● Documentation of the prior use of antiarrhythmics and/or rate-controlling agents. Here, the provider should review past records to assess the tolerance and efficacy of prior medications. ● Assessment for the presence of underlying heart disease (i.e., structural, ischemic) and family history of AF. The presence of underlying heart disease is best evaluated with diagnostic testing (echocardiogram and stress testing). ● Documentation of any previous interventions such as cardioversion; surgical or percutaneous ablation procedures, such as a maze procedure which creates scar tissue to interrupt abnormal conduction (Morillo et al., 2017; Pilgrim, 2018). The physical examination should prioritize the following: ● Airway, breathing, and circulation (ABCs) for hemodynamic stability. ● Vital signs, with a focus on heart rate, blood pressure, respiratory rate, and oxygen saturation. Obtain the patient’s baseline vital signs to better understand variations from baseline and to manage pharmacological agents. ● Evaluation of head and neck: Presence of JVD second to heart failure.
● Lungs: Presence of pulmonary vascular congestion, such as crackles, to assess for left-sided heart failure. ● Heart: PMI displaced laterally; S3, S4; regularity. The heart rate in AF is described as “irregularly irregular” noted as one of the hallmarks of AF. ● Lower extremities: Edema, color, strength of pulses. ● Nervous system: To evaluate the presence of ischemic stroke caused by thrombus migration to the brain from the left atrium (Pilgrim, 2018). Nursing consideration: In obtaining the history, one needs to be reminded of best practices as related to the patient’s health literacy, cultural background, and the social determinants of health (SDOH), as well as health disparities. The SDOH can be categorized by healthcare literacy and education access, economic stability, and components of the built environment, such as access to food, green space, and safe housing. Being cognizant of these variables can improve the patient-provider experience and resultant patient care outcomes. In one survey, patients placed a higher value on provider respect, concern, courtesy, and prevention education than on the time spent with the provider (Nesbitt & Palomarez, 2016).
DIAGNOSTIC EVALUATION
The diagnostic evaluation for AF can vary, yet typically includes the following tests. To be cognizant of cost, it is best to start simple and proceed to complex. Contacting the patient’s Laboratory testing ● The comprehensive metabolic panel (CMP) provides data on the presence of electrolyte imbalance and kidney function. Assessing the patient’s baseline or trended data will assist the provider in prescribing practices. Keeping the serum potassium level equal to or above 4.0 mmol/L and magnesium level equal to or above 2.0 mmol/L will stabilize the cardiac membrane as related to the Na-K-ATPase pump. Also noted within the CMP is albumin, a crude marker of protein status, which has implications in protein binding as related to pharmacokinetics. ● Assessing baseline liver function tests (LFT) is important when prescribing amiodarone since it is taken up and stored in the liver tissue. Thus, patients should be closely monitored for hepatotoxicity with LFT elevation, including AST and ALT. These enzymes should be monitored at baseline and every 6 months (Giardina & Zimetbaum, 2018). ● Thyroid studies, including thyroid stimulating hormone (TSH) and free T4, to rule out hyperthyroidism as an etiology for new onset AF. Baseline thyroid studies are also important to monitor when adding amiodarone. ● Complete blood count (CBC) is monitored to rule out anemia, infectious etiologies of AF, and baseline platelet count. A rapid decline in hemoglobin can induce cardiac ischemia with resultant AF. The baseline platelet count is also warranted when prescribing antiplatelet and anticoagulation therapy. Diagnostic testing Figure 2: Continuous Electrocardiogram Reading Showing Irregularly Irregular Rhythm
primary care provider and/or cardiologist to prevent repeat testing will also help reduce cost and allow for assessment of disease progression.
● Coagulation screening and serial coagulation profiles with prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT) are useful to assess suitability for and management with anticoagulation. ● C-Reactive Protein (CRP) identifies the presence of inflammation as related to myocarditis, pericarditis, cardiac surgery, sepsis, etc. The endothelial activation, production of monocytes, increased platelet activation, and fibrinogen expression seen in inflammatory states can be pro- thrombotic (Chung et al., 2020). ● B-type natriuretic peptide (BNP) is a hormone released when there are changes in the pressure of the heart, such as with higher preload and/or congestive heart failure. BNP can be very useful in the differential diagnosis for patients who present with dyspnea, orthopnea, and lower extremity edema. CHF is unlikely if a patient presents with acute dyspnea, yet the BNP is normal. ● Troponin, a diagnostic cardiac enzyme to rule out ischemic etiology of AF, is prudent to assess if the patient presents with anginal or anginal equivalent symptoms, such as dyspnea or epigastric pain. ● Drug screen to identify illicit drugs, such as methamphetamines and cocaine. (Pilgrim, 2018; Walsh & Caple, 2018) ● Irregular ventricular rate (QRS complexes), as noted in the graphic, are the hallmark of AF. ● Absence of discrete P waves, replaced by irregular, chaotic f waves (the stimulus is not being initiated by the SA node; these f waves signify depolarizations of 300 per minute). ● Paroxysmal AF (PAF) is seen in the image below. PAF can be initiated by a premature atrial contraction (PAC). In this instance, the PAC is followed by PAF and then converts spontaneously to normal sinus rhythm.
Note . Getty Images; Used with permission.
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Book Code: AUS3024
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