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Atrial Fibrillation

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General Information

Description

  • Atrial fibrillation is an abnormal supraventricular tachyarrhythmia caused by uncoordinated atrial activation and usually associated with irregular ventricular response.1

Also Called

  • AF
  • a fib

Definitions

  • first-diagnosed or first-time atrial fibrillation, often called new-onset atrial fibrillation, is when it is newly diagnosed in a patient, regardless of duration of atrial fibrillation or presence and severity of symptoms
  • paroxysmal atrial fibrillation defined as
    • atrial fibrillation that terminates within 7 days of onset (usually < 48 hours) either spontaneously or with interventions
    • may recur with variable frequency
  • recurrent atrial fibrillation defined as ≥ 2 episodes of atrial fibrillation
  • persistent atrial fibrillation defined as atrial fibrillation that is sustained > 7 days or requires termination by cardioversion or ablation
  • longstanding persistent atrial fibrillation defined as atrial fibrillation persistent > 1 year with decision to adopt rhythm control strategy
  • permanent atrial fibrillation (also called chronic atrial fibrillation) refers to
    • joint decision by patient and clinician to stop additional attempts to restore and maintain normal sinus rhythm
    • reasonable for acceptance to change based on evolution of symptoms, efficacy of therapeutic interventions, and patient and clinician preferences
  • lone atrial fibrillation is a historic term used to describe atrial fibrillation in younger patients (such as patients < 65 years old) with no history or echocardiographic evidence of cardiovascular disease, hypertension, or diabetes but lacks standard definition
  • References - 24682347Circulation 2014 Dec 2;130(23):e199OpenInNewfull-textOpenInNew, also published in 24685669J Am Coll Cardiol 2014 Dec 2;64(21):e1OpenInNewfull-textOpenInNew, corrections can be found in Circulation 2014 Dec 2;130(23):e272 and J Am Coll Cardiol 2014 Dec 2;64(21):2305; 27567465Europace 2016 Nov;18(11):1609OpenInNewfull-textPictureAsPdf
  • classification of severity of atrial fibrillation
    • Canadian Cardiovascular Society (CCS) Severity of Atrial Fibrillation (SAF) score
      • 0 asymptomatic
      • 1 minimal effect on quality of life
      • 2 modest effect on quality of life
      • 3 moderate effect on quality of life
      • 4 severe effect on quality of life
    • European Heart Rhythm Association (EHRA) class
      • I no symptoms
      • II mild symptoms
      • III severe symptoms; daily activity affected
      • IV disabling symptoms; normal daily activity discontinued
    • Reference - 21329856Can J Cardiol 2011 Jan-Feb;27(1):7OpenInNew

References

General References Used

  1. Fuster V, Rydén LE, Cannom DS, et al. 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. Circulation. 2006 Aug 15;114(7):e257-354OpenInNewfull-textOpenInNew, correction can be found in Circulation 2007 Aug 7;116(6):e138
  2. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016 Nov;18(11):1609-1678OpenInNew
  3. Healey JS, Parkash R, Pollak T, Tsang T, Dorian P; CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: etiology and initial investigations. Can J Cardiol. 2011 Jan-Feb;27(1):31-7OpenInNew
  4. January CT, Wann LS, Alpert JS, et al. 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. Circulation. 2014 Dec 2;130(23):e199-267OpenInNewPDFPictureAsPdf, also published in J Am Coll Cardiol 2014 Dec 2;64(21):e1OpenInNew, corrections can be found in Circulation 2014 Dec 2;130(23):e272 and J Am Coll Cardiol 2014 Dec 2;64(21):2305

Recommendation Grading Systems Used

  • American College of Cardiology/American Heart Association (ACC/AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
  • American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) grading system for recommendations
    • classes of recommendations
      • Class I (Strong) - should be performed or administered; indicated/useful/effective/beneficial
      • Class IIa (Moderate) - reasonable to perform or administer; can be useful/effective/beneficial
      • Class IIb (Weak) - may be considered; usefulness/effectiveness is unknown/unclear/uncertain or not well established
      • Class III: No Benefit (Moderate) - should not be performed or administered; not indicated/useful/effective/beneficial
      • Class III: Harm (Strong) - should not be performed or administered; potentially harmful, causes harm, or associated with excess morbidity/mortality
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial (RCT), meta-analyses of high-quality RCTs, or ≥ 1 RCTs corroborated by high-quality registry studies
      • Level B-R - moderate-quality evidence from ≥ 1 RCTs or meta-analysis of moderate-quality RCTs
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed, well-executed nonrandomized studies, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies in human subjects
      • Level C-EO - consensus of expert opinion based on clinical experience
    • Reference - AHA/ACC/HRS 2019 focused update of the 2014 AHA/ACC/HRS guideline on management of patients with atrial fibrillation (J Am Coll Cardiol 2019 Jul 9;74(1):104OpenInNew), also published in Circulation 2019 Jul 9;140(2):e125OpenInNew and Heart Rhythm 2019 Jan 28 early onlineOpenInNew
  • American Heart Association (AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
    • References
  • American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
    • Reference - HRS/EHRA/ECAS 2012 expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design (22389422Europace 2012 Apr;14(4):528OpenInNewfull-textOpenInNew or in 22386883Heart Rhythm 2012 Apr;9(4):632OpenInNew)
  • European Society of Cardiology (ESC) grading system for recommendations
    • classes of recommendations
      • Class I - evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well-established by evidence/opinion
      • Class III - evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or large nonrandomized studies
      • Level C - consensus of opinion of experts and/or small studies, retrospective studies, registries
    • References
  • Canadian Cardiovascular Society (CCS) grading system for recommendations
    • strength of recommendation
      • Strong
      • Conditional (weak)
    • quality of evidence
      • High - future research unlikely to change confidence in estimate of effect; multiple well-designed, well-conducted clinical trials
      • Moderate - further research likely to have important impact on confidence in estimate of effect and may change estimate; limited clinical trials, inconsistency of results, or study limitations
      • Low - further research very likely to have significant impact on estimate of effect and is likely to change estimate; small number of clinical studies or cohort observations
      • Very Low - estimate of effect is very uncertain; case studies or consensus opinion
    • References
  • American College of Chest Physicians (ACCP) uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to recommendations
    • grades of recommendation
      • Strong - benefits outweigh risk and burdens, or vice versa
      • Weak (Conditional) - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burden
      • Ungraded Consensus-Based Statement- uncertainty due to lack of evidence but expert opinion that benefits outweigh risk and burdens, or vice versa; insufficient evidence for a graded recommendation
    • quality of evidence
      • High - panel very confident that true effect lies close to estimate of effect
      • Moderate - moderate confidence in effect estimate; true effect likely to be close to estimate of effect, but possibility it is substantially different
      • Low - confidence in effect estimate is limited; true effect may be substantially different from estimate of effect
      • Very low - very little confidence in the effect estimate; true effect likely to be substantially different from estimate of effect
    • Reference - ACCP Evidence-Based Clinical Practice Guidelines for Antithrombotic Therapy and Prevention of Thrombosis (Ninth Edition) guideline and expert panel report on antithrombotic therapy for atrial fibrillation (Chest 2018 Nov;154(5):1121OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special Acknowledgements

  • Panagiotis Papageorgiou, MD, PhD (Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States)
  • Dr. Papageorgeiou declares no relevant financial conflicts of interest.
  • Amir Qaseem, MD, PhD, MHA, FACP (Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network (GIN); Germany)
  • Dr. Qaseem declares no relevant financial conflicts of interest.
  • Peter Oettgen MD, FACC, FAHA, FACP (Editor in Chief; Cardiologist, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School, Massachusetts, United States)
  • Dr. Oettgen declares no relevant financial conflicts of interest.
  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115288, Atrial Fibrillation; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115288. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

    • Prevention

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also Called

    • Definitions

  • KeyboardArrowRight

    Epidemiology

    • Incidence/Prevalence

    • KeyboardArrowRight

      Likely Risk Factors

      • Cardiac Abnormalities

      • Subclinical Hyperthyroidism

      • Alcohol Consumption

      • Obesity

      • NSAIDs and COX-2 Inhibitors

      • Other Likely Risk Factors

    • KeyboardArrowRight

      Possible Risk Factors

      • Corticosteroids

      • Genetic Factors

      • Other Risk Factors

    • Risk Prediction

    • Factors Not Associated with Increased Risk

    • Associated Conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief Concern (CC)

      • History of Present Illness (HPI)

      • Past Medical History (PMH)

      • Family History (FH)

      • Social History (SH)

    • KeyboardArrowRight

      Physical

      • General Physical

      • Neck

      • Cardiac

      • Lungs

      • Extremities

  • KeyboardArrowRight

    Diagnosis

    • Making the Diagnosis

    • Differential Diagnosis

    • Testing Overview

    • Blood Tests

    • KeyboardArrowRight

      Imaging Studies

      • KeyboardArrowRight

        Echocardiography

        • Indications

        • Transesophageal Echocardiogram (TEE) for Timing of Cardioversion

        • Intracardiac Echocardiography

      • Computed Tomography

    • KeyboardArrowRight

      Electrocardiography (ECG)

      • Indications for ECG and ECG Images

      • Evidence for ECG Detection of Atrial Fibrillation

      • Interpretive Software for ECG

    • Mobile Technology

  • KeyboardArrowRight

    Management

    • Management Overview

    • Treatment Setting

    • Rate Control

    • Cardioversion

    • Rhythm Control

    • Rate vs. Rhythm Control

    • Thromboembolic Prophylaxis

    • KeyboardArrowRight

      Activity

      • Exercise

      • Sexual Activity

      • Driving

    • KeyboardArrowRight

      Surgery and Procedures

      • Ablation Therapy

      • Implantable Atrial Defibrillator

      • Pacing

      • KeyboardArrowRight

        Left Atrial Appendage Closure

        • Background and Recommendations

        • Comparative Efficacy vs. Anticoagulant Therapy

        • Efficacy in Patients Undergoing Cardiac Surgery (vs. No Left Atrial Appendage Closure)

        • Device Complications

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • Prognosis Based on Atrial Fibrillation Burden

      • Recurrence Risk

      • Embolic Stroke and Thromboembolism

      • Cardiovascular Disease

      • Mortality Risk

  • KeyboardArrowRight

    Prevention and Screening

    • KeyboardArrowRight

      Prevention

      • Prevention of Recurrent Atrial Fibrillation

      • ACE Inhibitors and ARBs for Prevention

      • Statins

      • Physical Activity

      • Sick Sinus Syndrome

      • KeyboardArrowRight

        Perioperative Prevention of Atrial Fibrillation

        • Recommendations for Perioperative Prevention of Atrial Fibrillation

        • Antiarrhythmic Drugs (amiodarone, beta blockers, sotalol)

        • Statins for Perioperative Prevention

        • Magnesium for Perioperative Prevention

        • Steroids for Perioperative Prevention

        • Omega-3 Fatty Acids for Perioperative Prevention

        • Other Medications for Perioperative Prevention

        • Nonpharmacologic Interventions for Perioperative Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • American College of Cardiology (ACC)/American Heart Association (AHA) Performance Measures

    • Quality and Outcomes Framework Indicators

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International Guidelines

      • United States Guidelines

      • United Kingdom Guidelines

      • Canadian Guidelines

      • European Guidelines

      • Asian Guidelines

      • Australian and New Zealand Guidelines

      • Middle Eastern Guidelines

      • Quality Indicators

    • Review Articles

    • MEDLINE Search

  • Patient Decision Aids

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 Codes

  • KeyboardArrowRight

    References

    • General References Used

    • Recommendation Grading Systems Used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special Acknowledgements

    • How to cite

Topic Editor
Panagiotis Papageorgiou MD, PhD
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Affiliations

Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Papageorgeiou declares no relevant financial conflicts of interest.

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
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Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Peter Oettgen MD
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Affiliations

Editor in Chief, DynaMed; Cardiologist, Beth Israel Deaconess Medical Center; Massachusetts, United States; Associate Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Oettgen declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians

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