SOAP. – Atrial Fibrillation – SỔ TAY LÂM SÀNG

Laura A. Petty

Definition

A.Atrial fibrillation (AF) is the irregular and rapid heart rhythm caused by abnormal electrical impulses. These impulses make the heart’s upper chambers (the atria) beat chaotically and out of sync with the heart’s lower chambers (the ventricles), resulting in poor circulation of blood throughout the body.

B.Classification of AF:

1.Paroxysmal AF:

a.Also called intermittent AF.

b.AF that is self-terminating usually within 48 hours or with intervention within 7 days of onset.

2.Persistent AF:

a.AF that is sustained greater than 7 days.

b.Usually requires pharmacologic and/or cardioversion to restore sinus rhythm.

3.Long-standing persistent AF:

a.Continuous AF for greater than 12 months.

4.Permanent AF:

a.Term used when a patient and his or her clinician have reached a joint decision to cease further attempts to restore and/or maintain a sinus rhythm.

5.Nonvalvular AF:

a.The term used to reference patients with paroxysmal, persistent, or permanent AF who do not have valvular heart disease (e.g., rheumatic mitral stenosis, a mechanical or prosthetic heart valve, or mitral valve prolapse [MVP]).

6.Lone AF:

a.The term used historically to refer to younger patients without clinical or echocardiographic evidence of cardiopulmonary disease, hypertension (HTN), or diabetes.

Incidence

A.In 2017, the Journal of Geriatric Cardiology stated that AF is the most commonly diagnosed arrhythmia in clinical practice. The prevalence of AF in adults who are ≥65 years of age increased 5% per year from 1993 to 2007. More than 750,000 hospitalizations in the United States annually list AF as the primary admitting diagnosis. An estimated 130,000 deaths per year in the United States are attributed to AF. Patients with AF are hospitalized twice as often and are three times more likely to have multiple admissions. As of 2017, an estimated 2.7 million and 6.1 million American adults have AF. AF is predicted to affect 6 to 12 million in the United States by 2050. AF is more common in men than in women and more common in Caucasians than other ethnicities.

Pathogenesis

A.Multiple impulses travel throughout the atria, yielding continuous electrical activity and an atrial rate in excess of 300 bpm. The impulses enter the AV node in a completely random manner. A small percentage of the impulses are conducted to the ventricle, which results in a lower ventricular rate, usually 100 to 180 bpm, and an irregularly irregular rhythm. This leads to ineffective atrial contractions, a decrease in cardiac output, and an increased risk of thrombus formation.

Predisposing Factors

A.Increased age:

1.Approximately 1% of all AF patients are less than 60 years of age.

2.Approximately one-third of all AF patients are older than 80 years.

B.Hypertension (HTN).

C.Valvular heart disease:

1.Mitral valve stenosis.

2.Mitral regurgitation.

3.Tricuspid regurgitation.

4.Left ventricular (LV) hypertrophy.

D.Heart failure (HF).

E.Myocardial infarction (MI).

F.Hyperthyroidism.

G.Obstructive sleep apnea (OSA).

H.Obesity.

I.Pericarditis.

J.Myocarditis.

K.Electrocution.

L.Pneumonia.

M.Pulmonary embolism (PE).

N.Cardiothoracic surgery.

O.Diabetes mellitus.

P.Smoking.

Q.Excessive alcohol use.

Common Complaints

A.Palpitations.

B.Angina.

C.Fatigue.

D.Dyspnea at rest or on exertion.

E.Vertigo or dizziness.

F.Disorientation.

G.Confusion.

H.Syncope.

I.Headache.

J.Urinary frequency or urgency.

K.Anxiety.

L.Asymptomatic presentation, most often seen in the elderly and in patients with permanent AF.

Potential Complications

A.Stroke:

1.The risk for stroke increases four to five times during an episode of AF.

2.An AF-related stroke is more likely to be severe than a non-AF-related stroke.

B.HF:

1.The risk of HF increases three times in the presence of AF.

C.Dementia:

1.The risk of dementia increases two times in the presence of AF.

D.Mortality:

1.Overall mortality increases two times in the presence of AF.

2.Increased mortality in individuals who have other cardiovascular conditions or procedures, specifically HF, MI, coronary artery bypass surgery (CAB), stroke, and HTN.

E.PE.

F.Peripheral emboli:

1.May present as an ischemic extremity or ischemic bowel.

Subjective Data

A.Ask the patient what activity brought about or preceded the episode.

B.Have the patient describe the duration of symptoms and what time of day the symptoms began.

C.Ask the patient to describe his or her symptoms.

D.Ask the patient whether any previous episodes have occurred.

E.Ask the patient to list all medications, over-the-counter (OTC), and herbal products currently being taken or recently stopped:

1.Medications with links to AF:

a.Common complications with AF:

i.Theophylline (theophylline anhydrous, Theo-24, Elixophyllin).

ii.Digoxin (Lanoxin).

iii.Quinidine (quinidine gluconate, Nuedexta).

iv.Tricyclic antidepressants (TCAs).

b.Rare complications with AF:

i.Aricept (donepezil hydrochloride).

c.Questionable complications with AF:

i.Bisphosphonates (alendronate, risedronate, etidronate).

F.Ask patient to quantify his or her smoking history, alcohol history, and caffeine intake.

Physical Examination

A.Patients presenting with acute cardiovascular episode should be quickly assessed for the need to call emergency services/911 for immediate transport to the hospital.

B.Early screening is key. Current guidelines strongly suggest that all patients who present with breathlessness, palpitations, syncope, chest discomfort, and/or stroke symptoms have their pulse checked for irregularities and a 12-lead ECG.

C.Vital signs: Check blood pressure (BP), pulse, and respirations. Count heart rate for 1 full minute:

1.Check orthostatic BP: Sitting, standing, and lying down.

D.Inspect:

1.Inspect overall physical appearance, noting any distress.

2.Inspect the neck: Check jugular vein distension and pulsations:

a.Provoking maneuvers (i.e., carotid massage) should only be performed by a cardiologist.

3.Inspect extremities: Note edema, pallor, and cyanosis.

4.Perform a fundoscopic exam: Note hemorrhage, exudates, and papilledema to determine the presence of malignant HTN.

E.Palpate:

1.Palpate extremities for peripheral pulses in arm and groin; determine rate and regularity.

2.Assess capillary refill.

3.Palpate carotid arteries for thrills and heaves.

F.Auscultate:

1.Auscultate heart: While patient is sitting, standing, and in left lateral recumbent positions, noting normal and extra heart sounds (S3 and S4):

a.S4 is not present during AF.

2.Auscultate neck for carotid bruits.

3.Auscultate lungs: Note the presence of wheezing and crackles.

G.Additional areas for physical examination:

1.Assess for focal neurologic deficits (orientation, unilateral weakness, dysarthria).

Diagnostic Tests

A.Complete blood count (CBC), basic metabolic panel (BMP; including electrolytes, blood glucose, blood urea nitrogen [BUN], creatinine), magnesium, and liver function tests (LFTs).

B.Thyroid profile and lipid profile.

C.Brain natriuretic peptide (BNP) and N-terminal probrain natriuretic peptide (NT-proBNP).

D.Cardiac profile (including troponin, creatine phosphokinase [CPK] test, creatine kinase-muscle/brain [CK-MB]).

E.Serum drug levels, digoxin, amiodarone, quinidine (if applicable).

F.International normalized ratio (INR), if applicable.

G.Creatinine clearance (CrCl).

H.12-lead ECG, required to confirm the AF diagnosis.

I.2D echo.

J.Transesophageal echocardiogram (TEE), most sensitive and specific test to detect left atrial (LA) thrombi and identify features associated with an increased risk of LA thrombus formation and subsequent systemic embolism.

K.Chest x-ray.

L.Exercise stress test or thallium stress test, if exercise-induced arrhythmia or coronary artery disease (CAD) is suspected.

M.Holter monitoring.

N.Evaluation of sleep apnea.

Differential Diagnosis

A.AF.

B.MI.

C.CAD.

D.HF.

E.Mitral stenosis.

F.HTN.

G.Hyperthyroidism.

H.Digitalis intoxication.

I.Acute infections.

Plan

A.General interventions:

1.The goal of therapy is to improve the patient’s quality of life by reducing morbidity and prolonging survival.

B.Patient teaching:

1.See Section III: Patient Teaching Guide “Atrial Fibrillation.”

2.Educate patients about the adverse effects of their anti-coagulant and antiarrhythmic medications.

3.See Section III: Patient Teaching Guide “Atrial Fibrillation.”

4.Educate patients with implanted defibrillators and pacemakers about their susceptibility for external electrical fields and avoidance of exposure.

C.Prevention:

1.Control other chronic medical conditions, that is, HTN, diabetes, HF, pulmonary diseases, and hyperlipidemia.

D.Dietary management:

1.Counsel patient on proper nutrition, specifically a low-fat, low-cholesterol, and low-sodium diet. Give diet handouts.

2.Educate patients taking Coumadin (warfarin) regarding dietary modifications to prevent variations in INR levels.

E.Pharmaceutical therapy:

1.Anticoagulant therapy. Note: The CHA2DS2-VASc score evaluates the risk of ischemic stroke in patients with AF. To calculate a CHA2DS2-VASc score, go to clincalc.com/cardiology/stroke/chadsvasc.aspx. In general, the lower the score, the stronger the consideration for oral anticoagulation. The one exception to this is when the patient has a score of 1 due to gender alone.

2.Goal of therapy: Prevention of thromboembolism:

i.Doses: 1, 2, 2.5, 3, 4, 5, 6, 7.5, and 10 mg tablets.

ii.Warfarin dose calculator is located at www.globalrph.com/warfarin_calc.htm.

iii.Review all medications that may affect the anticoagulant effects of warfarin. Globalrph is a resource with a list of medications that both increase and decrease the INR (www.globalrph.com/warfarin_drug_interactions.htm). Because antibiotics can have a significant effect on both decreasing and increasing the INR (especially Bactrim, Cipro, and erythromycin), INRs should be checked at least twice weekly, through the duration of antibiotic therapy.

iv.The incidence of anticoagulation with warfarin often declines as age advances due to the increased risk of falls, bleeding, and other adverse events.

b.Pradaxa (dabigatran) Beers Criteria caution (age 65 and older): AVOID use in older adults with CrCl less than 30 due to increased risk of bleeds:

i.Pradaxa 75 and 150 mg tablets:

•Dosage indications based on CrCl:

–CrCl greater than 30 mL/min: 150 mg, taken twice a day.

–CrCl of 15 to 30 mL/min: 75 mg, taken twice a day.

c.Xarelto (rivaroxaban) Beers Criteria caution (age 65 and older): Reduce dose in older adults CrCl 30 to 50 and AVOID in older adults with CrCl less than 30:

i.Xarelto 10, 15, and 20 mg tablets:

•Dosage indications based on CrCl:

–CrCl greater than 50 mL/min: 20 mg with evening meal.

–CrCl of 15 to 50 mL/min: 15 mg with evening meal.

d.Eliquis (apixaban) Beers Criteria caution (age 65 and older): AVOID in older adults with CrCl less than 25:

i.Eliquis 2.5 and 5 mg tablets:

•Dosage indications: Recommended dose is 2.5 mg, taken twice a day in patients who fit any of the following criteria:

–80 years of age or older.

–Weight greater than or equal to 60 kg (132 lbs).

–Serum creatinine greater than or equal to 1.5 mg/dL.

3.Antiplatelet therapy:

a.Goal of therapy: Prevention of thromboembolism; modest preventative effect:

i.Plavix (clopidogrel bisulfate):

•75 mg (daily dose) and 300 mg (single loading dose).

ii.Aspirin:

•81 and 325 mg tablets:

Beers Criteria caution: (a) Use aspirin with caution in older adults over age 80 with no history of cardiovascular disease (CVD): No clear evidence that aspirin provides primary prevention for cardiac events, but there is a risk for GI bleeds. (b) In adults 65 and older, avoid use of greater than 325 mg because of risk of GI bleed, unless other alternatives are not effective and the patient can take a gastroprotective agent. (c) In older adults more than 75 years, or adults older than 65 taking corticosteroids, anticoagulants, or antiplatelet agents there is an increased risk of upper GI bleeds. The use of proton pump inhibitors (PPIs) reduces but does not eliminate risk. The risk for GI bleed increases with duration of use of NSAIDs, including highdose aspirin (ASA). At 1 year, the risk is 2% to 4% and this increases with each subsequent year

4.Combined anticoagulant and antiplatelet therapies:

a.Prescription of both antiplatelet medications (Plavix and aspirin) in addition to an anticoagulant is referred to as triple therapy. Triple therapy is commonly used to prevent complications when two or more of the following conditions are present:

i.AF.

ii.Mechanical valve prosthesis.

iii.Drug-eluting coronary stent.

b.Triple therapy is linked to an increase in bleeding complications ranging from mild to life threatening.

5.Heart rate control therapy:

a.Goal of therapy: Varies based on patient age but typically involves achieving a ventricular rate between 60 and 80 bpm at rest and 90 and 115 bpm during moderate exercise.

b.Beta-blockers:

i.Acebutolol (Sectral, acebutolol hydrochloride): 200 and 400 mg capsules.

ii.Atenolol (Tenormin): 25, 50 (scored), and 100 mg tablets.

iii.Betaxolol (Betoptic, Betoptic S, betaxolol hydrochloride): 10 and 20 mg tablets, all scored.

iv.Bisoprolol (Zebeta, bisoprolol fumarate): 5 (scored) and 10 mg tablets.

v.Metoprolol (Lopressor, Toprol-XL, metoprolol tartrate): 50 and 100 mg tablets, all scored.

vi.Nadolol (Corgard): 20, 40, and 80 mg tablets, all scored.

vii.Propranolol (Hemangeol, Inderal LA, Inderal XL, InnoPran XL, propranolol hydrochloride): 10, 20, 40, 60, and 80 mg tablets, all scored.

viii.Sotalol (Betapace, Sorine, sotalol hydrochloride): 80, 120, and 160 mg tablets, all scored.

ix.Timolol (Blocadren, timolol maleate): 5, 10 (scored), and 20 mg (scored) tablets.

c.Calcium channel blockers (CCBs):

i.Amlodipine (Norvasc, amlodipine besylate): 2.5, 5, and 10 mg tablets.

ii.Diltiazem (Cardizem, diltiazem hydrochloride): 30, 60 (scored), 90 (scored), and 120 mg (scored) tablets.

iii.Felodipine: 2.5, 5, and 10 mg tablets.

iv.Isradipine: 2.5 and 5 mg tablets.

v.Nicardipine (nicardipine hydrochloride):

•20 and 30 mg capsules.

•Cardene SR: 30, 45, and 60 mg capsules.

vi.Nifedipine (Procardia): 10 and 20 mg capsules.

vii.Nimodipine: 30 mg capsules.

viii.Nisoldipine (Sular): 8.5, 10, 17, 20, 25.5, 30, 34, and 40 mg tablets.

ix.Verapamil (Calan, verapamil hydrochloride, Tarka): 40, 80 (scored), and 120 mg (scored) tablets.

d.Digoxin:

i.Digoxin (Lanoxin):

Beers Criteria caution: Digoxin should be avoided as first-line therapy for AF and should not be prescribed in daily doses greater than 0.125 mg: 0.125 and 0.25 mg tablets, all scored.

6.Heart rhythm control therapy:

a.Goal of therapy: The maintenance of a normal rhythm and suppression of AF:

i.Sodium channel blockers:

•Disopyramide (Norpace): 100 and 150 mg capsules.

•Quinidine (quinidine gluconate): 200 and 300 mg tablets, all scored.

ii.Potassium channel blockers:

•Amiodarone (Cordarone, Pacerone, Nexterone, amiodarone hydrochloride):

Beers Criteria caution: Amiodarone should be avoided as first-line therapy for AF unless the patient has HF or substantial LVH: 200 mg tablet, scored.

•Dofetilide (Tikosyn): 125, 250, and 500 mcg capsules.

•Dronedarone (Multaq):

Beers Criteria caution: Dronedarone should be avoided in patients with permanent AF or with severe of recently decompensated HF: 400 mg tablet.

•Sotalol (Betapace, sotalol hydrochloride): 80, 120, and 160 mg tablets, all scored.

F.Surgical therapies:

1.Ablation therapy:

a.Goal of therapy: Prevention of recurrent AF.

b.Preferred clinical characteristics include the following:

i.Symptomatic paroxysmal AF.

ii.Failure of one or more antiarrhythmic medications.

iii.Normal to mildly dilated atria.

iv.Normal to mildly reduced ventricular function.

v.Absence of severe pulmonary disease.

c.The long-term efficacy of ablation therapy requires further study, especially with regard to patients with HF and structural heart disease.

Follow-Up

A.AF patients should be comanaged with a physician.

B.AF that is resistant to routine therapy should always be followed by a cardiologist.

C.Lab monitoring as indicated by the patient’s anticoagulant and antiarrhythmic medications:

1.CrCl for patients taking Pradaxa and Xarelto.

2.INR for patients taking Coumadin. Multiple medications affect the anticoagulant property of Coumadin.

D.Follow-up is determined by patient’s needs, frequency of AF reoccurrence, and the presence of other medical conditions.

E.After defibrillator or pacemaker placement, monitor patient utilizing regular follow-up appointments and ECGs to identify failure of implanted device, thromboembolism, lead dislodgement, infection, and complicating arrhythmias.

Emergent Issues/Instructions

A.Patients should go to the ED if they have any of the following symptoms:

1.Palpitations or a fluttering in their chest.

2.Chest pain.

3.Weakness or extreme tiredness.

4.Shortness of breath (SOB) at rest or with activity.

5.Dizziness.

6.Disorientation.

7.Confusion.

8.Passing out or losing consciousness.

9.Severe headache.

10.Frequent urination or a compelling urge to urinate.

11.Anxiety or panic symptoms.

12.Sudden weakness in an arm or leg.

13.Sudden change in vision.

14.Trouble speaking or understanding others.

15.If taking an anticoagulant and have any of these symptoms:

a.Nosebleed that will not stop with pressure.

b.Coughing up blood.

B.Patients should contact the office if they are taking an anticoagulant medication and have any of these symptoms:

1.Vomiting or other illness causes them to miss more than one dose of their medications.

2.Vomit that is bright red or dark that looks like coffee grounds or grape jelly.

3.Blood in their bowel movements that looks black or tarry in color.

4.Heavy periods, if female.

C.Patients should contact the office if they are experiencing any new symptom(s) not present at your last office visit.

Consultation/Referral

A.If you suspect an acute cardiovascular episode, refer patient for immediate hospitalization to initiate thrombolytic therapy, cardioversion, hypertensive management, and additional diagnostic testing.

B.Referral to cardiology as indicated by patient’s clinical situation, specifically the frequency of AF reoccurrence and the presence of other complex medical conditions.

C.AF that is resistant to routine therapy should always be followed by a cardiologist.