min), however dosing adjustments need to be considered for renal impairments and should be avoided with CrCl < 30 mL/ min (Chen, Stecker & Warden, 2020). Another provider-patient
decision is the cost of the DOAC compared to warfarin, which is generally much less expensive.
Evidence-based practice! A cross-sectional, longitudinal study was conducted from 2008 to 2014 on Medicare beneficiaries 65 years and older with AF and atrial flutter to examine trends in oral anticoagulant use. The authors found that 66% of patients with AF or atrial flutter were using an oral anticoagulant. Warfarin use decreased from 69.8% of patients prescribed an oral anticoagulant to 42.2% during the study period, accompanied by an increase in dabigatran use until 2011, when the use of dabigatran decreased. Rivaroxaban increased to 13.87% of patients in 2014 (Alalwan et al., 2017). While warfarin use has partially been replaced by the DOACs, it continues to be a key player in oral anticoagulation medication. Evaluation
The last part of the acronym RACE is to evaluate the patient’s response to the rate control, rhythm control, and anticoagulation interventions. A baseline physical appraisal, labs, and diagnostic tests are used to monitor for tolerance. A simple clinical rule of thumb is to start medications at the lowest possible dose and titrate these medications. If intolerant to the first class of medication, another medication class could be considered and administered. If the patient is refractory to one class to achieve rate control, another class for rate control can be added, yet this is not true of the classes used for rhythm control or anticoagulation. Teaching the patient to monitor heart rate and blood pressure will be important for both the rate and rhythm Nonpharmacological management of atrial fibrillation If pharmacologic management does not work to convert and maintain normal sinus rhythm, other modalities may be necessary. However, it is crucial for the provider to assess for potential underlying reversible causes before instituting nonpharmacological management. Cardioversion , also called synchronized electrical cardioversion , can be an elective procedure or prioritized for unstable patients with hypotension, uncontrolled angina, ischemic changes on the 12-lead, and/ or decompensated congestive heart failure (CHF). Ideally, Cardiac output is affected by the incidence of AF. Rapid heart rates decrease diastolic filling time, which decreases coronary artery perfusion. Stroke volume is further decreased, reducing cardiac output by 20%. Patients with systolic heart failure (HFrEF) will have more symptoms second to their EF being less than 40%. Thus, both atrial kick and ventricular ejection are compromised in a patient with AF and systolic heart failure. A key concept to remember in AF is that when the structure of the heart changes for any reason, the function changes, and thus you change the electrical conduction. AF is seen with patients in whom the structure of the heart has changed. Another key concept is that ischemic tissue is irritable tissue and irritable tissue is arrhythmic tissue. Hence patients with underlying ischemia will be predisposed to arrhythmias including AF. AF classifications are related to the time in AF. This will then affect further cardiac output, symptoms, selection of rate control/ rhythm control, and the need for anticoagulation. The history and physical assessment will vary based on the time in AF, as well as the co-morbid conditions that are present. Laboratory and diagnostic testing should be performed from simple to complex and as related to the patient’s acuity to determine the differential diagnosis and etiology of AF. Cost is always a factor in diagnostic testing. It is best practice to ascertain if testing has been done previously within an acceptable timeframe to avoid duplication. Referral to a
control classes of medications. Teaching the patient to monitor for signs of bleeding is important as well, noting that ecchymosis is to be expected, yet epistaxis, melena, and hematuria would warrant the provider to be notified and consideration of drug reversal should be discussed. Lastly, patients should be evaluated for adherence to the medication regimen, especially with the use of oral anticoagulants. Extensive patient teaching is required because of the potential danger of the medications, interactions with other medications, and the importance of a consistent diet with the use of warfarin. Using generic versus brand name agents will assist with cost control. cardioversion should be done under conscious sedation with anesthesia on standby for airway management. The risk of thromboembolism is associated with cardioversion in patients with AF =/> 48 hours (Engelke, 2018). Patients who are refractory to both pharmacological management and/or cardioversion can be referred for ablation procedures using radiofrequency energy and cryoablation during open-heart surgical ablation (Cox-Maze) or with catheter ablation.
SUMMARY OF KEY POINTS
cardiologist is the widely accepted practice for outpatient arrhythmia management. Complications from AF are related to the sequalae of decreased cardiac output, risk of thromboembolism, and quality of life. Pharmacologic treatment is complex. Cardiology referral is warranted to select the most appropriate classification of agents. The RACE acronym can be used to remember the approach to AF management: ● R is for rate control. ● A is for antiarrhythmic medications. ● C is for anti coagulation. ● E is for evaluation . Rate control is accomplished with beta blockers, CCBs, and lastly with digoxin. More than one class of medication may be needed to obtain the desired rate control. The selection of the antiarrhythmic class is more complex based on structural heart disease and the co-morbid conditions of the patient. The intention of anticoagulation is to prevent a stroke. Vitamin K antagonists (warfarin) or one of the direct oral anticoagulants (DOAC) could be selected for the patient. The provider should perform a risk stratification for thromboembolism and bleeding using accepted clinical tools. As with all care, the providers should have transparent conversations with the patient/family/significant others to determine the best care for the patient which is effective, affordable, and evidenced-based. in addition, she often awakens during the night with dyspnea (PND). She reports a 10-pound weight gain over the last 2 weeks with infrequent urination. Her exam and laboratory findings are as follows: ● Irregular, irregularity to cardiac auscultation. ● VS: HR 120, RR 22, and BP 186/78.
CASE STUDY AND SELF-ASSESSMENT QUIZ
A 67-year-old retired schoolteacher presents with AF. She has been admitted to the coronary care unit with a diagnosis of CHF. Past medical history: Hypertension for the last 10 years, currently on hydrochlorothiazide. No other history is identified. She complains of a 2-week duration of fatigue, dyspnea, and difficulty sleeping without four pillows (orthopnea) at night;
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