LONG-TERM CONDITIONS
Recognising and managing atrial fibrillation in the community Geraldine Lee, Carolyn Campbell-Cole
Geraldine Lee, Lecturer, Florence Nightingale School of Nursing and Midwifery, King’s College London; Carolyn Campbell-Cole, Arrhythmia Nurse Specialist, King’s College Hospital, London Email: [email protected]
ABSTRACT
Atrial fibrillation (AF) is the most common cardiac arrhythmia and has greater prevalence in the increasing ageing population, with an estimated 10% of those over 80 years having AF. Symptoms associated with AF include palpitations, dizziness, shortness of breath and fatigue. Those presenting with these symptoms need to be investigated and the appropriate treatment should be initiated if AF is detected. For those with AF, there is a significant risk of stroke if patients are not adequately anti-coagulated. This article outlines methods for detecting AF in the community and provides an overview of current treatment options, including the newer anti-coagulant agents. The importance of assessing stroke risk and conveying this risk to those with AF is essential. Community health professionals play an important role in monitoring, treating and managing AF within the community setting and supporting and educating the patient in minimising the risk of serious thromboembolic complications such as stroke.
KEY WORDS
w Atrial fibrillation w Stroke risk w Community w Management w Treatment options
422
including pulmonary vein isolation (commonly known as AF ablation), anti-arrhythmic drugs and the newer anticoagulants used to prevent thromboembolic complications. The article will also outline problems that have been identified by patients in living with AF.
Defining AF AF is defined as disorganised atrial electrical activation and is often accompanied by irregular ventricular response. AF can be a source of significant concern with increasing morbidity and mortality leading to the risk of heart failure, acute systemic stroke and thromboembolism (Lloyd-Jones et al, 2004; Rosamond et al, 2008). There are four different types of AF: paroxysmal (usually self-limiting and terminates within 48 hours), persistent (an episode that lasts longer than 7 days), longstanding persistent (lasting more than 1 year) and permanent AF (where it is not possible to revert to sinus rhythm). The treatment of AF specifically depends upon the type of AF diagnosed. The preferred treatment option for recent systematic onset of sustained AF is cardioversion (i.e. converting an abnormal heart rate using a synchronised shock or pharmaceuticals). However, the success rate may be lower in those cardioverted with permanent AF. It is therefore important that a thorough clinical history is undertaken and the health-care professional identifies the onset of symptoms and the duration of AF to determine the most suitable treatment option.
Symptoms Symptoms associated with AF are often reported as palpitations, dizziness, and shortness of breath, nausea and fatigue. These symptoms can be debilitating and affect individuals’ functional ability (i.e. they are unable to perform their daily activities without feeling ill or symptomatic). If a person has an existing cardiac condition such as heart failure, they may become haemodynamically compromised and require urgent hospitalisation. The earlier AF is detected, the better the outcome. AF is a serious condition and prompt diagnosis and appropriate treatment is imperative to avoid adverse events such as stroke. It is well documented that non-
© 2014 MA Healthcare Ltd
A
trial fibrillation (AF) is the most common cardiac arrhythmia and its prevalence increases with age (Falk, 2001; Lip et al, 2012). Recent statistics indicate that there are now 33.5 million people worldwide living with AF, and more than half of those are over 75 years (Chugh et al, 2014). The risk of developing AF increases with age (doubling every decade) and an estimated 10% of older adults over 80 years have AF (Lee et al, 2012). This places a major burden on health-care systems given that people are living much longer with several comorbid conditions. It is likely that nurses working in the community will treat and manage many people who have AF as one of their comorbid chronic illnesses alongside ischaemic heart disease, respiratory disease and diabetes, for example. The management of AF has changed considerably over the past 10 years. This article aims to provide an overview of current clinical practice, including assessing a person with AF, assessing the risk of stroke and treatment options
British Journal of Community Nursing September 2014 Vol 19, No 9
h Journal of Community Nursing.Downloaded from magonlinelibrary.com by 193.063.226.152 on February 12, 2015. For personal use only. No other uses without permission. . All rights rese
© 2014 MA Healthcare Ltd
LONG-TERM CONDITIONS
valvular AF stroke can be more debilitating than valvular stroke (O’Donnell et al, 2005). It is therefore imperative that stroke risk assessment is done on first identification or diagnosis of AF. However, in those who have not previously been diagnosed with AF, these symptoms are non-specific and could be attributed to any number of conditions. Unexplained or new symptoms need to be reviewed and assessed by a clinician to identify the cause and instigate treatment as appropriate (Lee et al, 2012). AF is often associated with cardiac diseases such as valve disease, hypertension, heart failure and myocardial infarction. AF is also common after cardiac surgery (especially cardiopulmonary artery bypass graft surgery or valve replacement surgery) (Chung, 2000; Booth et al, 2003). Non-cardiac causes of AF include infections that are often seen in older adults (especially chest infections and urinary tract infections), overactive thyroid, and excessive caffeine and alcohol intake. It is imperative that any underlying condition identified is treated and further review of AF is undertaken. For example, it would be expected that once treatment for an infection has been commenced, the heart rhythm is likely to return to sinus rhythm (this would be paroxysmal AF and is usually selfterminating). The longer AF is left untreated, the more likely it is to become permanent AF (as structural changes occur in the heart) and treatment options become more limited (Camm et al, 2010).
majority of individuals with AF cannot articulate exactly what AF is for them, they usually describe it as having ‘an irregular heartbeat’ or having a ‘funny fluttering sensation’. Therefore, it is useful to use these phrases when gathering information from a patient and determining whether they indeed have been previously investigated or diagnosed with AF. Due to cognitive impairment in some older adults, it may be necessary to consult a spouse about symptoms and obtain an accurate medical history. However, spouses may not always be accurate as differences in perceptions have previously been seen in cardiac patients and their spouses (Lee, 2008).
Methods for identifying AF
Pulmonary vein isolation
For high uptake and easy identification of AF, opportunistic screening should be practiced, especially in the form of a peripheral pulse check followed by confirmation of a diagnosis with a 12-lead electrocardiogram (ECG). Common opportunities for these checks occur in hypertension, diabetes and asthma clinics, and home visits or consultations. There is sometimes a difference between each beat, with every second beat feeling ‘weaker’ than the previous one (known as pulsus alternans). Although an irregular pulse is a strong indicator of an arrhythmia, a 12-lead ECG must be undertaken to record the electrical activity in the heart and confirm the presence of AF. In those with AF, the 12-lead ECG will show an absence of p-waves (representing atrial activity) or very small p-waves (i.e. the atria fibrillating and not beating properly). Depending on other signs and symptoms reported by the patient, clinicians may also order an echocardiogram to determine cardiac function and rule out any myocardial damage. A complete physical assessment should be undertaken along with a detailed medical history so that a clear picture of the onset of symptoms and how they are affecting the individual can be documented (Box 1). Often a cardiology referral will be made and, if there is no evidence of AF on a 12-lead ECG, a Holter monitor may be ordered, which can record continuously for 24 hours and up to 7 days. This will help to identify rate and rhythm and also often documents symptom correlation. Analysis of the heart rhythm will assist in the identification of the type of AF. In the author’s experience, the
Treatment options have also changed dramatically with the introduction of pulmonary vein isolation (also known as AF ablation). This procedure involves an incision to the femoral artery and placing a catheter in the heart. The procedure can be done under local or general anaesthetic and patients can be discharged in 48 hours following the ablation. AF ablation has shown benefits with improved quality of life in those who have undergone the procedure (Carnlöf et al, 2010). AF ablation is not always successful, but a repeat procedure can be undertaken. Where it is not possible to ablate the pulmonary veins and not possible to revert to sinus rhythm (i.e. permanent AF), assessment of stroke risk and initiation of anti-arrhythmics and anticoagulation is required.
Treatment of AF and reducing stroke risk Treatment of AF depends on the duration of symptoms and their severity. Historically, digoxin was commonly used to control the AF rate and was preferable in older people (Lee, 2007). Unfortunately, digoxin has a narrow therapeutic range and is not recommended for those with existing renal disease. To control the rate of AF, beta-blockers are often prescribed as the first line of treatment with the aim of relieving AF symptoms and reducing the resting heart rate. For those who remain symptomatic, other anti-arrhythmics such as sotalol and flecainide may need to be considered, although patients can become intolerant to them over time (Lee, 2013).
Anti-coagulants Anti-coagulants are the mainstay of stroke prevention in those with AF and stroke prevention is one of the main treatment goals in AF. For decades, warfarin was the only anticoagulant and has a narrow therapeutic range. As such, it requires regular blood tests to ensure the levels in the blood are appropriate. A high International Normalised Ratio (INR) can cause internal bleeding, whereas a low level is sub-therapeutic and increases the risk of thromboembolic complications. The ideal INR for most people with AF is 2.0 to 3.0. The main problem for patients taking warfarin is that it interacts with a plethora of prescribed and overthe-counter medication and also many common foods
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LONG-TERM CONDITIONS
w Regularly screen and assess older adults (65 years and older) for AF by
checking their pulse and in those with an irregular pulse, a 12-lead ECG be performed. Opportunities to screen for AF should be taken.
w Where possible, identify the cause of AF and ensure a comprehensive
clinical assessment and medical history is recorded including family history, alcohol intake, and previous episodes of palpitations.
w For older patients presenting with multiple medical problems, a comprehensive clinical geriatric assessment should be undertaken and functional and cognitive impairment documented.
Table 1. The CHA2DS2-VASc score Condition
Points
Congestive heart failure/left ventricular failure
1
Hypertension (consistently greater than 140/90 mmHg or treated hypertension on medication)
1
Age ≥ 75 years
2
Diabetes mellitus
1
Stroke/TIA/thrombo-embolism
2
Vascular disease
1
Age 65–74 years
1
Sex category (female sex)
1
Maximum score
9
Table 2. Clinical characteristics of the HASBLED bleeding risk score Letter
Clinical characteristic
Points awarded
H
Hypertension
1
A
Abnormal renal and liver function (1 point each)
1 or 2
S
Stroke
1
B
Bleeding
1
L
Labile INRs
1
E
Elderly
1
D
Drugs or alcohol (1 point each)
1 or 2
Maximum possible score is 9
424
(and, perhaps more importantly, alcohol). It is notoriously hard to manage and patients can often have two to three blood tests a week until optimal INR is achieved (Lee et al, 2012). Until around 5 years ago, there were no alternatives until the introduction of the new oral anti-coagulants. The newer anticoagulants (known as Xa inhibitors) work on a different pathway to warfarin (a vitamin K antagonist) and inhibit factor Xa on the clotting cascade. Examples of the newer agents include rivaroxaban, dabigitran and apixaban. Due to their mechanism of action, unlike warfarin, patients do not need regular blood tests. For elderly patients with multiple comorbidities and limited mobility, this can be a very important factor. Initial results comparing the newer agents suggested that they should be used with caution in the elderly (i.e. over 75 years), although more recent studies have stated that there is a significant reduction in risk of death with these new agents compared to warfarin (Mega, 2011; Halperin et al, 2014). It is anticipated that drugs to reverse the effects of the newer anti-coagulants will be available within the next 2 years. Recent guidelines released by the National Institute of Health and Care Excellence (NICE) do not recommend aspirin for stroke prevention in AF (NICE, 2014).
Stroke risk Treatment also depends on the individual’s stroke risk, and this needs to be assessed before initiation of treatment. Physicians should apply a stroke risk score and, in Europe, the most commonly used risk score is the CHA2DS2-VASc score (Lip and Halperin, 2010). As outlined in Table 1, points are assigned for other conditions, older age and female gender. The European Society of Cardiology recommends warfarin or other anti-coagulants for those with a score of 2 or more (Camm et al, 2010). It is important that all patients are assessed using a recognised stroke risk score and that the appropriate treatment is commenced to reduce the risk of stroke. For those with a score of zero, no anticoagulants should be prescribed and the latest recommendation is that aspirin should not be prescribed. Although it has previously been common practice, there is no evidence to support its use now in the management of AF (NICE, 2014).
Complications of AF: how real is the risk? Complications associated with AF are thromboembolic issues such as stroke and heart failure and, in severe cases, death. Many people with AF do not have any symptoms and, consequently, may not be aware of the risk of stroke. The first time that some people become aware of their AF is when they are admitted to hospital with a stroke and the treating clinician asks them if they knew they had AF. The risk of stroke is increased five-fold in the presence of AF, and this risk needs to be discussed with each AF patient and their family (Lee et al, 2012). The risk of stroke is also dramatically increased in older adults, with one study report-
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Box 1. Recommendations for assessing in atrial fibrillation
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LONG-TERM CONDITIONS
ing a three-fold or greater risk of stroke (risk ratio 3.3) in those over 65 years (Inoue and Atarashi, 2000). A study of patients presenting to the emergency department with stroke revealed that 25% experienced AF and 17% of deaths were attributable to AF (Marini et al, 2005). It can be hypothesised that if AF had been detected earlier, up to a quarter of the strokes could have been prevented. It has been reported that older adults are often not prescribed anti-coagulants, despite the need for them (Tulner et al, 2010). Anti-coagulants should also be prescribed in those who have had a previous stroke and transient ischemic attacks (TIAs), although under-utilisation in these vulnerable patients has also been noted (Weimar et al, 2008). One of the concerns for those experiencing AF is the risk of bleeding. Given that many individuals have multiple comorbidities, there is a need to assess the risk of bleeding in those taking anti-coagulants. To assist health professionals, the HAS-BLED risk score can easily be performed (Table 2) (Lip et al, 2010). The score takes several clinical characteristics into consideration: hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly and is an accepted and reliable method of assessing bleeding risk. When using the HAS-BLED score, a score of 3 or more alerts the clinician to be cautious in prescribing anti-coagulants and reinforces the need for close regular monitoring.
© 2014 MA Healthcare Ltd
Living with AF The key responsiblities of the health professional are to identify and investigate AF and then initiate and monitor treatment. A further element of the practitioner’s role is to educate the patient about AF and how to manage it. The main concerns of the patient and their family may be related to the side effects of medications, the risk of bleeding if prescribed warfarin and being unable to perform daily activities due to their AF symptoms. Unfortunately, to date, there is a paucity of research into patients’ experiences of living with AF. However, one study revealed that patients had daily concerns about their AF, were illinformed about factors that could worsen their AF symptoms, and limited their daily activities to avoid inducing symptoms (Ekblad et al, 2013). This study is one of the first to explore the patient and their family’s perceptions of living with AF and to suggest that increased education needs to be provided by health professionals. Anxiety is common in those with arrhythmias and this needs to be assessed before undertaking any education in AF patients (Lee, 2013; Lee and Boyde, 2012). Although health professionals have an important role to play in educating and supporting patients and their families, there are specific organisations that can offer support to those with AF. There are many groups for AF patients in the UK including Arrhythmia Alliance (www.heartrhythmcharity. org.uk) and the AF Association (www.atrialfibrillation. org.uk). The Arrhythmia Alliance website aims to help
patients and their families identify local support groups. They also offer a 24-hour helpline. These associations are also useful for health professionals and hold regular updates across the country as well as an annual conference.
Conclusion AF is a significant cause of morbidity and mortality in the community, and a modifiable risk factor for stroke. For those diagnosed with AF, medication adherence and the importance of anti-coagulation monitoring needs to be conveyed to patients and their families. There have been significant developments in all aspects of AF treatment and its early detection and optimal management can prevent serious complications such as stroke. Community nurses and other community-based health professionals are in an ideal position to screen their clients for AF and ensure appropriate follow-up is organised. BJCN Booth JV, Phillips-Bute B, McCants CB et al (2003) Low serum magnesium level predicts major adverse cardiac events after coronary artery bypass graft surgery. Am Heart J 145(6): 1108–13 Camm AJ, Lip GY, Schotten U et al (2010) Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 31(19): 2369–429. doi: 10.1093/eurheartj/ehq278 Carnlöf C, Insulander P, Pettersson PH, Jensen-Urstad M, Fossum B (2010) Health-related quality of life in patients with atrial fibrillation undergoing pulmonary vein isolation, before and after treatment. Eur J Cardiovasc Nurs 9(1): 45–9. doi: 10.1016/j.ejcnurse.2009.09.002 Chugh SS, Havmoeller R, Narayanan K et al (2014) Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 129(8): 837–47. doi: 10.1161/CIRCULATIONAHA.113.005119 Chung MK (2000) Cardiac surgery: postoperative arrhythmias. Crit Care Med 28(10 Suppl): N136–44 Ekblad H, Ronning H, Fridlund B, Malm D (2013) Patients’ well-being: experience and actions in their preventing and handling of atrial fibrillation. Eur J Cardiovasc Nurs 12(2): 132–9. doi: 10.1177/1474515112457132 Falk RH (2001) Atrial fibrillation. NEJM 344(14): 1067–78 Halperin JL, Hankley GJ, Wojdyla DM et al (2014) Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the ROCKET AF trial. Circulation 130(2):138–46. doi: 10.1161/CIRCULATIONAHA
British Journal of Community Nursing September 2014 Vol 19, No 9
KEY POINTS
w Atrial fibrillation (AF) is a serious condition that needs to be closely monitored w Given its prevalence in older people, opportunistic screening should be undertaken when possible
w AF greatly increases the risk of stroke and increases the risk of premature death
w Those diagnosed with AF should be assessed for stroke risk using the using the CHA2DS2-VASc score and prescribed oral anti-coagulants
w There is a risk of bleeding in those prescribed anti-coagulants and it can easily be assessed using the HASBLED score
w Community nurses need to ensure that those with AF are educated about stroke risk versus the benefits of anti-coagulants and the importance of taking their anti-coagulants
w For those presenting on warfarin, ensure INR is within the desired therapeutic range and the patient is educated about the importance of this
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LONG-TERM CONDITIONS
Inoue H, Atarashi H (2000) Risk factors for thromboembolism in patients with paroxysmal atrial fibrillation. Am J Cardiol 86(8): 852–5 Lee G (2007) A review of the literature on atrial fibrillation: rate reversion or control? J Clin Nurs 16(1): 77–83 Lee GA (2008) Patient and spouse perceived quality of life five years after coronary artery bypass graft surgery. Open Nurs J 2: 63–7. doi: 10.2174/1874434600802010063 Lee GA (2013) Always fibrillating: is your patient handling their atrial fibrillation? Eur Cardiovasc Nurs J 12(2): 107–8. doi: 10.1177/1474515112468631 Lee GA, Boyde M (2012) Challenges in educating a patient with severe anxiety and depression. J Nurs Educ Pract 2(4): 160–6 Lee GA, Stub D, Ling H (2012) Atrial fibrillation in the elderly: not a benign condition. Int Emerg Nurs 20: 221–7. doi: 10.1016/j.ienj.2012.05.003 Lip GY, Halperin JL (2010) Improving stroke risk stratification in atrial fibrillation. Am J Med 123(6): 484–8. doi: 10.1016/j.amjmed.2009.12.013 Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro heart survey on atrial fibrillation. Chest 137(2): 263–72. doi: 10.1378/chest.09-1584 Lip GYH, Frison L, Halperin JL, Lane DA (2011) Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 57(2): 173–80. doi: 10.1016/j.jacc.2010.09.024 Lip GY, Tse HF, Lane DA (2012) Seminar: management of atrial fibrillation. Lancet 379(9816): 648–61. doi:10.1016/S0140-6736(07)61300-2
Lloyd-Jones DM, Wang TJ, Leip EP et al (2004) Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation 110(9): 1042–6 Marini C, De Santis F, Sacco S, Russo T, Olivieri L, Totaro R (2005) Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 36(6): 1115–19 Mega JL (2011) A new era for anticoagulation in atrial fibrillation. N Engl J Med 365(11): 1052–4. doi: 10.1056/NEJMe1109748 National Institute of Health and Care Excellence (2014) Atrial Fibrillation: The Management of Atrial Fibrillation. http://tinyurl.com/mbcfjyq (accessed July 19 2014) O’Donnell M, Agnelli G, Weitz JI (2005) Emerging therapies for stroke prevention in atrial fibrillation. Eur Heart J 7(suppl C): C19–C27. doi: 10.1093/ eurheartj/sui016 Rosamond W, Flegal K, Furie K et al (2008) Heart disease and stroke statistics – 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 117(4): e25– e146 Tulner LR, Van Campen JP, Kuper IM, Gijsen GJ, Koks CH, Mac Gillavry MR (2010) Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study. Drugs Aging 27(1): 39–50 Weimar C, Benemann J, Katsarava Z, Weber R, Diener HC (2008) Adherence and quality of oral anticoagulation in cerebrovascular disease patients with atrial fibrillation. Euro Neuro 60(3): 142–8. doi: 10.1159/000144085
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British Journal of Community Nursing September 2014 Vol 19, No 9
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Recognising and managing atrial fibrillation in the community Geraldine Lee, Carolyn Campbell-Cole
Geraldine Lee, Lecturer, Florence Nightingale School of Nursing and Midwifery, King’s College London; Carolyn Campbell-Cole, Arrhythmia Nurse Specialist, King’s College Hospital, London Email: [email protected]
ABSTRACT
Atrial fibrillation (AF) is the most common cardiac arrhythmia and has greater prevalence in the increasing ageing population, with an estimated 10% of those over 80 years having AF. Symptoms associated with AF include palpitations, dizziness, shortness of breath and fatigue. Those presenting with these symptoms need to be investigated and the appropriate treatment should be initiated if AF is detected. For those with AF, there is a significant risk of stroke if patients are not adequately anti-coagulated. This article outlines methods for detecting AF in the community and provides an overview of current treatment options, including the newer anti-coagulant agents. The importance of assessing stroke risk and conveying this risk to those with AF is essential. Community health professionals play an important role in monitoring, treating and managing AF within the community setting and supporting and educating the patient in minimising the risk of serious thromboembolic complications such as stroke.
KEY WORDS
w Atrial fibrillation w Stroke risk w Community w Management w Treatment options
422
including pulmonary vein isolation (commonly known as AF ablation), anti-arrhythmic drugs and the newer anticoagulants used to prevent thromboembolic complications. The article will also outline problems that have been identified by patients in living with AF.
Defining AF AF is defined as disorganised atrial electrical activation and is often accompanied by irregular ventricular response. AF can be a source of significant concern with increasing morbidity and mortality leading to the risk of heart failure, acute systemic stroke and thromboembolism (Lloyd-Jones et al, 2004; Rosamond et al, 2008). There are four different types of AF: paroxysmal (usually self-limiting and terminates within 48 hours), persistent (an episode that lasts longer than 7 days), longstanding persistent (lasting more than 1 year) and permanent AF (where it is not possible to revert to sinus rhythm). The treatment of AF specifically depends upon the type of AF diagnosed. The preferred treatment option for recent systematic onset of sustained AF is cardioversion (i.e. converting an abnormal heart rate using a synchronised shock or pharmaceuticals). However, the success rate may be lower in those cardioverted with permanent AF. It is therefore important that a thorough clinical history is undertaken and the health-care professional identifies the onset of symptoms and the duration of AF to determine the most suitable treatment option.
Symptoms Symptoms associated with AF are often reported as palpitations, dizziness, and shortness of breath, nausea and fatigue. These symptoms can be debilitating and affect individuals’ functional ability (i.e. they are unable to perform their daily activities without feeling ill or symptomatic). If a person has an existing cardiac condition such as heart failure, they may become haemodynamically compromised and require urgent hospitalisation. The earlier AF is detected, the better the outcome. AF is a serious condition and prompt diagnosis and appropriate treatment is imperative to avoid adverse events such as stroke. It is well documented that non-
© 2014 MA Healthcare Ltd
A
trial fibrillation (AF) is the most common cardiac arrhythmia and its prevalence increases with age (Falk, 2001; Lip et al, 2012). Recent statistics indicate that there are now 33.5 million people worldwide living with AF, and more than half of those are over 75 years (Chugh et al, 2014). The risk of developing AF increases with age (doubling every decade) and an estimated 10% of older adults over 80 years have AF (Lee et al, 2012). This places a major burden on health-care systems given that people are living much longer with several comorbid conditions. It is likely that nurses working in the community will treat and manage many people who have AF as one of their comorbid chronic illnesses alongside ischaemic heart disease, respiratory disease and diabetes, for example. The management of AF has changed considerably over the past 10 years. This article aims to provide an overview of current clinical practice, including assessing a person with AF, assessing the risk of stroke and treatment options
British Journal of Community Nursing September 2014 Vol 19, No 9
h Journal of Community Nursing.Downloaded from magonlinelibrary.com by 193.063.226.152 on February 12, 2015. For personal use only. No other uses without permission. . All rights rese
© 2014 MA Healthcare Ltd
LONG-TERM CONDITIONS
valvular AF stroke can be more debilitating than valvular stroke (O’Donnell et al, 2005). It is therefore imperative that stroke risk assessment is done on first identification or diagnosis of AF. However, in those who have not previously been diagnosed with AF, these symptoms are non-specific and could be attributed to any number of conditions. Unexplained or new symptoms need to be reviewed and assessed by a clinician to identify the cause and instigate treatment as appropriate (Lee et al, 2012). AF is often associated with cardiac diseases such as valve disease, hypertension, heart failure and myocardial infarction. AF is also common after cardiac surgery (especially cardiopulmonary artery bypass graft surgery or valve replacement surgery) (Chung, 2000; Booth et al, 2003). Non-cardiac causes of AF include infections that are often seen in older adults (especially chest infections and urinary tract infections), overactive thyroid, and excessive caffeine and alcohol intake. It is imperative that any underlying condition identified is treated and further review of AF is undertaken. For example, it would be expected that once treatment for an infection has been commenced, the heart rhythm is likely to return to sinus rhythm (this would be paroxysmal AF and is usually selfterminating). The longer AF is left untreated, the more likely it is to become permanent AF (as structural changes occur in the heart) and treatment options become more limited (Camm et al, 2010).
majority of individuals with AF cannot articulate exactly what AF is for them, they usually describe it as having ‘an irregular heartbeat’ or having a ‘funny fluttering sensation’. Therefore, it is useful to use these phrases when gathering information from a patient and determining whether they indeed have been previously investigated or diagnosed with AF. Due to cognitive impairment in some older adults, it may be necessary to consult a spouse about symptoms and obtain an accurate medical history. However, spouses may not always be accurate as differences in perceptions have previously been seen in cardiac patients and their spouses (Lee, 2008).
Methods for identifying AF
Pulmonary vein isolation
For high uptake and easy identification of AF, opportunistic screening should be practiced, especially in the form of a peripheral pulse check followed by confirmation of a diagnosis with a 12-lead electrocardiogram (ECG). Common opportunities for these checks occur in hypertension, diabetes and asthma clinics, and home visits or consultations. There is sometimes a difference between each beat, with every second beat feeling ‘weaker’ than the previous one (known as pulsus alternans). Although an irregular pulse is a strong indicator of an arrhythmia, a 12-lead ECG must be undertaken to record the electrical activity in the heart and confirm the presence of AF. In those with AF, the 12-lead ECG will show an absence of p-waves (representing atrial activity) or very small p-waves (i.e. the atria fibrillating and not beating properly). Depending on other signs and symptoms reported by the patient, clinicians may also order an echocardiogram to determine cardiac function and rule out any myocardial damage. A complete physical assessment should be undertaken along with a detailed medical history so that a clear picture of the onset of symptoms and how they are affecting the individual can be documented (Box 1). Often a cardiology referral will be made and, if there is no evidence of AF on a 12-lead ECG, a Holter monitor may be ordered, which can record continuously for 24 hours and up to 7 days. This will help to identify rate and rhythm and also often documents symptom correlation. Analysis of the heart rhythm will assist in the identification of the type of AF. In the author’s experience, the
Treatment options have also changed dramatically with the introduction of pulmonary vein isolation (also known as AF ablation). This procedure involves an incision to the femoral artery and placing a catheter in the heart. The procedure can be done under local or general anaesthetic and patients can be discharged in 48 hours following the ablation. AF ablation has shown benefits with improved quality of life in those who have undergone the procedure (Carnlöf et al, 2010). AF ablation is not always successful, but a repeat procedure can be undertaken. Where it is not possible to ablate the pulmonary veins and not possible to revert to sinus rhythm (i.e. permanent AF), assessment of stroke risk and initiation of anti-arrhythmics and anticoagulation is required.
Treatment of AF and reducing stroke risk Treatment of AF depends on the duration of symptoms and their severity. Historically, digoxin was commonly used to control the AF rate and was preferable in older people (Lee, 2007). Unfortunately, digoxin has a narrow therapeutic range and is not recommended for those with existing renal disease. To control the rate of AF, beta-blockers are often prescribed as the first line of treatment with the aim of relieving AF symptoms and reducing the resting heart rate. For those who remain symptomatic, other anti-arrhythmics such as sotalol and flecainide may need to be considered, although patients can become intolerant to them over time (Lee, 2013).
Anti-coagulants Anti-coagulants are the mainstay of stroke prevention in those with AF and stroke prevention is one of the main treatment goals in AF. For decades, warfarin was the only anticoagulant and has a narrow therapeutic range. As such, it requires regular blood tests to ensure the levels in the blood are appropriate. A high International Normalised Ratio (INR) can cause internal bleeding, whereas a low level is sub-therapeutic and increases the risk of thromboembolic complications. The ideal INR for most people with AF is 2.0 to 3.0. The main problem for patients taking warfarin is that it interacts with a plethora of prescribed and overthe-counter medication and also many common foods
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LONG-TERM CONDITIONS
w Regularly screen and assess older adults (65 years and older) for AF by
checking their pulse and in those with an irregular pulse, a 12-lead ECG be performed. Opportunities to screen for AF should be taken.
w Where possible, identify the cause of AF and ensure a comprehensive
clinical assessment and medical history is recorded including family history, alcohol intake, and previous episodes of palpitations.
w For older patients presenting with multiple medical problems, a comprehensive clinical geriatric assessment should be undertaken and functional and cognitive impairment documented.
Table 1. The CHA2DS2-VASc score Condition
Points
Congestive heart failure/left ventricular failure
1
Hypertension (consistently greater than 140/90 mmHg or treated hypertension on medication)
1
Age ≥ 75 years
2
Diabetes mellitus
1
Stroke/TIA/thrombo-embolism
2
Vascular disease
1
Age 65–74 years
1
Sex category (female sex)
1
Maximum score
9
Table 2. Clinical characteristics of the HASBLED bleeding risk score Letter
Clinical characteristic
Points awarded
H
Hypertension
1
A
Abnormal renal and liver function (1 point each)
1 or 2
S
Stroke
1
B
Bleeding
1
L
Labile INRs
1
E
Elderly
1
D
Drugs or alcohol (1 point each)
1 or 2
Maximum possible score is 9
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(and, perhaps more importantly, alcohol). It is notoriously hard to manage and patients can often have two to three blood tests a week until optimal INR is achieved (Lee et al, 2012). Until around 5 years ago, there were no alternatives until the introduction of the new oral anti-coagulants. The newer anticoagulants (known as Xa inhibitors) work on a different pathway to warfarin (a vitamin K antagonist) and inhibit factor Xa on the clotting cascade. Examples of the newer agents include rivaroxaban, dabigitran and apixaban. Due to their mechanism of action, unlike warfarin, patients do not need regular blood tests. For elderly patients with multiple comorbidities and limited mobility, this can be a very important factor. Initial results comparing the newer agents suggested that they should be used with caution in the elderly (i.e. over 75 years), although more recent studies have stated that there is a significant reduction in risk of death with these new agents compared to warfarin (Mega, 2011; Halperin et al, 2014). It is anticipated that drugs to reverse the effects of the newer anti-coagulants will be available within the next 2 years. Recent guidelines released by the National Institute of Health and Care Excellence (NICE) do not recommend aspirin for stroke prevention in AF (NICE, 2014).
Stroke risk Treatment also depends on the individual’s stroke risk, and this needs to be assessed before initiation of treatment. Physicians should apply a stroke risk score and, in Europe, the most commonly used risk score is the CHA2DS2-VASc score (Lip and Halperin, 2010). As outlined in Table 1, points are assigned for other conditions, older age and female gender. The European Society of Cardiology recommends warfarin or other anti-coagulants for those with a score of 2 or more (Camm et al, 2010). It is important that all patients are assessed using a recognised stroke risk score and that the appropriate treatment is commenced to reduce the risk of stroke. For those with a score of zero, no anticoagulants should be prescribed and the latest recommendation is that aspirin should not be prescribed. Although it has previously been common practice, there is no evidence to support its use now in the management of AF (NICE, 2014).
Complications of AF: how real is the risk? Complications associated with AF are thromboembolic issues such as stroke and heart failure and, in severe cases, death. Many people with AF do not have any symptoms and, consequently, may not be aware of the risk of stroke. The first time that some people become aware of their AF is when they are admitted to hospital with a stroke and the treating clinician asks them if they knew they had AF. The risk of stroke is increased five-fold in the presence of AF, and this risk needs to be discussed with each AF patient and their family (Lee et al, 2012). The risk of stroke is also dramatically increased in older adults, with one study report-
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Box 1. Recommendations for assessing in atrial fibrillation
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LONG-TERM CONDITIONS
ing a three-fold or greater risk of stroke (risk ratio 3.3) in those over 65 years (Inoue and Atarashi, 2000). A study of patients presenting to the emergency department with stroke revealed that 25% experienced AF and 17% of deaths were attributable to AF (Marini et al, 2005). It can be hypothesised that if AF had been detected earlier, up to a quarter of the strokes could have been prevented. It has been reported that older adults are often not prescribed anti-coagulants, despite the need for them (Tulner et al, 2010). Anti-coagulants should also be prescribed in those who have had a previous stroke and transient ischemic attacks (TIAs), although under-utilisation in these vulnerable patients has also been noted (Weimar et al, 2008). One of the concerns for those experiencing AF is the risk of bleeding. Given that many individuals have multiple comorbidities, there is a need to assess the risk of bleeding in those taking anti-coagulants. To assist health professionals, the HAS-BLED risk score can easily be performed (Table 2) (Lip et al, 2010). The score takes several clinical characteristics into consideration: hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly and is an accepted and reliable method of assessing bleeding risk. When using the HAS-BLED score, a score of 3 or more alerts the clinician to be cautious in prescribing anti-coagulants and reinforces the need for close regular monitoring.
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Living with AF The key responsiblities of the health professional are to identify and investigate AF and then initiate and monitor treatment. A further element of the practitioner’s role is to educate the patient about AF and how to manage it. The main concerns of the patient and their family may be related to the side effects of medications, the risk of bleeding if prescribed warfarin and being unable to perform daily activities due to their AF symptoms. Unfortunately, to date, there is a paucity of research into patients’ experiences of living with AF. However, one study revealed that patients had daily concerns about their AF, were illinformed about factors that could worsen their AF symptoms, and limited their daily activities to avoid inducing symptoms (Ekblad et al, 2013). This study is one of the first to explore the patient and their family’s perceptions of living with AF and to suggest that increased education needs to be provided by health professionals. Anxiety is common in those with arrhythmias and this needs to be assessed before undertaking any education in AF patients (Lee, 2013; Lee and Boyde, 2012). Although health professionals have an important role to play in educating and supporting patients and their families, there are specific organisations that can offer support to those with AF. There are many groups for AF patients in the UK including Arrhythmia Alliance (www.heartrhythmcharity. org.uk) and the AF Association (www.atrialfibrillation. org.uk). The Arrhythmia Alliance website aims to help
patients and their families identify local support groups. They also offer a 24-hour helpline. These associations are also useful for health professionals and hold regular updates across the country as well as an annual conference.
Conclusion AF is a significant cause of morbidity and mortality in the community, and a modifiable risk factor for stroke. For those diagnosed with AF, medication adherence and the importance of anti-coagulation monitoring needs to be conveyed to patients and their families. There have been significant developments in all aspects of AF treatment and its early detection and optimal management can prevent serious complications such as stroke. Community nurses and other community-based health professionals are in an ideal position to screen their clients for AF and ensure appropriate follow-up is organised. BJCN Booth JV, Phillips-Bute B, McCants CB et al (2003) Low serum magnesium level predicts major adverse cardiac events after coronary artery bypass graft surgery. Am Heart J 145(6): 1108–13 Camm AJ, Lip GY, Schotten U et al (2010) Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 31(19): 2369–429. doi: 10.1093/eurheartj/ehq278 Carnlöf C, Insulander P, Pettersson PH, Jensen-Urstad M, Fossum B (2010) Health-related quality of life in patients with atrial fibrillation undergoing pulmonary vein isolation, before and after treatment. Eur J Cardiovasc Nurs 9(1): 45–9. doi: 10.1016/j.ejcnurse.2009.09.002 Chugh SS, Havmoeller R, Narayanan K et al (2014) Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 129(8): 837–47. doi: 10.1161/CIRCULATIONAHA.113.005119 Chung MK (2000) Cardiac surgery: postoperative arrhythmias. Crit Care Med 28(10 Suppl): N136–44 Ekblad H, Ronning H, Fridlund B, Malm D (2013) Patients’ well-being: experience and actions in their preventing and handling of atrial fibrillation. Eur J Cardiovasc Nurs 12(2): 132–9. doi: 10.1177/1474515112457132 Falk RH (2001) Atrial fibrillation. NEJM 344(14): 1067–78 Halperin JL, Hankley GJ, Wojdyla DM et al (2014) Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the ROCKET AF trial. Circulation 130(2):138–46. doi: 10.1161/CIRCULATIONAHA
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KEY POINTS
w Atrial fibrillation (AF) is a serious condition that needs to be closely monitored w Given its prevalence in older people, opportunistic screening should be undertaken when possible
w AF greatly increases the risk of stroke and increases the risk of premature death
w Those diagnosed with AF should be assessed for stroke risk using the using the CHA2DS2-VASc score and prescribed oral anti-coagulants
w There is a risk of bleeding in those prescribed anti-coagulants and it can easily be assessed using the HASBLED score
w Community nurses need to ensure that those with AF are educated about stroke risk versus the benefits of anti-coagulants and the importance of taking their anti-coagulants
w For those presenting on warfarin, ensure INR is within the desired therapeutic range and the patient is educated about the importance of this
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Inoue H, Atarashi H (2000) Risk factors for thromboembolism in patients with paroxysmal atrial fibrillation. Am J Cardiol 86(8): 852–5 Lee G (2007) A review of the literature on atrial fibrillation: rate reversion or control? J Clin Nurs 16(1): 77–83 Lee GA (2008) Patient and spouse perceived quality of life five years after coronary artery bypass graft surgery. Open Nurs J 2: 63–7. doi: 10.2174/1874434600802010063 Lee GA (2013) Always fibrillating: is your patient handling their atrial fibrillation? Eur Cardiovasc Nurs J 12(2): 107–8. doi: 10.1177/1474515112468631 Lee GA, Boyde M (2012) Challenges in educating a patient with severe anxiety and depression. J Nurs Educ Pract 2(4): 160–6 Lee GA, Stub D, Ling H (2012) Atrial fibrillation in the elderly: not a benign condition. Int Emerg Nurs 20: 221–7. doi: 10.1016/j.ienj.2012.05.003 Lip GY, Halperin JL (2010) Improving stroke risk stratification in atrial fibrillation. Am J Med 123(6): 484–8. doi: 10.1016/j.amjmed.2009.12.013 Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro heart survey on atrial fibrillation. Chest 137(2): 263–72. doi: 10.1378/chest.09-1584 Lip GYH, Frison L, Halperin JL, Lane DA (2011) Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 57(2): 173–80. doi: 10.1016/j.jacc.2010.09.024 Lip GY, Tse HF, Lane DA (2012) Seminar: management of atrial fibrillation. Lancet 379(9816): 648–61. doi:10.1016/S0140-6736(07)61300-2
Lloyd-Jones DM, Wang TJ, Leip EP et al (2004) Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation 110(9): 1042–6 Marini C, De Santis F, Sacco S, Russo T, Olivieri L, Totaro R (2005) Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 36(6): 1115–19 Mega JL (2011) A new era for anticoagulation in atrial fibrillation. N Engl J Med 365(11): 1052–4. doi: 10.1056/NEJMe1109748 National Institute of Health and Care Excellence (2014) Atrial Fibrillation: The Management of Atrial Fibrillation. http://tinyurl.com/mbcfjyq (accessed July 19 2014) O’Donnell M, Agnelli G, Weitz JI (2005) Emerging therapies for stroke prevention in atrial fibrillation. Eur Heart J 7(suppl C): C19–C27. doi: 10.1093/ eurheartj/sui016 Rosamond W, Flegal K, Furie K et al (2008) Heart disease and stroke statistics – 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 117(4): e25– e146 Tulner LR, Van Campen JP, Kuper IM, Gijsen GJ, Koks CH, Mac Gillavry MR (2010) Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study. Drugs Aging 27(1): 39–50 Weimar C, Benemann J, Katsarava Z, Weber R, Diener HC (2008) Adherence and quality of oral anticoagulation in cerebrovascular disease patients with atrial fibrillation. Euro Neuro 60(3): 142–8. doi: 10.1159/000144085
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