a fib CCJM

8/6/2019 a fib CCJM

http://slidepdf.com/reader/full/a-fib-ccjm 1/7

EDUCATIONAL OBJECTIVE: Readers will manage newly diagnosed atrial brillation appropriately

Managing newly diagnosedatrial brillation:Rate, rhythm, and risk

■ ABSTRACT

The treatment o atrial fbrillation ocuses on controllingthe heart rate, preventing thromboembolic events, and,depending on the symptoms, restoring and maintainingsinus rhythm. In most cases, the rate or rhythm can bequickly controlled, and a long-term plan can be startedthat will minimize the impact o this disorder on the lieo the patient.

■ KEY POINTS

When atrial fbrillation is newly diagnosed, reversiblecauses and commonly associated processes should besought.

Agents to control the heart rate, eg, beta-blockers ornondihydropyridine calcium channel blockers, are otenstarted and titrated intravenously and then changed tooral dosing.

The beneft o rhythm control has not been frmly estab-

lished. Although we try cardioversion at least once whenatrial fbrillation is frst diagnosed, rhythm control isgenerally reserved or patients whose symptoms persistdespite rate control, or or patients in whom the heartrate cannot be controlled.

The need or short-term or long-term anticoagulationmust be estimated.

Three general concerns ditt tmmt ti biti:

• Cti t t t• Cti ymptm• Pvti tmbmbi vt, i-

udi tk.W i ptit wit wy di-

d ti biti, t m t - ud b kpt i mid, but v d-diti iu mut b ddd:• Rvib u ti biti mut

b ud ut

• T tu tim t t ti bi-ti d t quy t pidud b tid, i pib

• A u timti t ptit’ ymp-tm bud ud b md.

Ati biti i mm d uimpt i tm t mbidity, dt, dt itd wit it. It t m t2.2 mii Ami.1 Appximty 1 i10 pp v t 80 ti bi-ti, d t v t 40, t i-

tim ik dvpi it i i u.

2

Fm-im dt ut tt t ik dt ippximty twi i ptit witti biti mpd wit imi -t witut.3–5

■ IMPORTANT QUESTIONS DURINGTHE INITIAL WORKUP

Does the patient have a reversible causeo atrial fbrillation?Ati biti i tut t b du t ti-

tt iitit it d t mydi ub-

REVIEW

doi:10.3949/ccjm.78a.09165

CREDITCME

THOMAS CALLAHAN, MDDepartment o CardiovascularMedicine, Cleveland Clinic

BRIAN BARANOWSKI, MDDepartment o CardiovascularMedicine, Cleveland Clinic

258 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 4 APRIL 2011

8/6/2019 a fib CCJM


CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 4 APRIL 2011 259

CALLAHAN AND BARANOWSKI

tt tt uppt it. Wi it my dvpi t b t t di, it it itd wit ypti, dibt,bity, tutu t di (iudi

it t di), btutiv pp, dvd , d bu.

T, ti biti bdid, t ity, xmiti, d di-ti wkup ud b ditd twd k-i pttiy vib u d quty itd mbiditi. Cmmvib u iud: Hyperthyroidism. T bty vu-ti ud iud tytpi (tyid-timuti m, TSH) v. Alcohol use, piy bi diki.

Obstructive sleep apnea, i uptd t bi t ity t bdy bitu.

Structural heart disease u vvut di it t dt my pdip t ti biti. T-, it uy t t t d bti tti dim i tdy b d i yu upt i vvu di yti uti it mt t tudy.

How long has the patient beenin atrial fbrillation?T duti t ti biti t -t t ttmt tty. T, wt dii b md, it i imptt tty t timt w t ptit bi ti biti.

Ot, w mut tt timt, t ptit’ ti my b vu. Hw-v, i m , t ymptm p-ud tdipi tmtidt vib, wi t tim t

t b y dd.I dditi, it i pu t kw i t p-tit d pi pid tt w vbut t mdi ttti. T ti d,iit t ptit’ ptum ymptm du im t tik bk mt y d ty t t tim w imi- ymptm mit v ud.

How do the symptoms aectthe patient’s quality o lie?T iii mut timt t xtt t

wi t ymptm t t ptit’ qu-

ity i. Ti i bt d w t tt i ud t. I t ptit ti iit ymptm dpit dqut tt, t ytm t tty ud

pbby b puud.

■ MANAGING NEWLY DIAGNOSEDATRIAL FIBRILLATION

Control the heart rate with a beta-blocker,a calcium channel blocker, or digoxinMy ptit pt dui ti t pi-d ti biti wit pid v-tiu t, piy i ty t dytki du t w duti tu ttivtiu d. I t ymptm

ptiuy pud, ud ty t tt t t ud t quiky.

O t tk tim t b bbd d t wy y t titt. Itvubt-bk u mtp (Lp)d bt (Nmdy, Tdt) i-tvu ditizm (Cdizm) w tt t quiky d b tittd. Ot t t i td, t m b ttd, t w wi m t itv-u t. I ut mmt, w k t t t but 100 t 110 btp miut.

I t ptit’ bd pu i mi,di wit itvu dixi my b -idd. T d i 0.5 m itvuy,t 0.25 m itvuy i t t 6 ud t 0.25 m itvuy i t6 u. I ptit wit iuiyt d ud b , dixi ud bvidd tt. Ot, t bd puwi impv t t t i dd,wi t t t b iititd. Hwv,

i t ptit i ky yptiv wit tpi, t bt, dimiid v- iu, t my tidivi i iditd v i tiu-ti t yt b ttd (m buttiuti bw).

O m t m t t wk- t t t i t utptittti. O bt-bk d diydpyi-di ium bk (i, ditizm vpmi [C, V]) t t-it, bu w dixi i ud , it

i tivy p t ti t t t,

We try

to restore

sinus rhythm

at least once

when atrial

fbrillation

is frst ound

8/6/2019 a fib CCJM



ATRIAL FIBRILLATION

piy w t ptit i t t t.T i btw t t ud

b dittd by wt t ptit m-biditi u y ty di, t

iu, tiv iwy di. Ndiy-dpyidi ium bk -tivy tiditd i ptit wit tiu, wi bt-bk xbttiv iwy di.6

It i imptt t dumt tt tt t i dquty td utid tpit utptit ii, w t p-tit i typiy itti upi. Ti bd wit 6-miut wk, xi tt, Ht mit t-ti tv b tittd.7

When to try to restore sinus rhythmW ti biti i t did, it myt b pib t dtmi i it i pxym(i, -tmiti) pitt. I t pidd t quiky d it w, idtimy b iv t ti iu ytm.

Atu xpt dbt t mit t t pp v ytm t p-p mi ti biti i t tm, my, iudi uv, m-md tyi t t iu ytm t t w ti biti i t divd.It i t wy i ti biti ituy ymptmti. Symptm u tiu dd xi t b ubt.Additiy, t ymptm my b ttib-utd t t t u dditii,bity, dvi . Tu, i my -, y ti m iu ytm tim w t ptit d iii t uy t ymptm ttibutb t ti -biti.

T, i ptit wit wy di-d ti biti, ttmpt t tiu ytm i t wtd. Expti i t ptit w v pptymptm d w vy d dmdt i t tt divi. Direct-current cardioversion i typiyt ttmt i w ttmptit t iu ytm. T pdu b d witut tiuti witi 48u t t ti biti, i ttim t i .7 Hwv, iii

mut b u i di t t ti

biti ti pup.Symptm u tiu t

bt b vu i tm t xt tim t d t t b id up

t pup didi wt divi b d witut tiuti. Wi dubt, it i bt t t id tyd um tt t ti biti bi m t 48 u.

I t tim t i u i m t48 u v pd, t tw tt-i pdi t ti divi.

O i t order transesophageal echocar-diography d bi tiuti tpyt t m tim. I t i tmbu it t tium, t divi b

d.8 Tputi tiuti wit p-i, w-mu-wit pi, w-i (Cumdi) ud b ivd witi 24t 48 u tp di-py d divi t miimiz t ik tmbmbi vt, wi uv t iu ytm b td.

At u itituti, w typiy tiv tiv tputi tiuti wit i-t pi w-mu-wit pib divi i ti i tvid ituti i wi ptit my u-d divi but t i t ivtputi tiuti m tim dut u t.

T t pp i t start wararin d miti itti mizdti (INR) 2 t 3 3 wk, t witim divi b pmd ywitut tp dipy.8

Rd wi tty i ud, ti-uti ud b tiud t t 4wk t divi,8 ti dyutid t ik tk my pit dy twk t m iu ytm i td.9

Role o antiarrhythmic drugsAtiytmi du b ud mi- divi , m t, t p mi-ti iu ytm t dit-ut di-vi.

Bu mt t du v t t m ti m iu ytm,w d t w t m u w tt-i tm w pmi dit-ut

divi. Ptit ud t b ttd

I atrial

fbrillation

has lasted

> 48 hours

or i you are

not sure,

anticoagulate

beore

cardioversion

8/6/2019 a fib CCJM




tiytmi mditi uti tyv d dqut tiuti t t3 wk dqut tiuti d tp dim mi

tt t i tmbu i t t tium.Atiytmi du ud b ttd

i t ptit wit wy did tibiti i wm ytm t tt-y wi b puud. F ptit w i-ty ut i pid, pid ttpviuy -tmitd, tiytmimy t b y. F t wit qutpid w ity ut iti biti pid, ti-ytmi wi iky b quid t pvid b ivi dm m

ti biti.T i tiytmi du ud

b tid t t pi ptit.Propaenone (Rytm) d fecainide

(Tmb) t-i du7 but -tiditd i ptit wit y tydi d iit tutu t di-.10

Sotalol (Btp) d doetilide (Tik-y) b ud i ptit wit yty di. Hwv, t i tidi-td i ptit wit tiv t iu,d dtiid i it du it-ti. Bt mut b ud wit xtm u-ti i ptit wit iuiy, dpit dmii i quid iititi upwd titti t d. Amiodarone (Cd) i tiv, di t t tm it i typiy vy w t-td. Hwv, it -i, d itptti -tm txiity t mkit p i -tm ttmt. Ttxiity mid i wit t u-mutiv d. T, ti du ud bvidd -tm tpy ti bi-ti i yu ptit.

The ‘pill-in-the-pocket’ strategyT “pi-i-t-pkt” tty, i wi p-tit itutd t tk ti mditiy w ty v but ti bi-ti, i b pti ptit witymptmti u pxym tibiti. Ti tty i miy vd ptit w v tivy iqut u-

. T w v qut u

uuy m tivy ttd wit diydi tiytmi. Fiid dpp t t i tipp bu ti ty p d -

y i mi divi.Wi ti tty my b ttd

utptit bi i ptit wit , px-ym ti biti, t wit tutut di duti bmitiud b bvd i t pit dui ii-titi tpy t bv xiv PRpti dvpmt du wim ytmi.11–13

Additiy, t t d tty pid t tivtiu d,tby ii t vtiu t. I t

ti futt, ptit my b vtdm vib 2:1 p t 1:1 du-ti. Tu, ud id ui bt-bk wit ti tty.

Si t ti pp i t -vt t ptit t iu ytm witi wu t t ti biti, it myb impmtd witut t u wi.Ptit itutd tt i ty d tvt t m iu ytm witi wu, ty ud tiy t pyii ty ud ti divi witit 48-u widw m t t tibiti.

Dronedarone, a new antiarrhythmic drugDd (Mutq) i w vib d b w t b tiv i ttiti biti.14 It -i d mim ti imi t tt mi-d. Hwv, it my b ii t mi-d i tm y.15 It i mtbizdby CYP3A4. N d djutmt i dd ptit wit iuiy.

Bu dd k t idi mi-ty ud i mid, it ud t yt m txiity p. N pumy tyid txiity w ptd i y ti.16

Nvt, dd vimptt imitti. It i bk bxwi tti it i tiditd i p-tit wit v ty dmptdt iu, t mtity t w twi i w ti du w ud i u ptiti iiti tudi.17 Additiy, t v

b pt pttxiity quii iv

Continue

anticoagulation

or at least

4 weeks ater

cardioversion

8/6/2019 a fib CCJM



ATRIAL FIBRILLATION

tptti i m umb ptit.T xtt ti pbm d tti vidi it t yt dd t witi ti pp. A wit y w mditi, p-

tit w ttd dd udb bvd y y id t, dt ud b ptd t it i t dv-pmt t du’ ty p.

Pulmonary vein isolationI pdu tt pttiy u tibiti, tt itd it tt tium d i tiu tdud t ti t pumy vi uidiquy y, tiy ititm m t t t t tium.

Sm dbt xit t wt ti p-du my b b t-i tpy m ptit wit ti biti.18,19 Itmy b idd y ttmt tt-y i m ubt ptit, piyyu ptit wit ymptmti, utti biti, piy i ty vt -tm tiytmi tpy.

Bu ptit my ti b m p tti ytmi v wk t mtt t pdu, ty mut b b t t-t tiuti wit wi t tv mt.

Rate control vs rhythm controlT i btw t t tty ytm t tty i t tm it wy titwd. Wi ti bi-ti i y itd wit i m-bidity d mtity t, t w dtt dt wi tt ti d miti-i iu ytm i ptit wit ti bi-ti du t iid mbid mpi-

ti t ikid dt.Tu, ut uidi mmd t t tty i ptit w v ymptm, d ytm t tty i t t t b ivd i ymp-tm pit dpit dqut t tt t.7 T iumt d p- t idividu ptit ud ywit i ti dii.

Ti ud wy tt my d mit t tiv bt ytm -t wit bti tiytmi d t

t.

■ PREVENTING THROMBOEMBOLIC EVENTS

WararinI t t tm, wi tpy my b

dittd by p t t iu ytm. P-tit d wi t t 4 wk tdivi u it i pmd witi 48u t t ti biti. The CHADS2 score (1 pit ctiv t iu, hypti, a 75 d, d dibt mitu; 2 pit pi- stk tit imi ttk) i u-u w didi wt t iv -tmtiuti.

F ptit wit 0, t ik tk i w t t ik mj bd-

i mpiti wi tputi w-i.20,21 F t ptit, pii 81 t 325 mdiy i mmdd tk ppyxi.

F t wit 2 t, tik tk witut wi i t tt ik mj bdi mpiti witwi. T ptit ud iv w-i wit INR 2.0 t 3.0.7

Ptit wit CHADS2 1 pt dimm, ti ik tk witut w-i i but t m ti ik mjbdi mpiti wit wi. Ty b md wit it wi pii, -di t t pyii’ judmt.7 I t, t u bbi pitt mit i t ik bdi, p-ivd quy ti biti pid,d v ptit ppti but w-i t ud w didi btw pi-i d wi.

Ptit wit CHADS2 2 t wit i pid ti bi-ti d iky vib u my p dimm w didi wt t ttwi. T ptit v dmttdty t t v t ubtt t mititi biti. Ti ituti i pyii judmt. B i mid tt ymp-tmti u mm i ptitwit ti biti.22,23 A i CHADS2 dt t ik tk d myifu ti dii. It i uuy bit it t ptit i ti dii-mkip, ptit t v vy tpii but t t ik tk

wi tpy it.

With a CHADS2

score o 1,

the risk

o stroke

o wararin

equals the risk

o bleeding

on wararin

8/6/2019 a fib CCJM




Aspirin,

with or without

clopidogrel,

may be an

alternative

i wararin is

contraindicated

At tty i t tt tiutiwit wi d ivy mit -u. I t ptit u ti biti t 6 t 12 mt d t

vib u i vd, t -viit t d wi.

Role o aspirin and clopidogrelApii, i juti wit pi-d (Pvix), my pvid ttiv tk ppyxi i ptit i wm w-i i tiditd. Wi ii t w-i, t mbiti pii d pid- b w t d t iid mj tmbmbi vt, piytk.24 Hwv, t ik mj bdi

mpiti w iity id.Ti mbiti my b b

tty i t ptit wit CHADS2 2 t i wm wi tb ud u p vit t mditi, id t, bd-i mpiti i ptit w INR ixdiy diut t kp witi t t-puti .

Dabigatran, a new anticoagulantT wt pti tiuti i p-tit wit ti biti i dit tm-bi iibit, dbit (Pdx).

I t Rdmizd Evuti L-Tm Atiuti Tpy (RE-LY)ti,25 dbit w tudid d-t-dwit wi. T d dbit tudidw 110 m d 150 m twi dy. At 150m twi dy, ptit dbit d w t tk t wit wi (1.11%v 1.69%, P < .001), w w t t vu ytm bdi (0.10% v0.38% wit wi, P < .001). T t mj bdi w mpb i t p-tit ivi wi dbit 150m twi dy, but t t tittibdi w i i t dbit up(1.51% v 1.02% wit wi, P < .001).25

Dbit w ty ppvd by tUS Fd d Du Admiitti u iptit wit ti biti. D 150m d 75 m vib.

Dbit i y xtd, d t150 m twi--dy di i itdd p-

tit wit tii t t

30 mL/mi. T 75-m twi--dy di iitdd ptit wit tii - 15 t 30 mL/mi. Hwv, it udb td tt uty t dt t

uppt t 75-m twi--dy di.Dbit d v v dvt

v wi. Ptit d t d t vidd tii vitmi K, d uti -i miti d t pp t b dd.A wit y w mditi, ptit w ttd dbit ud b bvdy y id t, d t udb ptd t it i t dvpmt tdu’ ty p.

■ SPECIAL CIRCUMSTANCES

Ater cardiac or noncardiac surgeryAti biti i mm t p tuy, ui i ppximty 25% t50% ptit.26–28

W ti pp, t t twttmpt md t t iu ytm.Epiy i t y ptptiv pid,tiuti wit pi wi myb tiditd, u ttti mutb pid t t ptit’ t ytm ttti biti b izd quikyd divi pmd witi 48-uwidw t. Bt-bk, ditizm, dvpmi typiy ud t t.

W ti biti u i ptitw v ud p t uy, -tiytmi ttd y t p p-vt ut u. At u itituti,w uuy u mid, it i iy -tiv d w ttd i t t tm.W ttd mid ptp-tiv ti biti, ptit imd

tt t du wi b tppd t but 2 t3 mt. F ptit w tiu t vbut ti biti, t d ti-ytmi mditi b d, d,i dd, t ptim tiytmi mdi-ti -tm tpy t ptit b .

Atrial fbrillation in severe, acute illnessAti biti i mm i t tti xtm ytmi t u k dpi d w t ptit i bi upptd

wit itpi t. I ti tti, ptit

8/6/2019 a fib CCJM



ATRIAL FIBRILLATION

my b i i-tmi tt, dbt t t t d t t ytm myb vy diut t t.

Bt-bk d diydpyidi

ium bk ud t bud w ptit mditi tuppt bd pu, d i ti tti,w t ptit’ mdymi ttu p-mit t u t t, ti t myb miim.

Amid pp dixi my w

t t t mwt witut t mut t bd pu. Hwv, witmid, my v t pt ik mi divi.

Eti divi wit wit-ut t it tiytmi dumy t t t t by ti iuytm. Hwv, ti biti t -u, d i it u quiky my v tpt vtd t t uti t udy-i p i ddd. ■

■ REFERENCES1. Go AS, Hylek EM, Phillips KA, et al. Prevalence o diagnosed atrial

brillation in adults: national implications or rhythm management

and stroke prevention: the Anticoagulation and Risk Factors in

Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285:2370–2375.

2. Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lietime risk or develop-

ment o atrial brillation: the Framingham Heart Study. Circulation

2004; 110:1042–1046.

3. Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB,

Levy D. Impact o atrial brillation on the risk o death: the Fram-

ingham Heart Study. Circulation 1998; 98:946–952.

4. Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence,

prognosis, and predisposing conditions or atrial brillation:

population-based estimates. Am J Cardiol 1998; 82(8A):2N–9N.

5. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic

eatures o chronic atrial brillation: the Framingham study. N Engl

J Med 1982; 306:1018–1022.

6. The Multicenter Diltiazem Postinfarction Trial Research Group. The

eect o diltiazem on mortality and reinarction ater myocardial

inarction. N Engl J Med 1988; 319:385–392.

7. European heart Rhythm Association; Heart Rhythm society,Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC guidelines or

the management o patients with atrial brillation—executive

summary: a report o the American College o Cardiology/Ameri-

can Heart Association Task Force on Practice Guidelines and the

European Society o Cardiology Committee or Practice Guidelines

(Writing Committee to Revise the 2001 Guidelines or the Manage-

ment o Patients With Atrial Fibrillation). J Am Coll Cardiol 2006;

48:854–906.

8. Klein AL, Grimm RA, Murray RD, et al; Assessment of Cardiover-

sion Using Transesophageal Echocardiography Investigators. Use

o transesophageal echocardiography to guide cardioversion in

patients with atrial brillation. N Engl J Med 2001; 344:1411–1120.

9. Grimm RA, Leung DY, Black IW, Stewart WJ, Thomas JD, Klein AL.

Let atrial appendage “stunning” ater spontaneous conversion o

atrial brillation demonstrated by transesophageal Doppler echo-

cardiography. Am Heart J 1995; 130:174–176.10. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators.

Preliminary report: eect o encainide and fecainide on mortality

in a randomized trial o arrhythmia suppression ater myocardial

inarction. N Engl J Med 1989; 321:406–412.

11. Alboni P, Tomasi C, Menozzi C, et al. Ecacy and saety o out-o-

hospital sel-administered single-dose oral drug treatment in the

management o inrequent, well-tolerated paroxysmal supraven-

tricular tachycardia. J Am Coll Cardiol 2001; 37:548–553.

12. Capucci A, Villani GQ, Piepoli MF. Reproducible ecacy o loading

oral propaenone in restoring sinus rhythm in patients with parox-

ysmal atrial brillation. Am J Cardiol 2003; 92:1345–1347.

13. Khan IA. Single oral loading dose o propaenone or pharmaco-

logical cardioversion o recent-onset atrial brillation. J Am Coll

Cardiol 2001; 37:542–547.

14. Singh BN, Connolly SJ, Crijns HJ, et al; EURIDIS and ADONIS Inves-

tigators. Dronedarone or maintenance o sinus rhythm in atrial

brillation or futter. N Engl J Med 2007; 357:987–999.

15. Le Heuzey J, De Ferrari GM, Radzik D, Santini M, Zhu J, Davy JM .

A short-term, randomized, double-blind, parallel-group study to

evaluate the ecacy and saety o dronedarone versus amiodarone

in patients with persistent atrial brillation: the DIONYSOS study. JCardiovasc Electrophysiol 2010; 21:597–605.

16. Hohnloser SH, Crijns HJ, van Eickels M, et al. Eect o dronedarone

on cardiovascular events in atrial brillation. N Engl J Med 2009;

360:668–678.

17. Køber L, Torp-Pedersen C, McMurray JJ, et al; Dronedarone Study

Group. Increased mortality ater dronedarone therapy or severe

heart ailure. N Engl J Med 2008; 358:2678–2687.

18. Pappone C, Rosanio S, Augello G, et al . Mortality, morbidity, and

quality o lie ater circumerential pulmonary vein ablation or

atrial brillation: outcomes rom a controlled nonrandomized long-

term study. J Am Coll Cardiol 2003; 42:185–197.

19. Wazni OM, Marrouche NF, Martin DO, et al. Radiorequency abla-

tion vs antiarrhythmic drugs as rst-line treatment o symptomatic

atrial brillation: a randomized trial. JAMA 2005; 293:2634–2640.

20. van Walraven C, Hart RG, Singer DE, et al. Oral anticoagulants vs

aspirin in nonvalvular atrial brillation: an individual patient meta-analysis. JAMA 2002; 288:2441–2448.

21. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic

therapy to prevent stroke in patients with atrial brillation: a meta-

analysis. Ann Intern Med 1999; 131:492–501.

22. Page RL, Wilkinson WE, Clair WK, McCarthy EA, Pritchett EL.

Asymptomatic arrhythmias in patients with symptomatic paroxys-

mal atrial brillation and paroxysmal supraventricular tachycardia.

Circulation 1994; 89:224–227.

23. Savelieva I, Camm AJ. Clinical relevance o silent atrial brillation:

prevalence, prognosis, quality o lie, and management. J Intervent

Card Electrophysiol 2000; 4:369–382.

24. ACTIVE Investigators, Connolly SJ, Pogue J, Hart RG, et al. Eect o

clopidogrel added to aspirin in patients with atrial brillation. N

Engl J Med 2009; 360:2066–2078.

25. Connolly SJ, Ezekowitz MD, Yusuf S, et al; RE-LY Steering Commit-

tee and Investigators. Dabigatran versus wararin in patients with

atrial brillation. N Engl J Med 2009; 361:1139–1151. Erratum in: N

Engl J Med 2010; 363:1877.

26. Almassi GH, Schowalter T, Nicolosi AC, et al. Atrial brillation ater

cardiac surgery: a major morbid event? Ann Surg 1997; 226:501–

511.

27. Creswell LL, Schuessler RB, Rosenbloom M, Cox JL. Hazards o post-

operative atrial arrhythmias. Ann Thorac Surg 1993; 56:539–549.

28. Mathew JP, Fontes ML, Tudor IC, et al; Investigators of the Ischemia

Research and Education Foundation; Multicenter Study of Periop-

erative Ischemia Research Group. A multicenter risk index or atrial

brillation ater cardiac surgery. JAMA 2004; 291:1720–1729.

ADDRESS: Thomas Callahan, MD, Department of Cardiovascular Medicine,Cleveland Clinic, J2-2, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail [email protected].

Documents

a fib CCJM