Clinical
Atrial fibrillation: an update on
care provision
Sarah Chalkley is Senior Staff Nurse, Coronary Care Unit, Bristol Royal Infirmary, Bristol BS2 8HW
n March 2005, the government published Chapter 8 of
I the National Service Framework for Coronary Heart
Disease: Arrhythmias and sudden cardiac death
(Department of Health, 2005). This identified the need
for the organization of care provision and established
standards for all patients with cardiac arrhythmias,
including patients with atrial fibrillation (AF). It
highlighted inconsistencies in management across the
whole spectrum of AF.
Two quality requirements were introduced to ensure the
delivery of high quality services specific to patients’ needs
and wishes (DH, 2005). The first is the provision of patient
support; ensuring people with arrhythmias receive timely,
high quality support and information, based on an assess-
ment of their needs. The second quality requirement
concentrates on diagnosis and treatment of people
presenting with arrhythmias, in both emergency and
elective settings. The aim is to receive timely assessment by
an appropriate clinician to ensure accurate diagnosis,
effective treatment and rehabilitation (DH, 2005).
In providing better access to effective treatment in
primary, secondary and specialist settings, there should be
‘a reduction in hospital admissions, reduced mortality
rate, and a marked improvement in the quality of life for
patients and their families’ (DH, 2005:9). Being able to
identify those at greater risk may increase screening and
provide a more timely diagnosis (DH, 2005).
Atrial fibrillation affects up to 1% of the total population
in England costing the NHS 1% of its annual budget (DH,
2005). Effective care management will have a major
impact on the NHS budget as well as improve the standard
of service provision for this group of patients.
While chapter 8 of the NSF for CHD has demonstrated
the need for improvements in service provision, the pub-
lication of the National Institute for Health and Clinical
Excellence (NICE) guidelines on the management of atrial
fibrillation (NICE, 2006) provide national evidence-based
guidance for the management of the majority of patients
with AF (Lip and Rudolf, 2007).
It is vital that cardiac nurses understand this particular
arrhythmia and the national standards for best practice
being implemented to ensure high standards of individ-
ualized patient care. The role of nurses in the provision
of best practice should not be underestimated and
by effectively managing the most common cardiac
arrhythmia they can effect the biggest impact.
British Journal of Cardiac Nursing February 2008 Vol 3 No 2
Classification of atrial fibrillation
AF can be defined as ‘a rapid chaotic depolarization of
impulses occurring throughout the atrial myocardium,
replacing normal rhythmic activity by the sinoatrial node’
(Hand, 2002:14). There are three classifications of AF
(Blaauw et al, 2002):
w Paroxysmal AF
w Persistent AF
w Permanent AF
Paroxysmal AF is defined as terminating spontane-
ously within 7 days, persistent AF requires electrical or
pharmacological cardioversion for termination, and
permanent AF lasts longer than 1 year (Markides and
Schilling, 2003).
Atrial fibrillation shortens the atrial refractory period
and over time causes electrical remodelling, as well as
structural and contractile changes (Blaauw et al, 2002).
The initiation of AF is facilitated by the development of an
abnormal atrial tissue substrate capable of maintaining the
arrhythmia (Markides and Schilling, 2003). The longer an
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia,
increasing mortality and impairing quality of life (Khaykin, 2007).
The publication of chapter 8 of the National Service Framework for
Coronary Heart Disease (DH, 2005), and the National Institute for
Health and Clinical Excellence guidelines (NICE, 2006) have
highlighted the importance of individualized case management in the
treatment of AF. This article will summarize recommendations in the
management of AF in relation to the NSF and NICE guidelines and
assess the implications for practice.
The associated symptoms, risk factors and classification of each
type of AF will be defined. Different investigations will be discussed
in relation to symptoms of AF, highlighting treatment options specific
to each presentation. Consistent and effective management of AF
can have a significant impact on an individual’s quality of life and be
cost-effective for health care providers.
Key words
w Atrial fibrillation w National Service Framework for Coronary
Heart Disease w National Institute for Health and Clinical
Excellence w Effective care management
Submitted for peer review 15 October 2007. Accepted for publication
25 January 2008 Conflict of interest: None
63
Clinical
individual remains in AF, the more difficult it becomes to
restore sinus rhythm. This remodelling may also explain
why paroxysmal AF tends to develop into a persistent or
permanent arrhythmia over time (Blaauw et al, 2002).
However, converting AF to sinus rhythm within 2 weeks
of onset can reverse this modelling process, highlighting
the importance of timely rhythm restoration, where pos-
sible, to significantly reduce the risk of permanent AF
(Markides and Schilling, 2003).
Risk factors
There are several risk factors for the development of AF
(Table 1). By educating patients in ways to self-manage
their risk factors, nurses can empower patients to assist in
the improvement of their symptoms (Rocca, 2007).
A small number of people, around 15% of all cases,
develop AF with no predisposing risk factors and these
patients are described as having ‘lone AF’ (Hand, 2002).
Lone AF is less understood than AF with underlying
Table 1.
Risk factors for the development of AF
w Advancement of age (increasing to 4% in people
aged >65)
w Diabetes
w Hypertension
w Valvular heart disease
w Left ventricular heart disease
w Hyperthyroidism
w High alcohol consumption
w Pneumonia
Blaauw et al, 2002; Hand, 2002; Lip et al, 2001
Confirmed diagnosis of AF
Further investigations and clinical assessment
for stroke/thromboembolism
Paroxysmal AF Persistent AF Permanent AF
OR
remains symptomatic
Rhythm control Rate control
failure of rhythm control
Figure 1. Treatment strategy decision tree (NICE, 2006)
64
structural heart disease, however, it has been suggested
that its triggers may originate within the pulmonary vein
(Markides and Schilling, 2003).
Symptoms
Common symptoms of the onset of AF include palpita-
tions, dyspnoea, fatigue, dizziness, syncope and chest
discomfort (NICE, 2006). Some cases of AF are only diag-
nosed on presentation of a stroke or transient ischaemic
attack, and at least 15% of strokes may be attributed to AF
(Fuller and Dudley, 2005).
Health care providers must acknowledge the anxiety
and level of uncertainty patients will have with these
symptoms on presentation to the clinical environment
(Kang, 2005). Living with paroxysmal AF or continuously
reduced functional capacity would affect any individual’s
quality of life (Lip et al, 2001). It is therefore imperative
that nurses provide patients with support and education
regarding symptoms as well as risk factors (Rocca, 2007).
Investigations
Many of the clinical investigations can be completed in
primary care. The simplest yet most important test is the
opportunist checking of the pulse of all patients with pre-
disposing risk factors (NICE, 2006). In the detection of an
irregular pulse, a 12-lead electrocardiogram (ECG) must
be recorded and the patient provided with a personal copy
(NICE, 2006). Further tests suggested are blood tests,
including thyroid function tests, and a chest X ray (Davis
et al, 2007). In patients with suspected paroxysmal AF, an
ambulatory ECG or event recorder may be necessary
(NICE, 2006). A transthoracic echocardiogram should not
be performed for stroke risk stratification alone (taking
into account the cost implications), but it is indicated to
assess for any structural cardiac abnormality and when the
outcome will have a clear impact on care provision (Dewar
and Lip, 2007).
Treatments
The NICE guidelines for suitable treatment of atrial
fibrillation depend on the clinical type of AF on presenta-
tion and age of the patient. A treatment strategy decision
tree is included, to be used to guide treatment (NICE,
2006: 41) (Figure 1).
Acute onset of atrial fibrillation with
haemodynamic compromise
A small group of patients become considerably compro-
mised at the onset of AF (Mann et al, 2007). These patients
will present to the emergency department and will require
immediate intervention (Markides and Schilling, 2003).
This compromise may be due to the loss of atrial contribu-
tion to ventricular filling which normally contributes
20–30% of end diastolic volume (Lim et al, 2004). The
contribution from atrial contraction increases with
age and in conditions such as hypertension and cardio-
myopathy which cause impaired ventricular relaxation
(Lim et al, 2004). Along with the increased irregular heart
British Journal of Cardiac Nursing February 2008 Vol 3 No 2

rate, which reduces diastolic filling, this reduced atrial
contribution to cardiac output can cause rapid haemo-
dynamic compromise (Mann et al, 2007).
In these cases, the NICE guidelines (2006) recommend
an emergency electrical cardioversion, following trans-
oesophageal echocardiogram, regardless of the duration of
the AF. If there is a delay in organizing the electrical
cardioversion then amiodarone should be commenced
to begin chemical cardioversion (Mann et al, 2007). In
treating patients with Wolff-Parkinson-White syndrome,
the guidelines state that flecainide should be used instead
of amiodarone (NICE, 2006).
Where haemodynamic instability is related to a fast
ventricular rate, then pharmacological rate control is
advised, using beta-blockers or rate–limiting calcium antag-
onists (NICE, 2006). The traditional first-line therapy was
amiodarone, however NICE (2006) now recommends
amiodarone should be a second–line treatment, owing to its
toxicity when used long term (Mann et al, 2007).
When treating the arrhythmia, underlying causes must
also be identified and managed to reduce the risk of the
patient representing as an emergency case, as well as
increasing the likelihood of maintaining sinus rhythm
after successful cardioversion (Lim et al, 2004).
Postoperative atrial fibrillation
Postoperative atrial fibrillation occurs in approximately
one-third of patients who have undergone coronary artery
bypass surgery and this number increases further with
valvular heart surgery (Mann et al, 2007). To reduce the
incidence of AF following cardiothoracic surgery, NICE
(2006) recommends drug prophylaxis using amiodarone,
beta-blockers, sotalol or a rate-limiting calcium antago-
nist. Should a patient develop AF following surgery, the
NICE guidelines also set out the path for medical manage-
ment (Table 2).
Paroxysmal atrial fibrillation
As previously identified, paroxysmal AF usually termi-
nates within 7 days. When deciding on a treatment plan
for individuals with paroxysmal atrial fibrillation, the
main aims should include the management and preven-
Table 2.
Medical treatment of AF after surgery
AF following cardiac surgery
w Rhythm control
w Treat reversible causes e.g. electrolyte imbalance
AF following non-cardiac surgery
Follow acute onset of AF pathway:
w Emergency electrical cardioversion
w If delay in electrical therapy commence
amiodarone (if no contraindications)
NICE, 2006
British Journal of Cardiac Nursing February 2008 Vol 3 No 2
Clinical
tion of paroxysms, long term maintenance of sinus rhythm
and the consideration of antithrombotic therapy (Lip et al,
2001). If predisposing factors are present such as stress,
caffeine, alcohol, and inadequate treatment of underlying
diseases, these should be actively managed before the use
of any treatment for the reduction of paroxysms can be
appropriately implemented (Blaauw et al, 2002).
For patients with infrequent paroxysms and few symp-
toms, NICE (2006) recommends no long-term treatment,
but a ‘pill in the pocket’ strategy. This involves the patient
self-administering an antiarrhythmic drug only at the
onset of an episode of AF (NICE, 2006). This approach is
used when patients have infrequent paroxysms so do not
take drugs regularly, or it is taken as an extra dose in those
already having a low maintenance dose of that particular
drug (Sulke et al, 2007). Due to the pro-arrhythmic risk of
the pill in the pocket approach, it should only be provided
to those with no structural heart disease, heart failure or
left ventricular dysfunction, and where it has previously
been trialled successfully with the individual being a
monitored inpatient (Sulke et al, 2007). When the pill in
the pocket therapy is not appropriate, then paroxysmal AF
should be treated by rhythm control (Table 3).
While the guidelines recommend the use of amiodarone
for paroxysmal atrial fibrillation, the long-term toxicity
was not addressed in the evidence (Sulke et al, 2007).
Therefore, when treating individuals with paroxysmal
atrial fibrillation, the risk of side-effects in long term use
of the drug—such as thyroid dysfunction—must be
assessed against infrequent paroxysms (Markides and
Schilling, 2003).
Persistent atrial fibrillation
Persistent atrial fibrillation can be treated by rhythm or
rate control, depending on individual patient criteria as
recommended by the NICE guidelines (2006:12) (Table 4).
Rhythm control uses pharmacological or electrical cardio-
version, or electrophysiological interventions (Markides
and Schilling, 2003). Rate control includes the use of
Table 3.
Rhythm control treatment
options for paroxysmal AF
Initial treatment for all AF Standard beta-blocker
Standard beta-blocker ineffective Class 1c anti-arrhythmic agent
and patient has no coronary (flecainide/propafenone) or
heart disease sotalol
Standard beta-blocker ineffective Amiodarone or electrical
and patient has coronary heart cardioversion
disease
Standard beta-blocker ineffective Amiodarone or electrical
and patient has poor left cardioversion
ventricular function
NICE, 2006
65
Clinical
Table 4.
Rate and rhythm control recommendations options
Rate control Rhythm control
w Aged over 65 w Symptomatic
w Known coronary heart disease w Younger patients
w Contraindications to w First presentation of AF
anti-arrhythmic therapy w AF secondary to a treated/
w Unsuitable for cardioversion corrected precipitant
w Without congestive heart failure w With congestive heart failure
NICE, 2006
chronotropic drugs or electrophysiological intervention to
decrease symptoms and potentially decrease the risk of
associated morbidity (Sulke et al, 2007).
Rhythm control
Rhythm control involves the conversion of AF to sinus
rhythm using pharmacological (flecainide or amiodarone)
or electrical therapy.
If the treatment chosen is electrical cardioversion then
the patient must receive therapeutic anticoagulation (i.e.
achieving a therapeutic INR level) for 3 weeks before
cardioversion, and a minimum of 4 weeks following
successful cardioversion (NICE, 2006). This is because of
the high risk of recurrence of the arrhythmia within the
first few days, and a risk of thrombus formation as
mechanical atrial function may be slow to return (Markides
and Schilling, 2003).
The shorter time an individual remains in AF the more
successful an electrical cardioversion is likely to be (Blaauw
et al, 2002). If the patient has to wait a minimum of
3 weeks for therapeutic anticoagulation, the likely success
of the cardioversion may be reduced (Markides and
Schilling, 2003). By performing a transoesophageal
echocardiogram–guided cardioversion in patients whose
duration of AF is greater than 48 hours, the clinician is
able to rule out any intracardiac thrombus (Sulke et al,
2007). In the absence of a thrombus NICE (2006) recom-
mends the administration of heparin before cardioversion
followed by a minimum of 4 weeks therapeutic anticoagu-
lation. When a thrombus is identified, then therapeutic
anticoagulation must be administered for 3–4 weeks
before a repeat transoesophageal echocardiogram (Sulke
et al, 2007).
Clinical practice favours pharmacological cardioversion
if the onset of AF is less than 48 hours and electrical
cardioversion if the AF is prolonged. However, both treat-
ments are considered equally effective (Sulke et al, 2007).
Therefore, if both treatments are available within the same
timeframe, then the opportunity for patient choice and
individualized patient care should be taken up (DH,
2005). In the UK nurse-led elective cardioversions are
being carried out with extremely positive results.
Pre-assessment clinics provide information to patients
66
ahead of the procedure, and the consistency of the nurses
has reduced waiting times significantly, which may
improve the long term outcome (Currie et al, 2004).
Following successful cardioversion, where the underlying
condition cannot be resolved, the use of antiarrhythmic
drugs is recommended to maintain sinus rhythm (Sulke et
al, 2007). If the cause of persistent AF (such as infection)
has been corrected, and there are no other risk factors, then
no antiarrhythmic therapy is needed to maintain sinus
rhythm (NICE, 2006).
Rate control for persistent and permanent
atrial fibrillation
It is generally considered that the heart rate in AF should
be faster than sinus rhythm to maintain the same cardiac
output (Camm et al, 2007). However, strict control may be
necessary to minimize symptoms and improve quality of
life (Markides and Schilling, 2003).
NICE (2006) recommends beta-blockers or calcium
antagonists as initial monotherapy in all patients. Adequate
rate control at rest does not necessarily imply that the rate
will be sufficiently controlled during exercise (Camm et al,
2007). Therefore, the use of digoxin is not recommended
in patients as the initial monotherapy owing to ineffective
control of heart rate during exercise (Blaauw et al, 2002).
When monotherapy is inadequate and further control is
necessary during normal activities only, then digoxin
should be given alongside beta-blockers or rate-limiting
calcium antagonists (NICE, 2006). When further rate
control is required during both normal activities and exer-
cise, then rate–limiting calcium antagonists should be
given with digoxin (NICE, 2006).
Quality of life
Symptoms of AF including palpitations, shortness of
breath, fatigue and dizziness will all impact on the quality
of life for these affected patients (NICE, 2006). Treating
patients with either rate or rhythm control may increase
their cardiac output and therefore their exercise tolerance
(Lee, 2006).
The Atrial Fibrillation Follow-Up Investigation of
Rhythm Management (AFFIRM) functional status sub-
study investigated quality of life of 4 060 patients with
AF managed under the rate or rhythm control treat-
ments (Chung et al, 2005). The study used a mini-mental
state examination and 6 minute walk tests to compare
treatments in an attempt to identify which treatment was
the most effective. Results showed a modest improve-
ment in exercise tolerance for the rhythm–controlled
patients. However, the presence of AF was significantly
associated with higher heart rates and worse New York
Heart Association classification of Functional Capacity
(NYHA-FC) (Criteria Committee of the New York Heart
Association, 1994). No difference in cognitive function
was detected, although this may be due to effective anti-
coagulation therapy and therefore a reduced risk of silent
embolic strokes or decrease in cerebral blood flow
(Chung et al, 2005).
British Journal of Cardiac Nursing February 2008 Vol 3 No 2
 Clinical

Limitations of the study include the omission of
patients with frequent and severe AF symptoms and the
baseline assessment of functional status before randomi-
sation (Gerstenfeld, 2005). However, the effects of careful
rate control or rhythm control for these patients cannot
be underestimated.
Reducing symptoms and anxiety in these patients can be
effectively done through clinical management, support
and education, to empower individuals in their care
provision (Rocca, 2007). Cardiovascular nurses may be
the first to discover possible AF in a patient and the
support and education they can provide to the patient may
be invaluable at this early stage (Rocca, 2007).
Anticoagulation therapy
Remaining in AF for longer than 48 hours causes the stasis
of blood in the fibrillating atrium which can lead to
thrombus formation and systemic embolism (Hand, 2002).
For this reason, when AF extends beyond 48 hours, anti-
coagulation should be commenced in accordance with the
stroke risk stratification of the NICE guidelines (2006:47)
(Figure 2).

Patients with paroxysmal,

persistent of permanent AF

1
Determine
stroke/thromboembolic risk

High risk Moderate risk Low risk

Previous ischaemic stroke/TIA or Age ≥65 with no high Age <65 with no
thromboembolic event risk factors moderate or high risk
factors
Age ≥ 75 with hypertension, Age <75 with hypertension,
diabetes or vascular disease* diabetes or vascular disease*
Clinical evidence of valve
disease, heart failure or
impaired LV function on
echocardiography**

2
Anticoagulation Consider
with warfarin anticoagulation or
aspirin

Aspirin 75 to
Contraindications Yes 300 mg/day if no
to warfarin? contraindications

No

Warfarin, target Reassess risk

INR 2.5 (range stratification whenever
2.0 to 3.0) individual risk factors
are reviewed

1. Note that risk factors are not mutually exclusive, and are additive to each other in producing a composite risk.
Since the incidence of stroke and thromboembolic events in patients with thyrotoxicosis appears similar to that in
patients with other aetiologies of AF, antithrombotic treatments should be chosen based on the presence of
validated stroke risk factors.
2. Owing to lack of sufficient clear-cut evidence, treatment may be decided on an individual basis, and the physician
must balance the risk and benefits of warfarin versus aspirin. As stroke risk factors are cumulative, warfarin may,
for example, be used in the presence of two or more moderate stroke risk factors. Referral and echocardiography may help
in cases of uncertainty.

Coronary artery disease or peripheral artery disease.

*

An echocardiogram is not needed for routine assessment, but refines clinical risk stratification in the case of
**

moderate or severe LV dysfunction and valve disease.

Figure 2. Stroke risk stratification algorithm (NICE, 2006)

British Journal of Cardiac Nursing February 2008 Vol 3 No 2 67

Clinical
In clinical practice, it is recognized that physicians are
less likely to prescribe anticoagulation for patients with
paroxysmal atrial fibrillation than they are for those with
persistent AF (Markides and Schilling, 2003). However,
paroxysmal AF carries a similar risk of stroke to persistent
AF (Dewar and Lip, 2007), and therefore anticoagulation
should be approached in accordance with the stroke risk
stratification (NICE, 2006).
The most common reason for the underuse of warfarin
is the perception that patients will not comply with the
treatment (DeWilde et al, 2006). While it is important to
understand the impact on an individual with dietary
restrictions and regular monitoring for INR, it is impor-
tant to remember the potentially serious consequences of
not receiving warfarin when clinical guidelines recom-
mend it (Waldo et al, 2005).
Nurses have an important role to play in ensuring
patients are involved in their own care and enabling them
to make informed decisions (Rocca, 2007). Consequently,
empowering patients may reduce anxiety, increase medi-
cation compliance and therefore improve individual out-
comes (DeWilde et al, 2006).
Cost implications of treatment
The hospital cost of AF is hard to quantify as many
patients will present with other conditions requiring treat-
ment and it is therefore difficult to identify length of stay
and costs specifically related to AF (Lee, 2006).
Hagens et al (2004) carried out a cost-effectiveness
analysis in their randomized controlled trial, RAte
Control versus Electrical cardioversion (RACE). The
trial looked at 522 participants with recurrent persistent
AF or atrial flutter, over 2.3 years. Costs of care included
were cardioversions, medications, outpatient visits, hos-
pital admissions, general practitioner visits, laboratory
investigations, professional help, informal care and travel
costs. They found rate control to be more cost-effective
than rhythm control.
However, it has also been argued that symptomatic AF
requires immediate rhythm control to improve quality of
life, regardless of cost (Lee, 2006).
While the NICE (2006) guidelines support rate or
rhythm control, they state that treatment decisions must
be specific to each individual patient’s needs. Effective
anticoagulation (where appropriate) in the treatment of
Key Points
w Atrial fibrillation (AF) is the most common cardiac arrhythmia
w By understanding medical guidelines nurses can be more proactive
in taking on the role of patient’s advocate and ensuring best practice
w Effective care management will have a major impact on the NHS
budget as well as improve the standard of service provision for this
group of patients
68
AF will reduce the risk of stroke (DeWilde et al, 2006).
This in turn will enable patients to maintain their quality
of life and reduce future NHS spending on unnecessary
devastating strokes (Waldo et al, 2005).
Further treatments
Although not discussed in the NICE guidelines for the
management of AF, cardiologists specializing in electro-
physiology may use other therapies where pharmacologi-
cal treatments have not been successful. One option is the
maze procedure, which uses surgical incisions to interrupt
the potential multiple wavelet re-entry circuits, in an
attempt to prevent or terminate AF (Blaauw et al, 2002).
The radiofrequency ablation of the AV node and implan-
tation of a permanent pacemaker can be used to eliminate
the arrhythmia (Blaauw et al, 2002). Pulmonary vein abla-
tion is a rapidly developing field, preventing AF recur-
rences, and in a few cases, terminating chronic AF
(Khaykin 2007). Although the procedure is expensive,
long-term medical treatment of AF may present a more
costly option when the restoration and maintenance of
sinus rhythm has been shown to improve quality of life
and functional performance (Khaykin 2007).
Conclusions
Chapter 8 of the National Service Framework for Coronary
Heart Disease (DH, 2005) introduced quality require-
ments to improve standards and introduce individualized
care for patients with cardiac arrhythmias. The publication
of the NICE guidelines for the management of AF (NICE,
2006) provided a uniform standard for specific medical
therapies and the treatment of different types of AF.
The guidelines have not been developed as a fully com-
prehensible manual, rather guidelines to be tailored to
individual cases (Lip and Rudolf, 2007). Each type of AF
has been identified and treatment options provided based
on the most recent research-based evidence at the time
(NICE, 2006).
Through the regular checking of pulses to identify this
arrhythmia, nurses may be able to further reduce the risk
(Dewar and Lip, 2007).
It is important for nurses working on cardiovascular
care to be familiar with these guidelines in their entirety to
ensure that patients receive effective evidence-based care.
By understanding the guidelines, they will be better posi-
tioned to provide patients with information to allow them
to make informed choices about treatments most suited to
their needs.
All treatment provision should be individually discussed
to ensure patient-centred care (Markides and Schilling,
2003). Providing information enabling each individual
to make fully informed decisions increases quality in
care provision (DH, 2005) and may increase treatment
compliance (Hand, 2002).
The implementation of therapeutic anticoagulation
therapy when indicated is vital for the reduction of AF-
induced stroke (Fuller and Dudley, 2005). Nurses can
make a big difference by acting as advocates ensuring
British Journal of Cardiac Nursing February 2008 Vol 3 No 2

therapy is optimized and patients are appropriately referred
for anticoagulation (Rocca, 2007).
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