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Atrial Brillation: An Update On Care Provision
Atrial Brillation: An Update On Care Provision
individual remains in AF, the more difficult it becomes to structural heart disease, however, it has been suggested
restore sinus rhythm. This remodelling may also explain that its triggers may originate within the pulmonary vein
why paroxysmal AF tends to develop into a persistent or (Markides and Schilling, 2003).
permanent arrhythmia over time (Blaauw et al, 2002).
However, converting AF to sinus rhythm within 2 weeks Symptoms
of onset can reverse this modelling process, highlighting Common symptoms of the onset of AF include palpita-
the importance of timely rhythm restoration, where pos- tions, dyspnoea, fatigue, dizziness, syncope and chest
sible, to significantly reduce the risk of permanent AF discomfort (NICE, 2006). Some cases of AF are only diag-
(Markides and Schilling, 2003). nosed on presentation of a stroke or transient ischaemic
attack, and at least 15% of strokes may be attributed to AF
Risk factors (Fuller and Dudley, 2005).
There are several risk factors for the development of AF Health care providers must acknowledge the anxiety
(Table 1). By educating patients in ways to self-manage and level of uncertainty patients will have with these
their risk factors, nurses can empower patients to assist in symptoms on presentation to the clinical environment
the improvement of their symptoms (Rocca, 2007). (Kang, 2005). Living with paroxysmal AF or continuously
A small number of people, around 15% of all cases, reduced functional capacity would affect any individual’s
develop AF with no predisposing risk factors and these quality of life (Lip et al, 2001). It is therefore imperative
patients are described as having ‘lone AF’ (Hand, 2002). that nurses provide patients with support and education
Lone AF is less understood than AF with underlying regarding symptoms as well as risk factors (Rocca, 2007).
Table 1. Investigations
Many of the clinical investigations can be completed in
Risk factors for the development of AF
primary care. The simplest yet most important test is the
w Advancement of age (increasing to 4% in people opportunist checking of the pulse of all patients with pre-
aged >65) disposing risk factors (NICE, 2006). In the detection of an
w Diabetes irregular pulse, a 12-lead electrocardiogram (ECG) must
be recorded and the patient provided with a personal copy
w Hypertension
(NICE, 2006). Further tests suggested are blood tests,
w Valvular heart disease including thyroid function tests, and a chest X ray (Davis
w Left ventricular heart disease et al, 2007). In patients with suspected paroxysmal AF, an
w Hyperthyroidism ambulatory ECG or event recorder may be necessary
(NICE, 2006). A transthoracic echocardiogram should not
w High alcohol consumption
be performed for stroke risk stratification alone (taking
w Pneumonia into account the cost implications), but it is indicated to
Blaauw et al, 2002; Hand, 2002; Lip et al, 2001 assess for any structural cardiac abnormality and when the
outcome will have a clear impact on care provision (Dewar
and Lip, 2007).
Treatments
Confirmed diagnosis of AF The NICE guidelines for suitable treatment of atrial
fibrillation depend on the clinical type of AF on presenta-
Further investigations and clinical assessment
tion and age of the patient. A treatment strategy decision
for stroke/thromboembolism tree is included, to be used to guide treatment (NICE,
2006: 41) (Figure 1).
rate, which reduces diastolic filling, this reduced atrial tion of paroxysms, long term maintenance of sinus rhythm
contribution to cardiac output can cause rapid haemo- and the consideration of antithrombotic therapy (Lip et al,
dynamic compromise (Mann et al, 2007). 2001). If predisposing factors are present such as stress,
In these cases, the NICE guidelines (2006) recommend caffeine, alcohol, and inadequate treatment of underlying
an emergency electrical cardioversion, following trans- diseases, these should be actively managed before the use
oesophageal echocardiogram, regardless of the duration of of any treatment for the reduction of paroxysms can be
the AF. If there is a delay in organizing the electrical appropriately implemented (Blaauw et al, 2002).
cardioversion then amiodarone should be commenced For patients with infrequent paroxysms and few symp-
to begin chemical cardioversion (Mann et al, 2007). In toms, NICE (2006) recommends no long-term treatment,
treating patients with Wolff-Parkinson-White syndrome, but a ‘pill in the pocket’ strategy. This involves the patient
the guidelines state that flecainide should be used instead self-administering an antiarrhythmic drug only at the
of amiodarone (NICE, 2006). onset of an episode of AF (NICE, 2006). This approach is
Where haemodynamic instability is related to a fast used when patients have infrequent paroxysms so do not
ventricular rate, then pharmacological rate control is take drugs regularly, or it is taken as an extra dose in those
advised, using beta-blockers or rate–limiting calcium antag- already having a low maintenance dose of that particular
onists (NICE, 2006). The traditional first-line therapy was drug (Sulke et al, 2007). Due to the pro-arrhythmic risk of
amiodarone, however NICE (2006) now recommends the pill in the pocket approach, it should only be provided
amiodarone should be a second–line treatment, owing to its to those with no structural heart disease, heart failure or
toxicity when used long term (Mann et al, 2007). left ventricular dysfunction, and where it has previously
When treating the arrhythmia, underlying causes must been trialled successfully with the individual being a
also be identified and managed to reduce the risk of the monitored inpatient (Sulke et al, 2007). When the pill in
patient representing as an emergency case, as well as the pocket therapy is not appropriate, then paroxysmal AF
increasing the likelihood of maintaining sinus rhythm should be treated by rhythm control (Table 3).
after successful cardioversion (Lim et al, 2004). While the guidelines recommend the use of amiodarone
for paroxysmal atrial fibrillation, the long-term toxicity
Postoperative atrial fibrillation was not addressed in the evidence (Sulke et al, 2007).
Postoperative atrial fibrillation occurs in approximately Therefore, when treating individuals with paroxysmal
one-third of patients who have undergone coronary artery atrial fibrillation, the risk of side-effects in long term use
bypass surgery and this number increases further with of the drug—such as thyroid dysfunction—must be
valvular heart surgery (Mann et al, 2007). To reduce the assessed against infrequent paroxysms (Markides and
incidence of AF following cardiothoracic surgery, NICE Schilling, 2003).
(2006) recommends drug prophylaxis using amiodarone,
beta-blockers, sotalol or a rate-limiting calcium antago- Persistent atrial fibrillation
nist. Should a patient develop AF following surgery, the Persistent atrial fibrillation can be treated by rhythm or
NICE guidelines also set out the path for medical manage- rate control, depending on individual patient criteria as
ment (Table 2). recommended by the NICE guidelines (2006:12) (Table 4).
Rhythm control uses pharmacological or electrical cardio-
Paroxysmal atrial fibrillation version, or electrophysiological interventions (Markides
As previously identified, paroxysmal AF usually termi- and Schilling, 2003). Rate control includes the use of
nates within 7 days. When deciding on a treatment plan
for individuals with paroxysmal atrial fibrillation, the Table 3.
main aims should include the management and preven-
Rhythm control treatment
options for paroxysmal AF
Table 2.
Medical treatment of AF after surgery Initial treatment for all AF Standard beta-blocker
Limitations of the study include the omission of support and education they can provide to the patient may
patients with frequent and severe AF symptoms and the be invaluable at this early stage (Rocca, 2007).
baseline assessment of functional status before randomi-
sation (Gerstenfeld, 2005). However, the effects of careful Anticoagulation therapy
rate control or rhythm control for these patients cannot Remaining in AF for longer than 48 hours causes the stasis
be underestimated. of blood in the fibrillating atrium which can lead to
Reducing symptoms and anxiety in these patients can be thrombus formation and systemic embolism (Hand, 2002).
effectively done through clinical management, support For this reason, when AF extends beyond 48 hours, anti-
and education, to empower individuals in their care coagulation should be commenced in accordance with the
provision (Rocca, 2007). Cardiovascular nurses may be stroke risk stratification of the NICE guidelines (2006:47)
the first to discover possible AF in a patient and the (Figure 2).
1
Determine
stroke/thromboembolic risk
2
Anticoagulation Consider
with warfarin anticoagulation or
aspirin
Aspirin 75 to
Contraindications Yes 300 mg/day if no
to warfarin? contraindications
No
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.
An echocardiogram is not needed for routine assessment, but refines clinical risk stratification in the case of
**
In clinical practice, it is recognized that physicians are AF will reduce the risk of stroke (DeWilde et al, 2006).
less likely to prescribe anticoagulation for patients with This in turn will enable patients to maintain their quality
paroxysmal atrial fibrillation than they are for those with of life and reduce future NHS spending on unnecessary
persistent AF (Markides and Schilling, 2003). However, devastating strokes (Waldo et al, 2005).
paroxysmal AF carries a similar risk of stroke to persistent
AF (Dewar and Lip, 2007), and therefore anticoagulation Further treatments
should be approached in accordance with the stroke risk Although not discussed in the NICE guidelines for the
stratification (NICE, 2006). management of AF, cardiologists specializing in electro-
The most common reason for the underuse of warfarin physiology may use other therapies where pharmacologi-
is the perception that patients will not comply with the cal treatments have not been successful. One option is the
treatment (DeWilde et al, 2006). While it is important to maze procedure, which uses surgical incisions to interrupt
understand the impact on an individual with dietary the potential multiple wavelet re-entry circuits, in an
restrictions and regular monitoring for INR, it is impor- attempt to prevent or terminate AF (Blaauw et al, 2002).
tant to remember the potentially serious consequences of The radiofrequency ablation of the AV node and implan-
not receiving warfarin when clinical guidelines recom- tation of a permanent pacemaker can be used to eliminate
mend it (Waldo et al, 2005). the arrhythmia (Blaauw et al, 2002). Pulmonary vein abla-
Nurses have an important role to play in ensuring tion is a rapidly developing field, preventing AF recur-
patients are involved in their own care and enabling them rences, and in a few cases, terminating chronic AF
to make informed decisions (Rocca, 2007). Consequently, (Khaykin 2007). Although the procedure is expensive,
empowering patients may reduce anxiety, increase medi- long-term medical treatment of AF may present a more
cation compliance and therefore improve individual out- costly option when the restoration and maintenance of
comes (DeWilde et al, 2006). sinus rhythm has been shown to improve quality of life
and functional performance (Khaykin 2007).
Cost implications of treatment
The hospital cost of AF is hard to quantify as many Conclusions
patients will present with other conditions requiring treat- Chapter 8 of the National Service Framework for Coronary
ment and it is therefore difficult to identify length of stay Heart Disease (DH, 2005) introduced quality require-
and costs specifically related to AF (Lee, 2006). ments to improve standards and introduce individualized
Hagens et al (2004) carried out a cost-effectiveness care for patients with cardiac arrhythmias. The publication
analysis in their randomized controlled trial, RAte of the NICE guidelines for the management of AF (NICE,
Control versus Electrical cardioversion (RACE). The 2006) provided a uniform standard for specific medical
trial looked at 522 participants with recurrent persistent therapies and the treatment of different types of AF.
AF or atrial flutter, over 2.3 years. Costs of care included The guidelines have not been developed as a fully com-
were cardioversions, medications, outpatient visits, hos- prehensible manual, rather guidelines to be tailored to
pital admissions, general practitioner visits, laboratory individual cases (Lip and Rudolf, 2007). Each type of AF
investigations, professional help, informal care and travel has been identified and treatment options provided based
costs. They found rate control to be more cost-effective on the most recent research-based evidence at the time
than rhythm control. (NICE, 2006).
However, it has also been argued that symptomatic AF Through the regular checking of pulses to identify this
requires immediate rhythm control to improve quality of arrhythmia, nurses may be able to further reduce the risk
life, regardless of cost (Lee, 2006). (Dewar and Lip, 2007).
While the NICE (2006) guidelines support rate or It is important for nurses working on cardiovascular
rhythm control, they state that treatment decisions must care to be familiar with these guidelines in their entirety to
be specific to each individual patient’s needs. Effective ensure that patients receive effective evidence-based care.
anticoagulation (where appropriate) in the treatment of 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.
Key Points All treatment provision should be individually discussed
w Atrial fibrillation (AF) is the most common cardiac arrhythmia to ensure patient-centred care (Markides and Schilling,
2003). Providing information enabling each individual
w By understanding medical guidelines nurses can be more proactive to make fully informed decisions increases quality in
in taking on the role of patient’s advocate and ensuring best practice care provision (DH, 2005) and may increase treatment
w Effective care management will have a major impact on the NHS compliance (Hand, 2002).
budget as well as improve the standard of service provision for this The implementation of therapeutic anticoagulation
group of patients 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
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