Atrial fibrillation: An Update On Care Provision

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 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 assessment 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 publication 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 individualized 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.

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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 spontaneously 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

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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 possible, 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

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 palpitations, dyspnoea, fatigue, dizziness, syncope and chest discomfort (NICE, 2006). Some cases of AF are only diagnosed 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 predisposing 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 Confirmed diagnosis of AF

Further investigations and clinical assessment for stroke/thromboembolism

Paroxysmal AF

Persistent AF

Permanent AF

OR

remains symptomatic Rhythm control failure of rhythm control

Figure 1. Treatment strategy decision tree (NICE, 2006)

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Rate control

The NICE guidelines for suitable treatment of atrial fibrillation depend on the clinical type of AF on presentation 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 compromised 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 contribution 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 cardiomyopathy which cause impaired ventricular relaxation (Lim et al, 2004). Along with the increased irregular heart

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Clinical rate, which reduces diastolic filling, this reduced atrial contribution to cardiac output can cause rapid haemodynamic compromise (Mann et al, 2007). In these cases, the NICE guidelines (2006) recommend an emergency electrical cardioversion, following transoesophageal 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 antagonists (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 antagonist. Should a patient develop AF following surgery, the NICE guidelines also set out the path for medical management (Table 2).

Paroxysmal atrial fibrillation As previously identified, paroxysmal AF usually terminates 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)

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 cardioversion, 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 and patient has no coronary heart disease

Class 1c anti-arrhythmic agent (flecainide/propafenone) or sotalol

Standard beta-blocker ineffective and patient has coronary heart disease

Amiodarone or electrical cardioversion

Standard beta-blocker ineffective and patient has poor left ventricular function

Amiodarone or electrical cardioversion

NICE, 2006

NICE, 2006

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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 symptoms, 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).

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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 Unsuitable for cardioversion

w AF secondary to a treated/ 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) recommends the administration of heparin before cardioversion followed by a minimum of 4 weeks therapeutic anticoagulation. 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 treatments 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

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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 exercise, 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 substudy investigated quality of life of 4 060 patients with AF managed under the rate or rhythm control treatments (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 improvement 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 anticoagulation therapy and therefore a reduced risk of silent embolic strokes or decrease in cerebral blood flow (Chung et al, 2005).

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Clinical Limitations of the study include the omission of patients with frequent and severe AF symptoms and the baseline assessment of functional status before randomisation (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, anticoagulation 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 Previous ischaemic stroke/TIA or thromboembolic event

Moderate risk Age ≥65 with no high risk factors

Age ≥ 75 with hypertension, diabetes or vascular disease*

Age <75 with hypertension, diabetes or vascular disease*

Low risk Age <65 with no moderate or high risk factors

Clinical evidence of valve disease, heart failure or impaired LV function on echocardiography**

2 Consider anticoagulation or aspirin

Anticoagulation with warfarin

Contraindications to warfarin?

Aspirin 75 to 300 mg/day if no contraindications

Yes

No Warfarin, target INR 2.5 (range 2.0 to 3.0)

Reassess risk stratification whenever 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)

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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 important to remember the potentially serious consequences of not receiving warfarin when clinical guidelines recommend 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 medication compliance and therefore improve individual outcomes (DeWilde et al, 2006).

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 electrophysiology may use other therapies where pharmacological 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 implantation of a permanent pacemaker can be used to eliminate the arrhythmia (Blaauw et al, 2002). Pulmonary vein ablation is a rapidly developing field, preventing AF recurrences, 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).

Cost implications of treatment The hospital cost of AF is hard to quantify as many patients will present with other conditions requiring treatment 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, hospital 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

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Conclusions Chapter 8 of the National Service Framework for Coronary Heart Disease (DH, 2005) introduced quality requirements 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 comprehensible 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 positioned 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 AFinduced stroke (Fuller and Dudley, 2005). Nurses can make a big difference by acting as advocates ensuring

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