Dr. Hardin is Associate Professor, School of Nursing, University of North Carolina at Charlotte, Charlotte, and Mr. Steele is Clinical Assistant Professor, College of Nursing, East Carolina University, Greenville, North Carolina.Acknowledgments
The authors acknowledge Dr. Mary H. Palmer, Helen W. & Thomas L. Umphlet Distinguished Professor in Aging at the University of North Carolina at Chapel Hill, for reviewing parts of the manuscript.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This article was developed during Dr. Hardin’s postdoctoral fellowship at the University of North Carolina at Chapel Hill and was supported by grant T32 NR07091-Interventions to Prevent and Manage Chronic Illness.
Address correspondence to Sonya R. Hardin, RN, PhD, CCRN, ACNS-BC, Associate Professor, School of Nursing, University of North Carolina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223; e-mail: firstname.lastname@example.org.
The purpose of this article is to review an individual example of an elderly man diagnosed with atrial fibrillation and to discuss the pathophysiology of the clinical manifestations, diagnostic testing and treatments, and strategies required for long-term management of chronic atrial fibrillation. Atrial fibrillation is a supraventricular tachycardia characterized by rapid reentrant impulses that result in incomplete contractions and ineffective emptying of the atria. The reentrant impulses occur at such a rapid rate that a decline in cardiac output occurs, along with stasis of blood. This stasis may cause a thrombus formation, which can result in an embolus or stroke. An estimated 15% to 25% of strokes are associated with atrial fibrillation (Rosenthal, 2007). Approximately 5% of individuals older than age 69 and 8% of those older than age 80 will experience atrial fibrillation (Rosenthal, 2007); therefore, understanding the nursing care for this patient population is critical for geriatric nurses.
Valvular heart disease, dilated cardiomyopathy, aortic stenosis, hypertension, coronary artery disease, pericarditis, thyrotoxicosis, pulmonary disease, cardiac surgery, alcohol excess, and alcohol withdrawal are associated with atrial fibrillation. Atrial fibrillation occurs when atrial systole is not coordinated and results in multiple reentrant electrical impulses in the atria. The atrioventricular (AV) node, which controls the atrial rate, can be affected by a patient’s hydration status, the presence of medications, and physiological factors that change the AV node refractory period, which should be less than or equal to 0.20 seconds. Due to the increased electrical impulses in the atria, an irregular ventricular response will result, typically causing tachycardia.
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Classification of Atrial Fibrillation
Classification of atrial fibrillation has been proposed by the American College of Cardiology, the American Heart Association, and the European Society of Cardiology. The classification is divided into three major categories (Fuster et al., 2006):
- First detected atrial fibrillation.
- Recurrent atrial fibrillation.
- Lone atrial fibrillation.
Any individual can experience first detected atrial fibrillation when the onset of atrial fibrillation is newly diagnosed. Such individuals will have an uncertain mechanism of cause that will need to be identified.
Individuals with recurrent atrial fibrillation have experienced two or more episodes of atrial fibrillation in their lifetimes. This category is further divided into paroxysmal (ending within 7 days) and chronic (lasting more than 7 days). The individual’s history is important in determining whether the diagnosis is paroxysmal or chronic (Lévy, 1998, 2000).
The classification of lone atrial fibrillation is used when there are no clinical findings of cardiopulmonary disease or echocardiographic reasons for the onset. Treatment is dependent on the classification and whether conversion can occur with medications or cardioversion. Regardless of initial treatment, any patient who remains in atrial fibrillation will be classified as chronic and will require lifelong anticoagulation therapy and management by a health care provider. The individual example presented in the Sidebar on page 28, which describes chronic atrial fibrillation in an elderly man, is a scenario that nurses working with older adults could likely experience.
Atrial fibrillation is thought to be associated with atrial fibrosis and loss of atrial muscle mass. Atrial fibrosis has been linked to a genetic defect—mutations of the lamin AC gene (van Berlo et al., 2005). Fibrosis can develop as a result of atrial dilation, which is commonly found in heart diseases such as valvular disease, hypertension, heart failure, and coronary atherosclerosis. In patients with heart disease, atrial fibrillation causes cardiac output to fall because of a rapid rate that allows less time for the ventricles to fill and loss of effective atrial contractions. As much as a 20% to 30% drop in cardiac output can be experienced with atrial fibrillation (Stewart, 2002).
The greatest risk of atrial fibrillation is a thromboembolism (Becker et al., 2001). Thromboembolism can result in a stroke, pulmonary embolus, or renal embolus (Bubien & Sanchez, 2001). Atrial fibrillation prevents the blood from being completely emptied from the atrium. As a result, blood can pool, forming a clot that could potentially move into the lungs or into the carotid artery, causing a stroke. The average rate of ischemic stroke among older adults with atrial fibrillation is 5% per year. Approximately half of atrial fibrillation-associated strokes occur in patients older than age 75, and atrial fibrillation is the most frequent cause of disabling stroke in older women (Robinson, McNamara, Bass, & Powe, 2001).
The prevalence of atrial fibrillation increases with age and is more common in men than in women. Patients in long-term care facilities are not monitored with an electrocardiogram; therefore, nurses and nursing assistants must be acutely aware of any changes in patients’ pulse rate and regularity when performing routine assessments. Although not all patients exhibit symptoms, those who do commonly describe feelings of a rapid or irregular heartbeat or palpitations or fluttering in the chest. Other symptoms include weakness, shortness of breath, chest pain, feeling faint, and syncope (McCabe & Geoffroy, 2002).
The electrocardiogram, along with the patient-described symptoms, provide data for the diagnosis. When monitoring is available, atrial fibrillation is characterized by changes on the electrocardiogram in the following ways:
- Rate. The atrial rate is 350 to 600 beats per minute; ventricular response is usually 120 to 200 beats per minute.
- P wave. The atria are beating erratically at a rapid rate. No discernible P waves are found; irregular undulation (termed atrial fibrillation or f waves) is seen; PR interval cannot be measured.
- QRS complex is usually normal.
- Conduction is usually normal through the ventricles and is characterized by an irregular ventricular response because the AV node is incapable of responding to the rapid atrial rate. Impulses that are transmitted cause the ventricles to respond irregularly.
The risk of embolism from atrial fibrillation requires assessment of clinical manifestations of a stroke, pulmonary embolus, or renal embolus (Fuster et al., 2006). A stroke results in neurological changes that can manifest as weakness, slurred speech, changes in mental status, or loss of consciousness. Signs of a pulmonary embolus include sudden shortness of breath, chest pain, a cough with blood in the sputum, excessive sweating, syncope, or cyanosis. Signs of a renal embolus are flank, chest, or abdominal pain. Frequent assessment of the patient is warranted for early identification of an embolism (Davidson et al., 2004).
Treatment goals involve heart rate and rhythm control and prevention of embolism (de Denus, Sanoski, Carlsson, Opolski, & Spinler, 2005; Singer et al., 2004; St-Louis & Robichaud-Ekstrand, 2003). A choice of intervention then occurs to restore sinus rhythm. The first option is usually medication; however, when drugs do not restore the patient’s sinus rhythm, the second option is ablation therapy (AV nodal ablation, surgical Maze procedure, catheter Maze procedure, or pulmonary vein ablation) (level of evidence = B). (Levels of evidence are classified by the U.S. Preventive Services Task Force [2000–2003].)
When drugs are used, a beta blocker, such as esmolol (Brevibloc®), metoprolol (Dutoprol®), or propranolol (Inderal®) (level of evidence for all three = C), or a non-dihydropyridine calcium channel antagonist, such as diltiazem (Cardizem®) or verapamil (Calan®) (level of evidence for both = B), is recommended to slow ventricular response in atrial fibrillation. Digoxin (Lanoxin®) should be used with patients with heart failure (level of evidence = B). Table 1 provides information on the drug therapies that are recommended to control ventricular response and restore sinus rhythm.
Table 1: Intravenous (IV) Medications for Controlling Ventricular Response and Restoring Sinus Rhythm
Special consideration of stroke prophylaxis in this age group is critical to prevention. Therefore, anti-thrombotic therapy is recommended for all patients, except those with contraindications (level of evidence = A). Antithrombotic therapy may include heparin, low-molecular weight heparin, warfarin (Coumadin®), and/or aspirin. Individuals in inpatient settings are typically administered heparin or a low-molecular weight heparin first and are also given warfarin to obtain a therapeutic international normalized ratio value of 2 to 3. Long-term anticoagulation is maintained with warfarin and/or aspirin at 325 mg per day (Rosenthal, 2007). The herbs listed in the Sidebar on this page have side effects that are important to review when administering anticoagulant agents to patients (Lilley & Guanci, 1998).
Ablation therapy is the cauterization of abnormal tissue responsible for the arrhythmia. AV nodal ablation was initially used to control atrial fibrillation; however, it results in lifelong dependence on a pacemaker. New procedures include the surgical Maze procedure, catheter Maze procedure, and pulmonary vein ablation therapy.
The surgical Maze procedure is conducted during open-heart surgery. Incisions are made in the atria, dividing them into compartments and preventing the transmission of chaotic electrical signals. The catheter Maze procedure is accomplished by inserting a catheter through the leg vein into the atria and dragging an ablating catheter along the atria to create lines of conduction block. Pulmonary vein ablation therapy involves ablation of foci within the pulmonary vein that can cause paroxysmal atrial fibrillation (Green, 2002; Thompson, Reich, & Meadows, 2004).
Cardioversion is used when the patient becomes unstable or drug therapy does not convert the patient to a normal sinus rhythm. Synchronized cardioversion is conducted in a controlled setting within 48 hours of the onset of atrial fibrillation and is initially started with a progression of voltage from 100 J, to 200 J, to 300 J, to 360 J in monophasic machines. All patients with atrial fibrillation lasting longer than 48 hours should receive anticoagulant agents for 3 weeks; cardioversion can then be attempted with 4 weeks of continued anticoagulation therapy postcardioversion (Akhtar, Reeves, & Movahed, 1998). An atrial thrombus should be ruled out using transesophageal echocardiology. The plan of care for patients in atrial fibrillation is focused on several outcomes, as identified in Table 2.
Table 2: Plan of Care for Patients in Atrial Fibrillation
Assessing a patient’s comfort level postcardioversion should be included in the recovery phase of the procedure. Many individuals will experience soreness of the chest wall. Pain medication or a warm blanket on the chest wall can be used as a comfort measure (Pita-Fernández et al., 2005).
Plan for Prevention
Studies have shown that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor antagonists may decrease the incidence of atrial fibrillation by decreasing atrial pressure, reducing fibrosis, and lowering relapse in cardioversion (Li et al., 2001; Pedersen, Bagger, Kober, & Torp-Pedersen, 1999; Webster, Fitzpatrick, Nicholls, Ikram, & Wells, 1985). Therefore, health care providers should consider the benefits of ACE inhibitors and angiotension receptor antagonists in the plan of care.
Geriatric Considerations and Nursing Implications
The most common factor contributing to atrial fibrillation is advancing age. Therefore, atrial fibrillation is a condition that warrants gerontological nurses to be aware of its treatment and prevention in the older adult population. Atrial fibrillation may be sporadic or chronic in nature, and many patients have no symptoms (American Heart Association, 1996). Nurses must use good assessment skills to identify those individuals at risk and those with symptoms associated with atrial fibrillation.
Nurses who suspect atrial fibrillation in patients in long-term care settings may only identify an irregular heart rate, which is sufficient to warrant notification of the practitioner responsible for overseeing medical care in the facility (Kellen, 2004). The individual example presented in this article is an example of how nurses may identify clients in long-term care settings and the trajectory of the illness that can result from atrial fibrillation. Individuals providing care should be observant of those at risk (i.e., individuals with advancing age, heart disease, thyroid problems, alcohol use, and family history) (Kang, Daly, & Kim, 2004). Table 3 identifies important strategies that should be taught to all health care providers in long-term care.
Table 3: Long-Term Care Management for Patients in Atrial Fibrillation
The most common arrhythmia among older adults is atrial fibrillation (Resnick, 1999), and nurses need to understand the pathophysiology, signs and symptoms, and treatment protocols of this condition. Atrial fibrillation can be managed with drug therapy most of the time (Fuster et al., 2006); however, newer procedures, such as the Maze procedures and pulmonary vein ablation therapy, are becoming more common in the United States.
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Intravenous (IV) Medications for Controlling Ventricular Response and Restoring Sinus Rhythm
|Drug||Level of Evidence||IV Loading Dosage||Onset||Side Effects||Oral Maintenance|
|Esmolol (Brevibloc®)||C||500 mg/kg over 1 minute||5 minutes||Decreased blood pressure, heart failure, bradycardia, asthma, heart block|
|Metoprolol (Dutoprol®)||C||2.5 mg to 5 mg over 2 minutes||5 minutes||Decreased blood pressure, heart failure, bradycardia, asthma, heart block||25 mg to 100 mg twice daily|
|Propranolol (Inderal®)||C||0.15 mg/kg||5 minutes||Decreased blood pressure, heart failure, bradycardia, asthma, heart block||80 mg to 240 mg daily in divided dosages|
|Dilitazem (Cardizem®)||B||0.25mg/kg over 2 minutes||2 to 7 minutes||Decreased blood pressure, heart failure, heart block||120 mg to 360 mg daily in divided dosages|
|Verapamil (Calan®)||B||0.075 mg to 0.15 mg/kg over 3 minutes||3 to 5 minutes||Decreased blood pressure, heart failure, bradycardia||120 mg to 360 mg daily in divided dosages|
|Digoxin (Lanoxin®)||B||0.25 mg every 2 hours (up to 1.5 mg)||60 minutes||Digitalis toxicity, heart block, bradycardia||0.125 mg to 0.375 mg daily|
Plan of Care for Patients in Atrial Fibrillation
|Ventricular rate control||Administer beta blockers or nondihydropyridine calcium channel antagonist.||Administrating medication can decrease the ventricular rate and improve cardiac output.|
|Rhythm control||Administer beta blockers or nondihydropyridine calcium channel antagonist||Administrating medication can convert the patient back into a sinus rhythm.|
|Ablation therapy||Ablation therapy is recommended in patients who have no risk of cardiac disease.|
|Cardioversion||Cardioversion is used with an unstable patient or after anticoagulation therapy.|
|Prevention ofthromboembolism||Administer anticoagulant agents||Anticoagulant agents prevent the formation of emboli that could result in causing harm to the patient in the form of a stroke or pulmonary embolus.|
|Verbalization of comfort||Teach the importance of comfort measures||Like medication, comfort measures can be used to help with sleep.|
|Provide emotional support||Emotional support is needed for patients with an acute illness and for their families.|
Long-Term Care Management for Patients in Atrial Fibrillation
|Strategy||Nursing Role||Nursing Assistant Role|
Ensure that patient received anticoagulant therapy
Ensure laboratory tests are performed routinely for prothrombin time
Observe for signs of bleeding
Observe for signs of bleeding in patients receiving anticoagulant agents
Report signs of bleeding
Handle patients carefully to avoid bruising or skin tears
|Rate control of heart|
Ensure prescribed medications for atrial fibrillation are administered daily
Identify patients with an increase or decrease in heart rate
Report an increase or decrease in heart rate to the nurse
|Concurrent symptom assessment|
Assess for heart palpitations, increased fatigue, dizziness, chest pain, or shortness of breath
Report to the nurse any patient complaints of heart palpitations, increased fatigue, dizziness, chest pain, or shortness of breath
Possible Herb-Anticoagulant Agent Interactions
|Bromelain||Increases tendency for bleeding|
|Cinchoma bark||Increases anticoagulant effect|
|Feverfew||Possible additive platelet effect|
|Ginger||Possible additive platelet effect|
|Ginkgo biloba||Increased effect on blood coagulation|
|Ginseng||Potential for decreased effect on platelet aggregation|
|Goldenseal||Antagonizes action of heparin|
Table 4: Possible Herb-Anticoagulant Agent Interactions