AV junction, and to the effect of such concealed conduction on the propagation of subsequent impulses. The following facts are pointed out and illustrated as evidence of concealed AV and VA conduction during atrial fibrillation: (a) Occurrence of a "compensatory pause" following a ventricular premature systole. (b) Failure of an AV nodal escape to appear at the expected time due to concealed discharge of ...

Ventricular response in atrial fibrillation. role of concealed conduction in the av junction.

THE USE OF artificial pacing has greatly intensified interest in chronic A-V block. This interest, in turn, has brought into sharp focus the rare type of A-V block described independently in 1906 by Wenckebach' and by Hay2 and classified by Mobitz in 1924 as type 11.3 This type of block is characterized by failure of a ventricular response, without antecedent progressive lengthening of A-V conduction time. Furthermore, in its more advanced form several consecutive atrial impulses are blocked, giving rise to high degree partial block and to intermittent periods of prolonged ventricular asystole. Although Mobitz had appreciated the distinction between the functional nature of type I and the organic nature of type II block and had stated clearly that type II block was apt to be a forerunner of complete A-V block and Stokes-Adams attacks, it is surprising how the distinction between the genesis and prognosis of these two types of block has become blurred in clinical electrocardiography. Although a definitive anatomic-electrocardiographic study that would relate type II block to a particular anatomic lesion is still missing, the observations of Mahaim,4 Yater and associates,5 Lev and Unger,6 and Lenegre and Moreau7' 8 strongly suggest that bilateral bundle-branch block may be the usual anatomic substrate of type II A-V block. Recent

Atrioventricular Block, Type II (Mobitz)—Its Nature and Clinical Significance

In order to analyze the cause for the appearance and disappearance of ventricular premature systoles giving rise to temporary bigeminal rhythm, the electrocardiographic material was divided into two major groups: group A, consisting of ectopic beats with fixed coupling occurring during grossly irregular dominant rhythms, and group B, consisting of ectopic beats with varying coupling occurring during regular dominant rhythms. Analysis of group A, the subject of the present report, shows a definite relationship between the duration of the ventricular cycle and the occurrence of ventricular premature systoles, in that long cycles favor their appearance whereas short cycles tend to preclude it. This "rule of bigeminy" is best explained on the basis of a re-entry mechanism of the ventricular premature systoles. Criteria are given for the differential diagnosis between ventricular premature systoles and aberrant ventricular conduction of supraventricular impulses which is prone to occur under similar circumstances. The analysis of group B is presented in a subsequent report.

Mechanisms of intermittent ventricular bigeminy. I. Appearance of ectopic beats dependent upon length of the ventricular cycle, the "rule of bigeminy".

Recognition of concealed conduction of the cardiac impulse is shown to be indispensable for the understanding of many cardiac arrhythmias. After a historical review of the concept of concealed conduction, records are presented to demonstrate established, as well as hitherto undescribed, aspects of concealed A-V conduction. Then, the manifestations of concealed intraventricular conduction are pointed out and, finally, the relationship of the phase of concealed conduction to the supernormal phase is discussed.

Richard Langendorf

Papers

Tachycardia-bradycardia syndrome (so-called “sick sinus syndrome”): Pathology, mechanisms and treatment

Ventricular response in atrial fibrillation. role of concealed conduction in the av junction.

Atrioventricular Block, Type II (Mobitz)—Its Nature and Clinical Significance

Mechanisms of intermittent ventricular bigeminy. I. Appearance of ectopic beats dependent upon length of the ventricular cycle, the "rule of bigeminy".

Concealed conduction further evaluation of a fundamental aspect of propagation of the cardiac impulse.