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CE: Atrial Fibrillation: Updated Management Guidelines and Nursing Implications

Cutugno, Christine L. PhD, RN

AJN, American Journal of Nursing: May 2015 - Volume 115 - Issue 5 - p 26–38
doi: 10.1097/01.NAJ.0000465028.05223.39
Feature Articles

OVERVIEW: Atrial fibrillation, the most common chronic cardiac arrhythmia, adversely affects the quality of life of millions of people. The condition is frequently associated with advancing age, structural cardiac dysfunction, and preexisting comorbidities. The most common complications, stroke and heart failure, result in significant morbidity and mortality. Indeed, atrial fibrillation is responsible for over 450,000 hospitalizations and 99,000 deaths annually and adds up to $26 billion to U.S. health care costs each year. Given the aging of the U.S. population, the incidence of atrial fibrillation is expected to double within the next 50 years. There is evidence that nursing intervention in patient education and transition of care coordination can improve adherence to treatment plans and patient outcomes.

This article reviews the recently updated guideline for the management of atrial fibrillation, issued jointly by the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society. It focuses on the prevention of thromboembolism and on symptom control, and stresses the importance of patient adherence to treatment plans in order to ensure better outcomes.

A review of the recently updated guidelines for managing atrial fibrillation, including prevention of thromboembolism and symptom control.

Christine L. Cutugno is an assistant professor of nursing and graduate coordinator for the Adult-Gerontology Clinical Nurse Specialist Program at the Hunter-Bellevue School of Nursing in New York City. A critical care nurse for over 30 years, she was most recently the director of the Critical Care Division at St. Joseph's Regional Medical Center in Paterson, NJ, from 2003 to 2009, and at Jacobi Medical Center, Bronx, NY, from 1999 to 2003. Contact author: ccutugno@hunter.cuny.edu. The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

A trial fibrillation, the most common chronic cardiac arrhythmia,1 is frequently associated with advancing age, structural cardiac dysfunction, and preexisting comorbidities.2 It's estimated that between 2.7 and 6.1 million Americans currently live with this condition,2, 3 with nearly 75% of cases reportedly occurring in people over 65 years of age.4 According to results from the Framingham Heart Study, the lifetime risk of developing atrial fibrillation is one in four.5 Given the aging of the U.S. population, the incidence is expected to more than double over the next 50 years.3, 6

Atrial fibrillation has significant financial implications for our health care system. Atrial fibrillation–related expenses alone add an estimated $6 billion to U.S. health care costs annually; when other associated cardiovascular and noncardiovascular care costs are factored in, this figure jumps to $26 billion.7 An analysis of 2001 data found that in the United States, atrial fibrillation accounted for about 350,000 hospitalizations, 5 million office visits, 276,000 ED visits, and 234,000 ambulatory care visits annually.8 More recent estimates put the number of hospitalizations with atrial fibrillation as the primary diagnosis at over 450,000 per year.2 As the number of older Americans rises, the costs associated with atrial fibrillation can be expected to increase as well.

Adherence to treatment guidelines for atrial fibrillation can help to optimize treatment and reduce associated costs.9 Indeed, in general, the importance of patient adherence to the prescribed treatment regimen is well known. Nurses thus have a vital role to play in ensuring that patients (or their caregivers) understand and can follow the plan of care.

This article reviews the recently updated guideline for the management of atrial fibrillation and discusses the nursing implications. The guideline was issued jointly last year by the American Heart Association (AHA), the American College of Cardiology (ACC), and the Heart Rhythm Society (HRS).2 Its recommendations constitute the most current evidence-based standard—what the guideline refers to as “guideline-directed medical therapy”—for the management of atrial fibrillation. The primary therapeutic goals are the prevention of thromboembolism and symptom control.

The frequency with which treatment guidelines for atrial fibrillation continue to be updated speaks to both the prevalence and the serious health care implications of the condition. The 2014 AHA/ACC/HRS guideline updates earlier versions published in 2006 and 2011.2 (The European Society of Cardiology has also updated its guidelines, most recently in 2010 and 2012.6, 10) Notable themes in this newest guideline are the importance of patient involvement in and adherence to the prescribed plan of care and the value of an individualized treatment plan. (See Table 1 2, 11-16 for a summary of past and current guideline recommendations.)

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ATRIAL FIBRILLATION: AN OVERVIEW

Pathophysiology. Unlike other cells, cardiac cells are capable of self-stimulation. Although this ability is protective if the heart's conduction system fails, it can also cause ectopic activity in the cardiac cells and result in atrial (or, worse, ventricular) fibrillation. In atrial fibrillation, multiple atrial cells self-stimulate, behaving as individual pacemakers and competing with the sinoatrial node for control of cardiac activity. Normal atrial contractions are replaced by rapid quivering movements, and the atria stop contracting effectively.

This lack of coordinated atrial contractions can result in two of the most common complications of atrial fibrillation—thrombi formation and heart failure. The formation of thrombi on the atrial walls and within the left atrial appendage (LAA) occurs when ineffective emptying allows blood to pool in these chambers. Commonly referred to as mural thrombi, these clots can dislodge and cause strokes and other systemic thromboemboli. The lack of coordinated atrial contractions can also result in less blood entering and leaving the left ventricle. The loss of what is often called “atrial kick” can decrease cardiac output by as much as 30%.17 If normal cardiac output cannot be maintained, heart failure and pulmonary congestion will result.

Atrial fibrillation often occurs in patients with comorbidities and with structural cardiac defects. As January and colleagues note in the current AHA/ACC/HRS guideline, structural abnormalities such as fibrosis and hypertrophy “occur most commonly in the setting of underlying heart disease associated with hypertension, coronary artery disease, valvular heart disease, cardiomyopathies, and [heart failure],” and these conditions “tend to increase [left atrial] pressure, cause atrial dilation, and alter wall stress.”2 Comorbidities such as obesity, diabetes mellitus, and hyperthyroidism; alcohol or drug use; and systemic influences such as excessive autonomic nervous system stimulation (causing catecholamine imbalances) and excessive renin–angiotensin–aldosterone activation (causing sodium retention and hypertension) can also cause abnormalities.2

An analysis of 2011 data from the Centers for Medicare and Medicaid Services serves to illustrate the incidence of various chronic comorbidities in two groups of beneficiaries with atrial fibrillation: those younger than 65 years and those ages 65 and older.2 In both groups, more than 80% had hypertension and more than 50% had ischemic heart disease, hyperlipidemia, or heart failure. Other common comorbidities included anemia, arthritis, diabetes mellitus, and chronic kidney disease. (It's also worth noting the difference in the numbers of beneficiaries in the two groups: 105,878 in the younger group and 2,426,865 in the older group.)

January and colleagues also point to aging and environmental stress as factors; both have been linked to inflammation and may play a role in the onset of atrial fibrillation.2 Inflammatory mediators (such as C-reactive protein and interleukin-6) have been associated with such physiologic stressors as pericarditis, cardioversion, and cardiac surgery, and have been implicated in the onset of atrial fibrillation.2 Because of these multiple variables and potential complications, managing atrial fibrillation is challenging.

Disease classification. Atrial fibrillation is characterized by the frequency and duration of episodes, and is classified into five categories: paroxysmal, persistent, long-standing persistent, permanent, and nonvalvular. (For detailed descriptions of the five categories, see Table 2 2) A single patient can have both paroxysmal and persistent episodes. Categorization has implications for various treatment procedures (such as catheter ablation) and therapy decisions, including the medications indicated and the diagnostic procedures chosen (such as cardioversion), as discussed later in this article.

Risk factors. The incidence of atrial fibrillation is strongly associated with having one or more risk factors, with one study finding that 57% of patients with atrial fibrillation had one or more risk factors, hypertension being the most common.18 Besides advancing age, hypertension, and the aforementioned cardiac diseases, other clinical risk factors include diabetes mellitus; hyperthyroidism; obesity; obstructive sleep apnea; and alcohol, tobacco, or drug use.2 Biomarkers include increased levels of C-reactive protein and B-type natriuretic peptide.2

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CLINICAL ASSESSMENT

A diagnosis of atrial fibrillation is confirmed by electrocardiography (ECG) and other studies suggested by the patient's history and physical assessment. These may include chest X-ray, transesophageal echocardiography (TEE), various types of ambulatory rhythm monitoring (such as by using a Holter monitor or a Zio patch, insertable loop recorder, or event recorder), exercise testing, and electrophysiological studies.2 Additional testing may be indicated by the presence of risk factors and associated comorbidities.

Signs and symptoms. Atrial fibrillation can be asymptomatic and may go unrecognized. Common symptoms include fatigue, palpitations, dyspnea, hypotension, and syncope. Less commonly, patients may present with symptoms (such as shortness of breath or evidence of systemic emboli) of serious hemodynamic conditions (such as heart failure or stroke, respectively). One study enrolled 2,580 older adults with hypertension and no history of atrial fibrillation and monitored them continuously for three months.19 Over the course of the study, the researchers found “a substantial incidence of subclinical atrial tachyarrhythmias”; the occurrence of such tachyarrhythmias was associated with a significantly higher risk of stroke.

On physical assessment, the heart rate of new onset or untreated atrial fibrillation is generally rapid, because the ventricles are responding with relatively little impediment to excessive atrial activity. Patients usually present with tachycardia, with rates often as high as 130 beats per minute (or higher). Atrial fibrillation can frequently be detected when taking a pulse. The patient's pulse may be noticeably irregular and vary in strength as a result of irregular ventricular filling times (and thus varying stroke volumes). Atrial fibrillation can be recognized on ECG by its wavy, erratic baseline; the absence of discreet and identifiable P waves; and varying R-R intervals (reflecting varying ventricular response.) (See Figure 1 for illustrative ECG strips.)

Early evaluation of the effectiveness of cardiac activity is essential. Sustained tachycardia can result in cardiac ischemia, angina, and heart failure. Coronary arteries are perfused during diastole (or between diastole and systole); thus, the faster the heart rate, the less diastolic filling time, limiting such perfusion. Ischemia, seen on ECG as ST-segment and T-wave changes, can be more readily observable during tachycardia.

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MANAGEMENT: THE UPDATED GUIDELINES

Managing or preventing atrial fibrillation involves addressing modifiable risk factors through lifestyle changes, which might include smoking cessation, exercise, weight management, and treatment for alcohol or drug abuse. Beyond this, treatment centers on preventing thromboembolism and controlling heart rate. Because of the effects of atrial fibrillation on cardiac output, even when heart rate is within the normal range, heart failure can occur. If atrial fibrillation remains symptomatic despite rate control, more aggressive measures such as ablation may be considered.

Stroke prevention: stroke and bleeding risk stratification. People with untreated or undertreated atrial fibrillation are at high risk for thromboembolism; to lower that risk, anticoagulation therapy is recommended.11 But this increases the risk of bleeding complications and a potentially devastating outcome. Risk stratification for both stroke and bleeding can help guide informed decision making.20

Stroke risk stratification tools include the CHADS2 score (the acronym stands for congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism [doubled]) and the more recently developed CHA2DS2-VASc score (the acronym stands for congestive heart failure, hypertension, age 75 years or older [doubled], diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism [doubled], vascular disease, age 65 to 74 years, sex category). As the acronym shows, the latter tool considers additional risk factors such as female sex and the presence of vascular disease; it also allows for some differentiation by age, which is important because stroke risk increases with every year over the age of 65.20 The 2014 AHA/ACC/HRS guideline discusses the broader use of CHA2DS2-VASc for assessing stroke risk in patients with nonvalvular atrial fibrillation. Using the recommended CHA2DS2-VASc tool, adjusted stroke rate scores have been found to range from 0% to 15.2% per year.21 (See Table 3 at http://links.lww.com/AJN/A67.2, 21)

Bleeding risk stratification scoring systems such as HAS-BLED (the acronym stands for hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio [INR], elderly, drugs or alcohol concomitantly) evaluate bleeding risk based on several salient factors. As the acronym suggests, the HAS-BLED system considers hypertension, history of stroke or bleeding, labile INRs, age over 65 years, use of drugs that promote bleeding or alcohol use (or both), and renal and liver function.2, 22 (See Table 4 at http://links.lww.com/AJN/A68.22)

Stroke prevention: antithrombotic agents. Antithrombotic agents currently used to treat atrial fibrillation include established anticoagulants such as warfarin (Coumadin, Jantoven), unfractionated heparin, and low-molecular-weight heparin; newer thrombin and factor Xa inhibitors; and antiplatelet drugs such as clopidogrel (Plavix). Aspirin alone is no longer recommended as data of effectiveness are lacking.2 The U.S. Food and Drug Administration has recently approved several newer antithrombotics, including dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis), and these may be considered in certain cases.2 Like warfarin, these newer drugs require strict adherence in order to be effective. Moreover, they have not been tested for use in patients with mechanical heart valves or hemodynamically significant mitral stenosis; these patients should be treated with warfarin.2

The choice of agent will be based on an assessment of the patient's clinical status, ability to adhere to the medication regimen, and bleeding risk; the drug's elimination route; potential drug–drug interactions; provider preference; and cost considerations. Although warfarin is an established and effective antithrombotic, it has several disadvantages, including the need for dietary restrictions, its potential for multiple drug interactions, and the need for frequent INR testing to determine adequate therapeutic levels. A recently published meta-analysis of eight trials of patients on warfarin found that, on average, patients spent only 55% to 68% of the trial period in the therapeutic INR range.23 Warfarin has the advantage of having a reversal agent, vitamin K; but the other antithrombotics have much shorter half-lives. Aspirin alone has not been found effective for preventing stroke in patients with atrial fibrillation.2 For more on pharmacologic therapy for atrial fibrillation, see Table 5 2. 24, 25

Rate control. For patients who are asymptomatic and show no signs of heart failure, the 2014 AHA/ACC/HRS guideline recommends a resting heart rate of less than 110 beats per minute.2 This relatively lenient target allows patients to achieve the target rate with fewer drugs, lower doses, and fewer provider visits. But for symptomatic patients, the recommended heart rate target is less than 80 beats per minute; and when patients have underlying cardiac disease or other comorbidities, the target rate must be individualized. Rate control reduces the morbidity associated with sustained tachycardia (such as cardiomyopathy) and decreases the distressing cardiac and hemodynamic symptoms associated with rapid heart rates.

Recommended and commonly used drugs for rate control include β-adrenergic antagonists (also called β-blockers) and calcium channel antagonists (also called calcium channel blockers); digoxin (Lanoxin) and amiodarone (Cordarone and others) may be indicated in particular clinical situations. The Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study evaluated the effectiveness of such drugs in controlling heart rate in 2,027 patients.26 Heart rate control was achieved in 70% of patients receiving β-blockers (alone or with digoxin), in 54% of those receiving calcium channel blockers (alone or with digoxin), and in 58% of those receiving digoxin alone.

With any drug, the potential for unwanted side effects must be considered relative to (or balanced against) the patient's clinical condition. Both β-blockers and calcium channel blockers can cause arrhythmias, heart failure, and hypotension. Heart failure can result from the negative inotropic effects of these drugs; and hypotension can result from their blocking of the vasoconstrictive effects of the sympathetic nervous system. Patients with asthma may be at higher risk for bronchospasm; the use of cardioselective β-blockers will mitigate this risk. In acutely ill patients, iv administration of these medications is indicated. Patients must be closely monitored for unwanted side effects. Since some of these medications can cause sustained bradycardia, in cases of long-term use prophylactic pacemaker insertion may be indicated.

Rhythm control. The conversion of atrial fibrillation to normal sinus rhythm has been shown to decrease symptoms.2 Rhythm control is most often used in patients with new-onset atrial fibrillation; in younger patients; and in patients whose symptoms remain unresponsive to, or who are intolerant of, rate-control medications. Atrial fibrillation of long duration is much more difficult to convert. Rhythm control may involve the use of antiarrhythmics, electrical cardioversion, ablation, or a combination of these. Treatment choices vary depending on the patient's age, the patient's clinical presentation, and the duration and classification of the atrial fibrillation. No benefits for rhythm-control versus rate-control strategies have been found; and neither approach has shown superiority in decreasing mortality.2, 12, 14

Pharmacologic cardioversion. Several antiarrhythmic agents (amiodarone, dofetilide [Tikosyn], flecainide [Tambocor], propafenone [Rythmol], and ibutilide IV [Corvert]) have demonstrated effectiveness in converting atrial fibrillation.2 But most have contraindications and will not be appropriate for all patients. Moreover, each has significant and life-threatening adverse effects that require some duration of ECG assessment for bradycardia or prolongation of the QT interval.2

A meta-analysis of 39 randomized controlled trials found that amiodarone was the most effective drug for maintaining normal sinus rhythm once atrial fibrillation had been converted; but it was also associated with the highest rate of adverse events.27 Dronedarone (Multaq) was associated with the lowest rate of adverse events. Other drugs shown to be effective in maintaining normal sinus rhythm following cardioversion include dofetilide, flecainide, propafenone, and sotalol (Betapace, Sorine).2, 27

Electrical cardioversion. The purpose of electrical cardioversion is to depolarize all of the cardiac cells simultaneously in an effort to prompt a normal cardiac rhythm. This involves delivering an electrical shock synchronized to the QRS complex (in order to avoid delivering current during the T wave, which could cause ventricular fibrillation). Cardioversion is performed under moderate sedation with ECG monitoring; advanced cardiac life support (ACLS)–trained staff should be present and resuscitation equipment available. The standard of care for hemodynamically unstable patients remains immediate electrical cardioversion.2

The 2014 AHA/ACC/HRS guideline mentions several factors that can increase the effectiveness of electrical cardioversion (such as the initial use of a higher-energy shock), although more specific recommendations aren't given.2 Current ACLS guidelines recommend using an initial biphasic energy level of 120 to 200 joules.28 A higher initial energy level may reduce both the number of shock attempts and the duration of sedation needed. It's also important to determine whether the cardioversion attempt resulted in normal sinus rhythm, even transiently. If it did, but atrial fibrillation has recurred, treatment with an antiarrhythmic medication before making subsequent attempts is recommended.2 If the rhythm wasn't converted, then measures to maximize energy delivery are recommended. These include using a biphasic defibrillator, using anteroposterior electrode placement, and pretreating the patient with a medication that lowers the defibrillation threshold (such as ibutilide).

Under nonemergent conditions, and depending on the patient's clinical presentation, anticoagulation pretreatment for at least three weeks may be recommended before either pharmacologic or electrical cardioversion.2, 29 When emergency cardioversion is performed, antithrombotics should be started before or during the procedure, if possible, and continued afterward; regardless, emergency cardioversion should not be delayed.29 When cardioversion is elective, TEE can provide an alternative to anticoagulation pretreatment.2, 29 TEE allows visualization of the inner chambers of the atria and can help in the detection of mural thrombi. If the atrial fibrillation has lasted 48 hours or less, neither TEE nor antithrombotic pretreatment is generally indicated, but antithrombotics should be given “at full venous thromboembolism treatment doses” during and after cardioversion.29 If the atrial fibrillation has lasted longer than 48 hours, or if the duration is unknown, evaluation with TEE and antithrombotic pretreatment are recommended.2, 29 Anticoagulation treatment should continue for at least four weeks after cardioversion.

For a summary of current AHA/ACC/HRS recommendations for cardioversion, see Table 6.2, 28

Supplemental treatment modalities include the following.

Occlusion of the LAA. The LAA is “the primary source” of thromboembolism in patients with nonvalvular atrial fibrillation.2, 30 It can be excluded as such a source either with devices inserted percutaneously or during cardiac surgery. The percutaneously inserted devices, which occlude or tie off the opening of the LAA, are still under investigation, but may be considered for use in patients who don't respond to pharmacologic anticoagulation. There is a lack of consensus regarding the use of surgical procedures to exclude the LAA during concomitant cardiac surgery. Removal has yielded “inconsistent results”; and the data reveal “highly variable rates of successful LAA occlusion.”2

Radiofrequency catheter ablation and the Cox maze procedure. The 2014 AHA/ACC/HRS guideline recommends radiofrequency catheter ablation for symptomatic patients who are refractory to or cannot tolerate other treatments.2 The procedure involves inserting catheters to locate areas of atrial tissue that are causing fibrillation and then scarring the pulmonary veins in those areas to prevent the conduction of ectopic stimuli.31 In a study of 323 patients treated with catheter ablation and followed for two years, 72% maintained normal sinus rhythm without antiarrhythmics; an additional 15% maintained it with antiarrhythmics.32 Improvement in atrial fibrillation–related symptoms and quality of life were also noted. A recent literature review concluded that catheter ablation appears to be safe for use in appropriately screened elderly patients, with one study reportedly finding an average complication rate of 4.5%.33 And a large study of adults who had undergone an initial ablation procedure found that 5% had serious periprocedural complications, including perforation, cardiac tamponade, and stroke.34 Other potential complications include atrial-esophageal fistula, myocardial infarction, pericarditis, pulmonary vein stenosis, vascular complications, and death.

Early versions of the Cox maze procedure (often called simply “the maze procedure”) required surgeons to surgically ablate atrial tissue using “cut and sew” methods. Of these, the Cox maze III is still sometimes performed. In the most recent version, known as the Cox maze IV, surgeons use radiofrequency ablation or cryoablation techniques to achieve the same end. The Cox maze procedure may be appropriate for select patients undergoing concomitant cardiac surgery for other reasons or for highly symptomatic patients whose atrial fibrillation isn't well managed.2 In a study of 112 patients undergoing the most recent procedure, 50% to 87% of patients were free from atrial fibrillation at six months’ follow-up.35 (The range reflects variation according to the duration of atrial fibrillation and whether patients required continuing treatment with antiarrhythmics.) The overall complication rate was 10%.

Pacemakers and nodal ablation. Pacemakers are indicated primarily for patients who develop symptomatic bradycardia as a result of pharmacotherapy for atrial fibrillation.2 (These patients often have underlying sick sinus syndrome.) Pacemakers are also used in patients with refractory atrial fibrillation who have been treated with nodal ablation.2 In nodal ablation, radiofrequency catheter ablation is used to obliterate the atrioventricular node, thus preventing the atria's rapid, irregular impulses from reaching the ventricles.

Aside from such cases, neither pacemakers nor implantable cardioverter–defibrillators have been shown to be effective in preventing or treating atrial fibrillation, and are not recommended.2

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NURSING IMPLICATIONS

The importance of nursing interventions to improving patient care outcomes has been well documented. With any illness, patient education and care coordination are vital to effective disease management. Multiple studies have evaluated nursing interventions used in the management of atrial fibrillation or of complications often associated with atrial fibrillation (such as heart failure), and found numerous benefits.36-40

For example, in an Australian study by Inglis and colleagues of 152 patients with atrial fibrillation and with or without concurrent heart failure, patients received either a nurse-led, multidisciplinary home-based intervention or usual postdischarge care.40 Those in the intervention group had fewer readmissions, shorter hospital stays, and fewer fatal events than those in the control group, although significance varied. Gillis and colleagues looked at data for Canadian patients who were referred to a nurse clinician–based atrial fibrillation clinic and found they had “markedly shorter” wait times to see a specialist than were usual for that region.37 In a Dutch study, a nurse-driven, guideline-based, integrated chronic care program was implemented for 111 patients with atrial fibrillation.39 Guideline adherence for patients in the program was 96%, compared with 70% for controls.

In a study by Benatar and colleagues, conducted among 216 patients with heart failure, patients received either home nurse visits from cardiac nurses or interdisciplinary home telemanagement implemented by an advanced practice nurse.36 After three months, the researchers found that compared with patients managed through traditional home care, those managed by home telemanagement had significantly fewer hospital readmissions (13 versus 24), shorter readmission lengths of stay (49.5 versus 105 days), and lower hospital charges ($65,023 versus $177,365). And in a study by Cowan and colleagues conducted among 1,207 hospitalized general medicine patients, patients received either usual care management or an intervention that included the involvement of an NP during hospitalization and for 30 days after discharge.41 The results showed that compared with controls, patients in the intervention group had shorter hospital stays and associated cost reductions. Further studies investigating the financial impact of implementing more nursing interventions and adding more nursing hours in order to improve outcomes and prevent readmissions are warranted.

Managing atrial fibrillation has traditionally been challenging for both providers and patients. A quantitative study by Aliot and colleagues involving 825 patients with atrial fibrillation and 810 cardiologists in 11 European countries found that the patients (who often had associated diseases) visited a physician an average of nine times per year, and that the physicians considered atrial fibrillation difficult and time consuming to manage.1 Achieving adequate anticoagulation offers a prime example of such difficulty. Strict adherence to the medication regimen is essential and may require frequent blood tests and dietary restrictions (as is the case for patients on warfarin). Inadequate anticoagulation of high-risk atrial fibrillation patients has been found to be associated with a significantly worse cardiovascular prognosis over the course of one year.42

All chronic diseases are known to affect quality of life, and this can influence patients’ desire or ability to follow prescribed treatment plans. Aliot and colleagues found that 24% of patients rated their ability to explain atrial fibrillation as poor and more than one-third were worried or fearful about the disease.1 Another study involving 101 patients with atrial fibrillation and 97 controls with hypertension found that about one-third of the atrial fibrillation patients had elevated levels of depression and anxiety, which persisted at six months.43 Depressive symptoms were found to be the strongest independent predictor of their future quality of life.

Care coordination and guideline adherence. The care of patients with atrial fibrillation is complex and can be confusing even for health care providers. Care coordination among providers is essential, as is adherence by patients and providers to both guideline recommendations and individual treatment plans. As the 2014 AHA/ACC/HRS guideline makes a point of noting, “Prescribed courses of treatment… are effective only if followed.”2

A systematic review of seven studies utilizing care pathway management for 3,690 patients with heart failure found that the use of care pathways decreased mortality and readmission rates.44 In another study, Hendricks and colleagues randomized 712 patients with atrial fibrillation to either a nurse-led care group or a usual care group; the nurse-led care group was guideline based and included more detailed patient education and the use of dedicated decision-making software.38 The researchers found that compared with patients in the usual care group, patients in the nurse-led care group were better informed and adherence to guideline recommendations by providers and patients was markedly improved.

Patient education. Since patient education is a common regulatory requirement, most patient health records document this. But providing information doesn't guarantee understanding. The content that patients with atrial fibrillation need to be taught about the condition and their treatment plan is generally recognized (for a summary, see Table 7 45). Ensuring that patients understand this content is more difficult and requires more than a cursory discussion.

It's well known that patients need time to access information and to clarify with providers anything they don't fully understand. Indeed, it's an accepted principle in education that repeating what one has been taught improves comprehension and retention. But time is a scarce resource in busy, often understaffed, hospitals.

The effectiveness of evidence-based, RN-led, follow-up care plans has also been demonstrated.36, 38, 40, 41 Yet such plans usually require more nurses and nursing hours, and unfortunately predominate only in the literature. It's my observation, based on nearly 40 years in hospital nursing, that the usual discharge instructions typically delivered just once by a harried staff nurse or medical resident don't begin to meet patient education needs. And follow-up care must consist of more than scheduling a follow-up appointment with a provider. Sustained follow-up by an outpatient or home care nurse can provide opportunities for patients to have their questions answered and can reinforce the goals of treatment.

Given that U.S. expenditures for the treatment of atrial fibrillation and associated conditions stand at $26 billion annually,7 and with nearly 75% of these costs associated with inpatient care,8 it also makes financial sense to make sure that patients are well-informed and understand their treatment plans. Focused efforts to prepare patients for care transitions may prevent unnecessary—and often unreimbursed—readmissions.

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LOOKING AHEAD

The 2014 AHA/ACC/HRS guideline invites a recommitment to the effective management of patients with atrial fibrillation. Its recommendations, which are based on the most recent evidence available, focus particularly on measures to prevent thromboembolism and control symptoms. The guideline also stresses the importance of patient adherence to treatment plans in achieving improved outcomes. And there is evidence that nursing interventions in patient education and in care coordination, particularly at transition points, can also improve patient outcomes and decrease costs. More resources must be dedicated if these goals are to be realized.

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Keywords:

arrhythmia; atrial fibrillation; care coordination; older adults; patient education; stroke prevention; treatment guidelines

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