1. NR601-Primary Care of the Maturing and Aged Family Practicum
Atrial Fibrillation
NR601-Primary Care of the Maturing and Aged Family Practicum

2. Objectives Recognize the risk factors for atrial fibrillation
Describe the classifications of atrial fibrillation
Describe appropriate evaluation of patients with suspected atrial fibrillation
Identify treatment options associated with atrial fibrillation

3. Prevalence of Atrial Fibrillation (A-fib or AF)
Is the most common heart arrhythmia (CDC, )
Is estimated that million people in the U.S. in 2010 had AF; it is projected that by 2050, this number will be tripled (Colilla et al., 2013).
2% of those with AF are younger than 65 years
Prevalence increases with age (Berry, Padgett & Holton, 2015).

4. Burden of AF on Health Care System
750,000 hospitalizations per year
130,000 associated deaths per year
Overall costs: 6 billion per year

5. Definition of AF Rapid, irregularly irregular atrial rhythm
The atria do not contract
The AV conduction system has increased electrical stimuli that causes the irregularly irregular ventricular rate
The rhythm has no regular pattern
Cannot located consistent “P” waves on ECG
(Cheng & Kumar, 2015)

6. Risk Factors (Olshansky & Arora, 2015)
Hypertension (60-80%)
Advanced age
Obesity
European ancestry
Diabetes (20%)
Heart Failure (25-30%)
Ischemic heart disease
Hyperthyroidism
Chronic kidney disease
Heavy alcohol use
Enlarged chambers of the heart
First degree relative who developed AF at a young age

7. Other Less Common Risk Factors (Mitchell, 2015; Olshansky & Arora, 2015)
Pulmonary embolism
Atrial septal or other congenital heart defects
COPD
Myocarditis
Pericarditis
Caffeine and energy drinks possibly but not confirmed

8. Pathophysiology
Exact mechanisms for developing AF are not completely understood
Atrial myocardium
Fast-response tissue depends on rapid activating sodium for phase 0 of the action potential
Normal function
Short action potential duration
Short refractory period allows for rapid cellular reactivation
Very rapid electrical conduction
Refractory period decreases with age
These electrophysiologic patterns allow complex patterns like AF

9. Classifications of AF (Cheng & Kumar, 2015)
Paroxysmal AF
Persistent AF
Long-standing AF
Permanent AF
Lone AF
Recurrent AF

10. Paroxysmal AF Rhythm will terminate spontaneously OR
Patient will go back to normal sinus rhythm (NSR) after seven days of intervention
(Cheng & Kumar, 2015)

11. Persistent AF Fails to terminate in 7 days
Most often requires medication or electrical cardioversion to return to NSR
(Cheng & Kumar, 2015)

12. Long-Standing AF
AF lasts more than 12 months
(Cheng & Kumar, 2015)

13. Permanent AF
Persistent AF when patient and provider decide to no longer try for rhythm cardioversion
(Cheng & Kumar, 2015)

14. Lone AF
Is paroxysmal, persistent, or permanent without structural heart disease
CHADS2 of 0
Usually less than or equal 60
(Cheng & Kumar, 2015)

15. Recurrent 90% of AF patients are seen on recurrent monitoring
Most patients have no symptoms of the occurrences
(Cheng & Kumar, 2015)

16. Patient Evaluation: Identify Symptoms
“Fluttering heart”
Fatigue
Rapid and irregular heart rate
Dizziness
Dyspnea
Anxiety
Weakness
Faintness or confusion
Sweating
Chest pain or pressure
(CDC, 2016)

17. Patient Evaluation: Work-Up for AF
Many patients with AF may be asymptomatic. Therefore, AF may be found during the exam
NOTE: currently no standard for routine screening of patients with asymptomatic AF exists

18. Evaluation of Symptomatic Patients
Echocardiogram
Evaluates the size of the right and left atria and left ventricular function
Evaluates for the presence of valvular disease, left ventricular hypertrophy, pericardial disease, and ejection fraction
Other testing
Exercise stress test for anyone with ischemic heart disease
Cardiac monitoring may help to diagnosis intermittent AF
Labs: TSH, CMP, urine analysis for protein, CBC
(Cheng & Kumar, 2015)

19. Goals of Treatment Control rhythm Restore to NSR or rate control
Based on patient’s associated symptoms and comorbid cardiac conditions
Anticoagulant therapy: to assess the risk for stroke, the provider may use the following scores:
CHA2DS2-VASc score: calculates the stroke risk for patients with a-fib; depending on the score, it alerts the provider of the patients’ stroke risk and the need for anticoagulant therapy. A score of >2 indicates to start the patient of Warfarin.
HASBLED score: assesses bleeding risk in patients as it is being determined if the patient is prescribed anticoagulation therapy or can remain on it.

20. Considerations Before Initiating Treatment Options
Review and treat any other precipitating factors:
Obstructive sleep apnea
Hyperthyroidism
HTN
Heart Failure
Excessive alcohol
(Berry & Padgett, 2015)

21. AF Treatment Goals Known AF Assess need for anticoagulants Rate
First line for individuals with heart failure or reversible cause (Berry & Padgett, 2015)
OR rhythm control options
New onset
Periodic review of current treatment for optimum benefits (Cheng & Kumar, 2015)

22. AF and Stroke Prevention
Selection of medication for stroke prevention can be broken into these types:
ASA
No longer used as single agent to prevent stroke
Antiplatelet agents
Warfarin
Novel Oral anticoagulants (Berry & Padgett, 2015)

23. Stroke Prevention Warfarin (Coumadin)
Variable absorption, elimination and protein binding
Requires INR testing
Reduces stroke by 64%
Reversible
Half life approximately 37 hours (Berry & Padgett, 2015)

24. Stoke Prevention Novel Oral Anticoagulation (NOAC)
Apixaban, dabigatran and rivaroxaban
Non-valvular AF
Predictable pharmacokinetics
Half-life less than 24 hours (Berry & Padgett, 2015)

25. Rate Verses Rhythm Control
Once ventricular rate is controlled, if applicable. The decision for rate verses rhythm control should be made. Either choice should also consist of need for anticoagulants.
Rhythm control consists of:
Antiarrhythmic drugs
Percutaneous catheter ablation
Surgical procedures
Cardioversion
Rate control consists of:
Beta-blockers
Rate limiting Calcium Channel Blockers (CCM) (Kumar, 2016)

26. AV Nodal Blocker Therapy
Typically used congruently with antiarrhythmic medications
Beta blockers- Class II
Protect against reoccurrence
Preferred
CCB
Less desirable in systolic HF patients
Digoxin
Systolic HF patients to help with symptom control (Kumar, 2016)

27. Antiarrhythmic Medications
Amiodarone (Cardarone, Nexterone and Paracerone)
Most effective to control rhythm
Highest side effect profile
Associated complications related to toxicity
Flecainide (Tambocor)
Significant risk with LVH
Dofetilide (Tikosyn)
Rarely used due to decreased efficacy
Propafenone (Rythmol)
Sotalol (Betapace, Sorine and Sotylize)
Dronedarone (Multaq)
Rarely used due to decrease efficacy
Significant side effects (Kumar, 2016)

28. Antiarrhythmic Medications in AF
Without structural heart disease
Class III antiarrhythmic agent
Sotalol (Betapace, Sorine and Sotylize)
Class IC antiarrhythmic agent
Propafenone (Rythmol)
Flecainide (Tambocor) (Berry & Padgett, 2014; Kumar, 2016)

29. Antiarrhythmic Medications in AF
With structural heart disease- Class III antiarrhythmic medications.
Amiodarone (Cardarone, Nexterone and Paracerone)
Preferred with HF (EF <35)
Sotalol (Betapace, Sorine and Sotylize)
Preferred with CAD
Increased risk with LVH
Dofetilide (Tikosyn)
Preferred with HF (EF < 35) (Kumar, 2016)

30. AV Node Ablation Permanent Leads to pacemaker dependency
Medications should be tried for optimum rate control
Thromboembolic risk remains as the atria are still fibrillating (Berry & Padgett, 2015)

31. Catheter Ablation
Use of cryotherapy or heat to destroy tissue and erratic signals
If this corrects the issue, there is no need for medications or implantable devices.

32. Indications for Electrical Cardioversion
Hemodynamic instability
First episode
Long term rhythm control
Symptomatic persistent AF
Potentially reversible cause
Infrequent symptomatic episodes

33. Reasons to Avoid Cardioversion
Asymptomatic
Multiple co-morbid conditions
Advanced age
Low likelihood of success
Left atrial enlargement
Recurrence after previous cardioversion
AF for greater than one year
Uncorrected underlying causes
(Naccarellli, Ganz & Manning, 2016)

34. Summary AF is the most common cardiac arrhythmia
Hypertensive heart disease and CAD are the most common underlying disorders
Is most often a recurrent rhythm
Two major treatment decisions:
Long term anticoagulant therapy
Rate vs. rhythm control

35. You may receive a patient who is on anticoagulant therapy
If a patient comes in with the presence of arrhythmia, but no history of PE/DVT or they have not had a very recent joint replacement, consider that your patient is taking the anticoagulant due to atrial fibrillation. Consider the following questions for accurate diagnosis:
1. Is the patient on an anticoagulant?
2. Reason for the medication? History of irregular rhythm?
3. Can you be specific in your confirmation of diagnosis and/or use of anticoagulant?

36. References
Berry, E., Padgett, H., & Holton, C. (2015). Atrial fibrillation guidelines for management: What’s New? British Journal of Cardiac Nursing, Centers for Disease Control and Prevention. (2015). Atrial fibrillation fact sheet. Retrieved from orders/arrhythmias-and-conduction-disorders/atria-fibrillation Colilla, S., Crow, A., Petkun, W., Singer, D., Simon, T., & Liu (2013). Estimates of current and future incidence and prevalence of atrial fibrillation in the US adult population. The American Journal of Cardiology, 112(8),