Atrial Fibrillation:
Assessment (A) Noticing:
Risk Factors: Increased age, hypertension, diabetes, obesity, valvular heart disease,
heart failure, obstructive sleep apnea, alcohol abuse, hyperthyroidism, myocardial
infarction, smoking, exercise, cardiothoracic surgery, increased pulse pressure,
European ancestry, and family history.
Some patients are asymptomatic. Others experience palpitations and clinical
manifestations of heart failure (shortness of breath, hypotension, dyspnea on
exertion, fatigue). Patients with atrial fibrillation may exhibit a pulse deficit - a
numeric difference between apical and radial pulse rates. The shorter time in
diastole reduces the time available for coronary artery perfusion, thereby increasing
the risk of myocardial ischemia with the onset of anginal symptoms.
Obtain a history and physical examination that identifies the onset and nature of
signs and symptoms, including their frequency, duration and any precipitating
factors, and any response to medications. A 12-lead ECG is performed to verify the
atrial fibrillation rhythm, as well as to identify the presence of left ventricular
hypertrophy, bundle branch block, prior myocardial ischemia, or other arrhythmias.
Analysis (D = Diagnosis) Interpreting:
Atrial rate: 300 to 600 beats per minute
Ventricular rate: 120 to 200 beats per minute
Ventricular and atrial rhythm: highly irregular
P wave: no discernable P wave
PR interval: can’t be measured
P:QRS Interval: Many:1
A transesophageal echocardiogram can identify the presence of valvular heart
disease, provide information about LV and RV size and function, RV pressures (to
identify pulmonary hypertension, which may exist concomitant with atrial
fibrillation), LV hypertrophy, and presence of left atrial thrombi.
Blood tests to screen for diseases that are known risks for atrial fibrillation including
thyroid, renal, and hepatic function.
Planning/Outcomes (P) Anticipate/Prioritize:
Medical management revolves around preventing embolic events such as stroke
with anticoagulant medications, controlling the ventricular rate of response with
antiarrhythmic agents, and treating the arrhythmia as indicated so that it is
converted to a sinus rhythm (cardioversion).
Prevent heart failure, myocardial ischemia, and embolic events such as stroke.
Priorities:
1. Repeat or start ECG
2. Administer antithrombotic (anticoagulants and antiplatelet, warfarin, Eliquis)
medications.
3. Assess risk for stroke
a. Congestive heart failure
b. Hypertension
c. Age > 75 years
d. Diabetes
e. Prior stroke/TIA/Thromboembolism
f. Vascular disease (prior MI, PAD, or aortic plaque)
g. Age 65 – 74 years
h. Sex category (female gender)
Implementation (I) Taking Action:
1. Administer medications that control heart rate (beta-blockers, calcium
channel blockers)
2. Administer medications that convert the heart rhythm or prevent atrial
fibrillation (amiodarone, flecainide, dofetilide, propafenone, ibutilide)
3. Electrical cardioversion for patients with atrial fibrillation who are
hemodynamically unstable and do not respond to medications.
4. Catheter ablation therapy: A special catheter is advanced at or near the
origin of the arrhythmia, where high-frequency, low-energy sound waves are
passed through the catheter, causing thermal injury, localized cell
destruction, and scarring. Cryoablation may also be performed. The goal of
each of these ablation procedures is to eliminate the arrhythmia, by
preventing the ectopic activity arising from the pulmonary veins from
reaching the atria, thereby stopping fibrillation.
5. Synchronized cardioversion
6. Left Atrial appendage device (Watchman)
Evaluation E:
Re-Assess
