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New onset atrial fibrillation

Authors: Robert Phang, MD, FACC, FHRS, Brian Olshansky, MD
Section Editors: Peter J Zimetbaum, MD, Hugh Calkins, MD
Deputy Editor: Gordon M Saperia, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature rev iew current through: Mar 2020. | This topic last updated: Oct 01, 2019.

INTRODUCTION

The most common scenarios in which a diagnosis of new onset (and/or first-detected) atrial
fibrillation (AF) is made include: a patient with new symptoms attributable to AF (see
'Presentation' below), an asymptomatic patient with an irregularly irregular and often rapid pulse
(with a an electrocardiogram consistent with AF), or with an electrocardiographic rhythm
recording device such as an external or implantable monitor or during pacemaker interrogation.

In those with a new diagnosis, AF can be paroxysmal (defined as stopping spontaneously within
seven days) or be persistent (longer than seven days of continuous AF). (See "Overview of atrial
fibrillation", section on 'General classification'.)

This topic presents a broad overview to the approach to patients with newly diagnosed AF. Other
related AF topics include:

● (See "Epidemiology of and risk factors for atrial fibrillation".)

● (See "Paroxysmal atrial fibrillation".)
● (See "Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism".)
● (See "Rhythm control versus rate control in atrial fibrillation".)
●

PRESENTATION

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The findings of the history, physical examination, and electrocardiogram, as well as the initial
evaluation of patients with AF are presented separately. (See "Overview of atrial fibrillation",
section on 'Evaluation'.)

A new diagnosis of AF may result from one of the following clinical scenarios:

● At the time of a routine examination, during which the patient complains of symptoms
possibly due to AF or is being evaluated for another reason and is found to have an
irregularly irregular pulse.

● On an electrocardiogram obtained for other reasons such as a preoperative evaluation.

● A patient with a cerebrovascular accident or arterial thromboembolism is found to have AF

that has not been previously diagnosed [1]. In some cases, this is picked up during
extended monitoring in an attempt to diagnose the cause for the stroke.

● During electrocardiographic monitoring with a 24-hour ambulatory monitor obtained for

some other reason or during interrogation of an implanted cardiac rhythm device.

● During hospitalization for another reason such as cardiac and noncardiac surgery, infection,
recent myocardial infarction, thyrotoxicosis, pulmonary embolism, myocarditis, and
pericarditis, among others [2-5].

● During recording from a patient-acquired recording device.

PATIENTS REQUIRING URGENT MANAGEMENT

Patients with newly diagnosed AF can often be managed in an outpatient setting. However,
some patients require direct hospital admission or transfer to emergency department from an
outpatient setting. Indications for transfer to a facility with emergency services include
hemodynamic instability (usually manifested as hypotension), symptoms or signs of myocardial
ischemia/infarction or heart failure, or evidence of pre-excitation (Wolff-Parkinson-White
syndrome) on the electrocardiogram. Extreme, uncontrolled tachycardia independent of these
findings may also be sufficient reason to admit. In addition, some patients with bothersome
symptoms may require urgent rate control. (See 'Rate control' below.)

For some patients, the unstable condition may improve quickly after urgent rate control. For
others, sinus rhythm needs to be restored immediately. Clinical judgment is needed to
determine whether rate control should be attempted or whether to proceed directly to
cardioversion, but the need for and type of anticoagulation before cardioversion must be

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considered first (see 'Rate control' below). Circumstances for which urgent or emergent
cardioversion may be needed include (see "Atrial fibrillation: Cardioversion", section on
'Electrical cardioversion'):

● Active ischemia (symptomatic [eg, angina] with electrocardiographic evidence).

● Evidence of organ hypoperfusion or shock (eg, cold clammy skin, confusion, acute kidney
injury).

● Manifestations of severe heart failure. (See "The management of atrial fibrillation in patients
with heart failure".)

● Hypotension for which AF is suspected to be causal or contributory and for which standard
therapy to treat underlying causes and hypotension including intravenous fluids, attempts at
rate control, potentially inotropic therapy, and other measures that have failed. Care must be
given to other potentially inciting factors such as sepsis, fluid depletion, or vasodilation.

Rarely, in a patient with an indication for urgent cardioversion, and no alternative treatment
options and/or failure to respond to rate control, the need to restore normal sinus rhythm can
take precedence over the need for protection from thromboembolic risk with anticoagulation.
This is generally not the case and unless severe refractory untreatable hypotension is present, it
is prudent to attempt to control the rate. There is little evidence that acute cardioversion improves
long-term outcomes. For patients who are selected to undergo urgent or emergent
cardioversion, anticoagulation is started as soon as possible but no later than the time of
cardioversion. (See 'Anticoagulation' below.)

For patients whose AF is thought to be secondary to a comorbidity such as pneumonia, urgent

treatment of the underlying cause of AF is primary and essential.

Finally, for those patients who require urgent management, we generally obtain the same
baseline diagnostic tests as in stable patients unless other clinical characteristics suggest
otherwise. (See 'Approach to stable patients' below.)

Indications for hospitalization — Many patients with new onset AF evaluated in an emergency
room may not need to be hospitalized. However, indications for hospitalization in these patients
include:

● Patients in whom ablation of an accessory pathway is being considered, particularly if the

AF was highly symptomatic and associated with hemodynamic collapse and rapid
ventricular response rate.

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● Severe bradycardia or prolonged pauses.

● Patients with severe bradycardia or prolonged pauses after cardioversion. (See "Sinus node
dysfunction: Epidemiology, etiology, and natural history".)

● Treatment of an associated medical problem, which is often the reason for the arrhythmia.
Examples include the treatment of hypertension, infection, exacerbation of chronic
obstructive pulmonary disease, pulmonary embolism, persistent myocardial ischemia, or
acute pericarditis. Patients may be placed in an observation protocol to rule out acute
myocardial infarction, and hospitalization is no longer required unless there is ongoing
ischemia or suspected acute coronary syndrome that requires intervention. AF alone is not
an indication to rule out myocardial infarction. The "rule-out" should be done only if other
factors suggest the presence of unstable coronary artery disease.

● Further management of heart failure or hypotension after control of the rhythm or rate

● Initiation of antiarrhythmic drug therapy. Ultimately, the decision to hospitalize needs to take
into account patient and drug characteristics.

● Difficult-to-control ventricular rates with evidence of ischemia, congestive heart failure

symptoms or signs, and severe symptoms are indications for at least a 24-hour admission.

APPROACH TO STABLE PATIENTS

For stable patients not meeting the above criteria for transfer to an emergency facility, and who
present for the first evaluation of new onset AF, we try to accomplish the following in the
outpatient setting:

● Perform a complete history and physical examination, including an attempt to obtain old
records that might contain information about prior supraventricular arrhythmias and risk
factors for AF, as well as disease associations. (See "Overview of atrial fibrillation", section
on 'History and physical examination'.).

● Review a current 12-lead electrocardiogram (ECG) to confirm the diagnosis, determine if

atrial flutter or other supraventricular arrhythmias have been present, look for evidence of
myocardial ischemia, and consider the presence of other structural abnormalities that may
be manifested by the ECG (ventricular hypertrophy, bundle branch block, etc). (See "The
electrocardiogram in atrial fibrillation" and "Overview of atrial fibrillation", section on
'Electrocardiogram'.)

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● Obtain a complete blood count, serum electrolytes, and assessment of renal function,
particularly in patients for whom a non-vitamin oral anticoagulant might be started. We do
not order troponin unless ischemia is suspected.

● Obtain a transthoracic echocardiogram to evaluate associated cardiac conditions (valvular

heart disease, cardiomyopathy, or left atrial dilation) even if the physical examination is
otherwise normal. This test does not need to be done at the time of the first visit in stable
patients. (See "Role of echocardiography in atrial fibrillation".)

● Order tests that evaluate the patient for a predisposing cause.

Thyroid stimulating hormone should be obtained in all patients at least once even if there
are no symptoms suggestive of hyperthyroidism (and if thyroid function has not been
measured recently). (See "Subclinical hyperthyroidism in nonpregnant adults" and
"Cardiovascular effects of hyperthyroidism", section on 'Atrial fibrillation'.)

A chest radiograph in selected patients with evidence of dyspnea and potential heart failure
or risk of pneumonia.

● Evaluate the need to slow the ventricular rate. (See 'Rate control' below.)

● Discuss the possible need for cardioversion with the patient. (See 'Cardioversion' below.)

● Determine the need for acute and long-term anticoagulant therapy. (See 'Anticoagulation'
below.)

● Discuss the cause (if known) and natural history of AF. (See "Overview of atrial fibrillation",
section on 'Long-term outcome'.)

● Consider consultation with a cardiologist. Reasons to consult a cardiologist include the

need for cardioversion or the need to treat with antiarrhythmic drugs or catheter ablation.
(See 'Referral to a cardiologist' below.)

● Schedule follow-up. (See 'Follow-up' below.)

Possible predisposing cause — There are a few clinical situations in which the onset of AF is
triggered by another acute medical diagnosis: hyperthyroidism, acute pulmonary embolism,
myopericarditis, pneumonia, and after cardiac surgery. Treatment of hyperthyroidism and
healing from cardiac surgery, pulmonary embolism, or pericarditis may lead to years or even a
lifetime without further episodes of AF. In addition, some patients who develop AF after
noncardiac surgery may not develop subsequent AF. In the absence of an acute trigger, risk

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factors leading to the development of AF include (but are not limited to) the following conditions:
advanced age, hypertension, diabetes, obstructive sleep apnea, obesity, heart failure, valvular
heart disease, cardiomyopathies, chronic kidney disease, family history, etc [3,4]. For most
identified risk factors, we believe that treating the risk factor may reduce but not eliminate the
likelihood of subsequent episodes of AF. (See "Epidemiology of and risk factors for atrial
fibrillation".)

With regard to management in patients with an identified predisposing cause:

● Therapy directed at treating a suspected precipitating cause, either prior to possible

cardioversion or simultaneous with cardioversion, should be initiated in stable patients and
may result in reversion to sinus rhythm.

● For patients with severe hyperthyroidism, the main goal of therapy initially is rate control,
anticoagulation, treatment of their hyperthyroidism, and restoration of sinus rhythm once
they are euthyroid. (See "Graves' hyperthyroidism in nonpregnant adults: Overview of
treatment", section on 'Therapeutic approach'.)

● Treatment of AF in patients with heart failure and/or chronic obstructive pulmonary disease
should generally be undertaken simultaneously with treatment of their other condition. In
patients with heart failure, restoration of sinus rhythm is the best method for rate control as
long as episodic AF does not recur. (See "The management of atrial fibrillation in patients
with heart failure", section on 'Correction of reversible causes of AF and HF'.)

Rate control — For most patients with new onset AF and who are in AF at the time of
presentation, rate control will precede any attempt to restore sinus rhythm (rhythm control). The
principal exception is patients who are hemodynamically unstable. The stability of the patient’s
condition can be assessed by measurements of respiration rate, patient discomfort and
symptoms (including dyspnea and chest discomfort), hypotension, ECG changes consistent
with ischemia, oxygen saturation, and chronicity of the problem.

(See 'Patients requiring urgent management' above.).

The average heart rate will generally be above 90 beats per minute. Since the long-term goal is
to reduce the heart rate to less than 80 beats per minute, we start rate slowing therapy. In
patients with mild to moderate symptoms, slowing the rate often results in significant
improvement or even resolution of symptoms. The use of rate slowing medications is
discussed in detail elsewhere. (See "Control of ventricular rate in atrial fibrillation:
Pharmacologic therapy".)

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For patients with a new diagnosis of AF and for whom a rate control strategy has been chosen,
oral rate-slowing drugs such as beta blockers or calcium channel blockers are started in the
outpatient setting for patients with no or mild symptoms. In patients who are seen in an
outpatient setting and who are uncomfortable with their symptoms, consideration should be
given to transferring them to a facility capable of treatment with intravenous rate-slowing therapy.

There have been no well-performed studies that can be used to guide recommendations about
how quickly the heart rate should be slowed. We reevaluate the patient's heart rate once or twice
during the first week and make further adjustments to rate-control therapy as needed. Heart rate
logs by an automated blood pressure monitoring device or other device such as a smart phone
application or watch technology can be helpful, but are not perfect and are sometimes
erroneous. A 24-hour Holter monitor can give more accurate data and also give an average heart
rate for the day. An event/loop recorder can also be used to evaluate heart rate over longer
periods of time (several days up to one month). Worsening of symptoms should be reported by
the patient; this would lead to more aggressive rate slowing.

Longer-term monitoring of heart rate is an option if a patient continues to have symptoms

suggestive of uncontrolled or too strictly controlled rates, or if there is a needed change in
medication for rate control. This should only be considered for select patients in certain
circumstances. The use of patient-recorded heart rate using smart phones, watch technology, or
other devices may also have benefit to adjust medical therapy.

Cardioversion — For patients with new onset AF who are hemodynamically stable (with only
mild to moderate symptoms) and whose rate is or has been controlled, a decision needs to be
made regarding the potential benefit of restoring sinus rhythm. We believe that most patients
with new onset AF should have at least one attempt at cardioversion (either electrical or
chemical) to sinus rhythm if they do not convert spontaneously on their own. It is important to
recognize that AF will spontaneously convert to sinus rhythm within 48 to 72 hours in most
patients with new onset AF.

It is important to note that consideration of cardioversion demands that anticoagulation is

provided pre- (if >48 hours or unknown duration) and post-cardioversion, regardless of long-
term OAC strategy (or CHA2DS2-VASc score), since the acute cardioversion period is associated
with increased risk of thromboembolism. (see 'Anticoagulation' below). A detailed discussion of
cardioversion, including reasons to not cardiovert, is found elsewhere. (See "Atrial fibrillation:
Cardioversion" and "Rhythm control versus rate control in atrial fibrillation", section on 'Summary
and recommendations'.)

The choice of electrical or pharmacologic cardioversion differs based on the efficacy and safety

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of the approach, comorbidities, patient stability, patient preference, and comfort of the clinician to
use one or the other approach. This issue is discussed in detail elsewhere. (See "Atrial
fibrillation: Cardioversion", section on 'Electrical versus pharmacologic cardioversion'.)

The following is the rationale for cardioversion in stable patients:

● Some may never have a second episode, or will have very infrequent episodes.

● Cardioversion will likely improve symptom status, particularly in young people.

● It is also recognized that the duration of continuous AF is a strong predictor of the ability to
restore and maintain sinus rhythm. In longstanding persistent AF (6 to 12 months of
continuous AF), success in restoring sinus rhythm is markedly reduced [6]. However, the
duration of newly diagnosed AF may not be readily apparent in the asymptomatic to
minimally symptomatic patient. It is reasonable to attempt cardioversion in the newly
diagnosed patient, particularly to determine if any subtle symptoms resolve with the
restoration of sinus rhythm, thereby defining if those symptoms were attributable to AF or
not. For most patients, an attempt to maintain sinus rhythm is warranted, especially to
demonstrate if any subtle symptoms were attributable to AF [6].

The principal discussion of cardioversion in patients with AF is found elsewhere. (See "Atrial
fibrillation: Cardioversion".)

Timing — For patients with new onset AF, either early/immediate (within a couple of hours
after the diagnosis is made) or later cardioversion, once it is clear the AF episode will not
spontaneously convert to sinus rhythm, is an acceptable management strategy, depending on
the clinical circumstances and adherence to the pericardioversion principles of anticoagulation.
This recommendation is based in part on the results of the Acute Cardioversion Versus Wait And
See-approach for Symptomatic Atrial Fibrillation in the Emergency Department (RACE 7 ACWAS)
study [7], presented later in this section. In order to determine the optimal management strategy
for any patients presenting with an episode of AF, particularly those in an emergency department
setting, we suggest early consultation with a cardiologist. Clinical decision making involving the
patient, emergency department physician, and cardiologist is necessary for optimal care.

The timing of cardioversion (except in patients who are unstable) is determined in part by the
duration of the episode and if there is an acute condition causing AF, and whether the patient
has been on anticoagulation for the past three weeks or longer. There is a low risk of systemic
embolization if the duration of the arrhythmia is less than 48 hours, and there are no cardiac
abnormalities (particularly mitral valve disease or significant left ventricular enlargement due to a
cardiomyopathy) on transthoracic echocardiography [8]. A limitation of this 48-hour rule is that it

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relies on the patient to inform the physician when the AF episode actually started. Thus, it is not
known whether there is an advantage to immediate rather than delayed cardioversion.

New onset AF (and paroxysmal AF) often spontaneously reverts to normal sinus rhythm, with the
incidence of reversion related to the duration of the arrhythmia. This was illustrated in a study of
1822 patients admitted to the hospital because of AF: 356 had an arrhythmia duration less than
72 hours, 68 percent of whom spontaneously reverted to sinus rhythm [9]. Two-thirds of those
with spontaneous reversion had AF duration of less than 24 hours, which was the only predictor
of spontaneous reversion. Knowing that spontaneous reversion to sinus rhythm occurs in the
majority of patients with new onset AF, we generally do not attempt cardioversion within the first
24 hours of onset if the patient is stable. (See "Paroxysmal atrial fibrillation".)

The optimal timing of cardioversion for an episode of AF, whether it be the first or an acute
episode, was evaluated in the RACE 7 ACWAS trial [7]. In this study, 437 hemodynamically
stable but symptomatic patients with recent onset AF (<36 hours) were randomly assigned in an
emergency department to a wait-and-see approach (delayed cardioversion group) or early
(immediate) cardioversion on initial presentation. In the delayed cardioversion group, patients
were treated with rate control medication only and discharged home when they were
asymptomatic, and the rate was less than 110 beats per minute. Patients in this delayed group
returned for cardioversion if the AF did not resolve within 48 hours. The rate of the primary end
point (the presence of sinus rhythm on an electrocardiogram at four-week follow-up) was not
significantly different in the two groups (91 versus 94 percent). In the delayed cardioversion
group, conversion to sinus rhythm within 48 hours occurred spontaneously in 69 percent. Thus,
some episodes of acute onset AF will stop spontaneously and do not require cardioversion.
Therefore, choice of an immediate cardioversion is not required in all patients, and the choice for
early cardioversion can depend on clinical circumstances. Other end points are important in
patients who have symptomatic AF, including worsening of symptoms and risk for
thromboembolic events that can be difficult to assess in a small trial not designed for these
considerations.

Most patients with new onset AF of longer than 48 hours duration should have cardioversion
postponed until three weeks of effective anticoagulation has been achieved or a
transesophageal echocardiogram has been performed and shows no left atrial appendage clot
[10]. (See 'Anticoagulation' below.)

Safety — Emergency department or observational unit cardioversion of new onset AF (less

than 48 hours duration) is effective and safe [11-14]. This issue was addressed in a study of 289
such patients who were stable, did not have heart disease, and did not have another indication

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for hospital admission [13]. Pharmacologic cardioversion was attempted in 62 percent and was
successful in 50 percent; 28 percent underwent electrical cardioversion with a success rate of
89 percent. Overall, 97 percent of patients were discharged home directly from the emergency
department. Similar findings were noted in another small study [14]. (See "Atrial fibrillation:
Cardioversion", section on 'Pharmacologic cardioversion'.)

Anticoagulation — For each patient with new onset AF, at least two questions regarding
anticoagulation need to be asked:

● Should the patient be anticoagulated immediately? For most patients, the answer is yes.
This issue is discussed in detail separately. (See "Prevention of embolization prior to and
after restoration of sinus rhythm in atrial fibrillation".)

The two major groups of patients with new onset AF for whom immediate anticoagulation
should not be considered are:

• Those for whom the risks exceed the benefits (eg, history of and particularly recent
severe bleeding, recent major surgery, inability to comply with medical therapies, or
other contraindications to oral anticoagulation).

• CHA2DS2-VASc score of 0 in men or 1 in women who have short paroxysms of AF that

self-terminate.

● Does the patient need long-term anticoagulation? For most patients, the answer depends
on the CHA2DS2-VASc score. This issue is discussed in detail separately. (See "Atrial
fibrillation: Anticoagulant therapy to prevent thromboembolism", section on 'Our approach to
anticoagulation'.)

FOLLOW-UP

Follow-up after an episode of acute AF is necessary to evaluate the safety and efficacy of rate
control (see 'Rate control' above) or rhythm control, the compliance of the patient with
anticoagulant therapy, the need for these therapies, and the functional status of the patient. For
many patients, a one-week follow-up visit, or as soon as possible if one week is not realistic for
a particular patient, is a reasonable strategy. This early return is particularly important for
patients started on antiarrhythmic drug therapy to assess safety, efficacy, and side effects that
can be drug specific.

Following initial pre- and post-cardioversion anticoagulation, the decision to continue long-term

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anticoagulation following a single reversible incident is debatable and the decision is highly
individualized based on the presumed future risk of recurrent AF in that individual (vis a vis
CHA2DS2-VASc score). It is also reasonable to take an observational approach following a
reversible cause of AF involving clinical follow-up of symptoms and ambulatory monitoring in
surveillance for possible recurrence. (See 'Anticoagulation' above.)

REFERRAL TO A CARDIOLOGIST

AF is a common medical problem and can often be managed by primary care physicians without
need for consultation with a cardiologist. We suggest patient referral when the physician is not
comfortable with decision making or when catheter ablation of AF is under consideration. Also,
when cardioversion or antiarrhythmic drugs are contemplated, cardiology consultation is
advantageous.

RECOMMENDATIONS OF OTHERS

Recommendations made in this topic are generally consistent with those made by the American
Heart Association/American College of Cardiology/Heart Rhythm Society and the European
Society of Cardiology [15,16].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and
"Society guideline links: Arrhythmias in adults".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.”
The Basics patient education pieces are written in plain language, at the 5 th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10 th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

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Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)

● Basics topic (see "Patient education: Atrial fibrillation (The Basics)")

● Beyond the Basics topic (see "Patient education: Atrial fibrillation (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● The early steps in the management of a patient with new onset atrial fibrillation (AF) include
an assessment of the need for urgent hospital management (including emergency
cardioversion), search for a possible predisposing cause, initiation of rate-slowing therapy,
possible cardioversion, and initiation of anticoagulant therapy. (See 'Approach to stable
patients' above.)

● Urgent or emergency cardioversion should be considered for patients with active ischemia,
significant hypotension, severe heart failure, or the presence of a preexcitation syndrome
associated with rapid conduction using the accessory pathway. (See 'Patients requiring
urgent management' above.)

● Most patients will need to have the ventricular rate in AF slowed to improve symptoms. In
patients with no or mild symptoms, we start oral therapy in the office. For patients with
bothersome symptoms, we transfer the patient to a facility capable of administering
intravenous therapy. (See 'Rate control' above.)

● Most patients with symptomatic new onset AF should have at least one attempt at
cardioversion (either electrical or chemical) to sinus rhythm. (See 'Cardioversion' above.)

● The timing of cardioversion is determined in large measure by the duration of the episode.
(See 'Timing' above.)

● Most patients with new onset AF should be anticoagulated. (See 'Anticoagulation' above.)

ACKNOWLEDGMENT

The UpToDate editorial staff would like to thank Dr. James Hoekstra for his past contributions as
a section editor to prior versions of this topic review.

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REFERENCES

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6. Boriani G, Diemberger I, Biffi M, et al. Electrical cardioversion for persistent atrial fibrillation
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8. Weigner MJ, Caulfield TA, Danias PG, et al. Risk for clinical thromboembolism associated
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fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893.

Topic 1057 Version 49.0

Contributor Disclosures
Robert Phang, MD, FACC, FHRS Speaker's Bureau: Bristol-Myers Squibb; Pfizer [Stroke prevention in
NVAF (Apixaban)]. Brian Olshansky, MD Speaker’s Bureau: Lundbeck [Orthostatic hypotension
(Droxidopa)]. Consultant/Advisory Boards: Lundbeck [Orthostatic hypotension (Droxidopa)]; Sanofi Aventis;
Respircardia. Other Financial Interest: Amarin [Hypertriglyceridemia (EPA; Chair, Data and Safety Monitoring
Board)]; Boehringer Ingelheim [Atrial fibrillation (GLORIA AF trial)]. Peter J Zim etbaum ,
MD Consultant/Advisory Boards: Abbott Medical [lecture on lead extraction]; In carda Pharmaceuticals [Atrial
fibrillation (Novel antiarrhythmic drug in development)]; Medtronic [Atrial fibrillation (Linq)]. Hugh Calkins,
MD Grant/Research/Clinical Trial Support: Boston Scientific; St Jude Medical [Atrial fibrillation (ICD)].
Consultant/Advisory Boards: Medtronic [Atrial fibrillation (Cryoballoon ablation system)]; Atricure [Atrial
fibrillation (Atriclip device)]; Abbott [Atrial fibrillation (Ablation system)]; St Jude Medical [Atrial fibrillation
(ICD)]; Boehringer Ingelheim [Anticoagulation (Pradaxa)]; Biosense Webster [Catheter ablation]; Boston
Scientific [Catheter ablation]. Other Financial Interest: Medtronic; Boehringer Ingelheim; Biosense Webster
[Lecture (catheter ablation)]. Gordon M Saperia, MD Nothing to disclose

Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

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