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Journal of Cardiovascular Nursing
Vol. 27, No. 5, pp 445Y456 x Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Providing Best Practice in the Management
of Atrial Fibrillation in the United States
Marilyn A. Prasun, PhD, CCNS, FAHA
Background: Atrial fibrillation (AF) is a prevalent arrhythmia. Patients with AF may report a variety of
symptoms and often describe compromised quality of life. Atrial fibrillation increases the risk of stroke, heart
failure, and all-cause mortality. Purpose: The purpose of this review article was to provide an overview of
AF management based on current guidelines and new data. Conclusions: The 2011 American College
of Cardiology Foundation/American Heart Association/Heart Rhythm Society guideline update provides
diagnostic and management recommendations for the patient with AF based on the current evidence.
Clinical Implications: Nurses are integral to the care of patients with AF. It is essential for nurses to stay
apprised of current guidelines and new evidence so that the assessment, management, and education of the
AF patients and their families can be optimized.
KEY WORDS:
atrial fibrillation, nurses, treatment guidelines
A
trial fibrillation (AF) is a supraventricular arrhythmia that is frequently encountered in the clinical
setting. The earliest report of AF appears to be in
the Yellow Emperor’s Classic of Internal Medicine,
which dates from approximately 1696 to 2598 BC,
although the invention of the electrocardiograph did
not occur until 1900.1 Over the past century, AF was
often viewed as a benign arrhythmia. However, over
the past decade, extensive research has been performed
that has provided new insight into the impact and
treatment of AF.2Y5
The prevalence of AF in the United States is estimated to be 3.03 million and is projected to be
7.56 million in 2050.6 Given this continued increase
in AF and expanding treatment options, the practice
of evidence-based treatment is critical. Many management guidelines have been published, including
the guidelines for the management of patients with
AF from the American College of Cardiology (ACC),
American Heart Association (AHA), and European
Society of Cardiology (ESC)7 and the 2011 Focused
Update on the Management of Patients With Atrial
Fibrillation published by the American College of
Cardiology Foundation (ACCF), AHA, and the
Heart Rhythm Society (HRS) (some sections of the
2006 guidelines have not changed).8,9 Guidelines serve
to provide a range of recommendations for treatment
based on the current best evidence with the goal of
improving patient care and outcomes.7,8 Although
AF is common and comprehensive guidelines exist,
management of this patient population remains challenging and complex.
Nurses in a wide variety of settings play an important role in the treatment and management of patients with AF. Therefore, it is important for nurses to
be aware of the best evidence that supports current
recommendations and treatment strategies to improve
patient outcomes. The purpose of this review was to
provide an overview of AF management based on the
current AF guidelines, with a focus on patient outcomes,
available pharmacologic and nonpharmacologic therapies, and new and emerging treatment options.
Marilyn A. Prasun, PhD, CCNS, FAHA
Associate Professor, School of Nursing, Millikin University, Decatur, Illinois.
Editorial support for this article was provided by Vrinda Mahajan,
PharmD. Editorial support was funded by sanofi-aventis, Inc. The
opinions expressed in this article are those of the author. The author
received no honoraria or other form of financial support related to
the development of this manuscript.
The author has no conflicts of interest to disclose.
Correspondence:
Marilyn A. Prasun, PhD, CCNS, FAHA, School of Nursing, Millikin
University, Decatur, IL 62522 ([email protected]).
DOI: 10.1097/JCN.0b013e318241736f
Significance of Atrial Fibrillation
Atrial fibrillation is an uncoordinated atrial systole
characterized by an irregular ventricular response.
The loss of atrial synchrony is reflected on the electrocardiogram (ECG) by the absence of consistent
P waves (Figure 1). This irregular rhythm results
in loss of the atrial contribution to cardiac output
(with an overall reduction in cardiac output) and to
symptoms of palpitations, fatigue, and dyspnea. This
445
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
446 Journal of Cardiovascular Nursing x September/October 2012
FIGURE 1. Electrocardiogram showing atrial fibrillation with a controlled rate of ventricular response. P waves are replaced
by fibrillatory waves and the ventricular response is completely irregular.7 Reprinted from Journal of the American College
of Cardiology, vol 57, no 11, Fuster V, Ryden LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated
into the ACC/AHA/ESC 2006 guidelines for the management of patients with a trial fibrillation: a report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and
the Heart Rhythm Society, e101Ye198, 2011, with permission from Elsevier.
progressive disease becomes more difficult to treat
with increasing duration.10
In clinical practice, AF is the most commonly reported arrhythmia and accounts for approximately
one-third of cardiac arrhythmia hospitalizations.7 The
number of hospitalizations for AF has increased by
144% over the last 20 years,11,12 and patients with
AF are often rehospitalized, with most readmissions
occurring within 6 months of the initial hospitalization.13 Costs associated with inpatient management
are a key contributor to the overall healthcare costs
of AF.14 Data from the Framingham Heart Study revealed that AF was a predictor of mortality in both
men and women; at age 40, the lifetime risk for developing AF is 26.0% for men and 23.0% for women.15
The presence of AF is an independent risk factor for
ischemic stroke, which has an average rate of 5% per
year in patients with AF.7,16
Patients with AF also are reported to have a markedly impaired health-related quality of life (HRQOL).17
When compared with the HRQOL among other patient populations, HRQOL among AF patients was
either significantly worse or as impaired as that of
patients who were postYmyocardial infarction or diagnosed with heart failure (ie, patient populations
with a greater degree of structural heart disease than
do patients with AF).17
Classification of Atrial Fibrillation
According to the 2006 ACC/AHA/ESC guidelines,
the 3 major clinical categories of AF are defined as
paroxysmal, persistent, and permanent.7 Paroxysmal
AF refers to episodes of less than 7 days’ duration that
generally stop spontaneously. In persistent AF, episodes
last more than 7 days and are not self-terminating but
require cardioversion to restore sinus rhythm. Permanent AF is defined as sustained AF after failure of
cardioversion. The categories are not mutually exclusive, and patients should be categorized according
to their most frequent presentation.7
Goals of Therapy
Atrial fibrillation is a complex arrhythmia to treat.
Irrespective of the classification of AF, the management of patients should be guided by the patient’s
symptoms and associated comorbidities.7,8 The general cardiovascular health of the patient needs to be
addressed and managed. Although not recommended
by the 2006 ACC/AHA/ESC guidelines, there is some
clinical evidence to indicate that drugs modulating
the renin-angiotensin-aldosterone system (angiotensinconverting enzyme inhibitors and angiotensin receptor
blockers) may decrease the incidence of AF and that
HMG CoA-reductase inhibitors (statins) may prevent
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Best Practice in the Management of Atrial Fibrillation 447
AF recurrence.7 Treatment of AF should meet 3 general goals: (1) rate control, (2) reduction of thromboembolic complications, and (3) establishment and
maintenance of sinus rhythm.7 The initial decision in
managing patients with AF is to determine whether
to restore sinus rhythm or use a rate control strategy.
The treatment strategy should take into consideration
the stability of the patient, predisposing factors, AF
duration, patient age, and comorbid medical conditions.
Regardless of the treatment approach, anticoagulation
is based on stroke risk and not on whether sinus rhythm
is maintained.7
nym CHA2DS2-VASc (Congestive Heart Failure,
Hypertension, Age Q75 [Doubled], Diabetes, Stroke
[Doubled], Vascular Disease, Age 65Y74, and Sex
Category [female]). This scheme is based on a point
system in which 2 points are assigned for a history of
stroke or transient ischemic attack or age 75 years
or older and 1 point each is assigned for age 65 to
74 years, a history of hypertension, diabetes, recent
cardiac failure, vascular disease, and female sex. This
score defines patients and their risk of stroke. This
acronym extends the CHADS2 scheme by considering
additional stroke risk factors.19
Risk Stratification
Thromboprophylaxis
The presence of AF increases the risk for a thromboembolic event. Such an event is a devastating complication of AF and can be reduced with antithrombotic
therapy. Several antithrombotic clinical trials have facilitated identification of risk factors that predispose
patients with AF to a greater risk of ischemic stroke.18
Because stroke risk is dependent upon age and comorbid conditions, the Cardiac Failure, Hypertension, Age,
Diabetes, Stroke (Doubled) (CHADS2) scoring system
(Table 1) is frequently used to stratify the stroke risk of
AF patients and aid in the decision to use antithrombotic therapy.7
The CHADS2 acronym represents identified risk
factors. Each risk factor is assigned a score of 1, with
the exception of prior stroke or transient ischemic
attack, which is assigned a score of 2. Patients who
score 2 or higher with either 1 high-risk factor or
more than 1 moderate-risk factor are considered at
high risk for stroke. Patients who have no risk factors are considered at low risk. Patients who have 1
moderate-risk factor have an intermediate risk for
stroke (3%Y5% per year).7 The 2010 ESC guidelines
also recommend a risk factorYbased approach for patients with nonvalvular AF, expressed as the acro-
Stroke is the most common thromboembolic event
in AF and occurs at a higher frequency among individuals with AF compared with those without AF.7
Antithrombotic therapy has been shown to be effective in reducing the incidence of stroke; the 2006
ACC/AHA/ESC guidelines highlight the need for initiation of thromboprophylaxis with minimal delay
after establishing a diagnosis of AF.7 In general, anticoagulation is recommended whether the patient
has paroxysmal, persistent, or permanent AF.7,20 Antithrombotic recommendations according to categories
of risk are listed in Table 2.7 Unless contraindicated,
patients who are determined to be at high risk for a
thromboembolic event should be placed on warfarin.
An international normalized ratio (INR) range of 2.0
to 3.0 should be maintained. A meta-analysis revealed
that adjusted-dose warfarin is highly efficacious for
prevention of all strokes (both hemorrhagic and ischemic), with a risk reduction of approximately 60%
versus placebo in 6 clinical trials comprising 2900
participants.21 Among low-risk AF patients, aspirin
is recommended. However, in moderate-risk patients,
warfarin with maintenance of an INR between 2.0
and 3.0 or daily aspirin is recommended.7 Although
warfarin is more efficacious for prevention, aspirin
offers modest protection, with an approximately 20%
reduction in stroke among AF patients compared
with no treatment.20,21 Among patients considered
to be unsuitable for oral anticoagulation with warfarin
because of patient preference or physician assessment,
the addition of clopidogrel to aspirin to reduce the risk
of stroke may be considered.8,22,23 A careful balance
between stroke prevention and bleeding complications is necessary so that the benefit of antithrombotic
therapy offsets the occurrence of hemorrhage.21 Unfortunately, more than half of AF patients do not
receive appropriate antithrombotic therapy despite
guideline recommendations.24 Nonpharmacologic
stroke prevention (ie, atrial appendage closure devices) in patients who cannot safely undergo antithrombotic therapy is a rapidly growing area of study.7
TABLE 1 The Cardiac Failure, Hypertension,
Age, Diabetes, Stroke (Doubled) Index
Risk Criteria
Score
Prior stroke or TIA
Age 975 years
Hypertension
Diabetes mellitus
Heat failure
2
1
1
1
1
Abbreviation: TIA, transient ischemic attack.
Reprinted from Journal of the American College of Cardiology, vol 57,
no 11, Fuster V, Ryden LE, Cannom DS, et al. 2011 ACCF/AHA/HRS
focused updates incorporated into the ACC/AHA/ESC 2006 guidelines
for the management of patients with a trial fibrillation: a report of
the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines Developed in partnership
with the European Society of Cardiology and in collaboration with
the European Heart Rhythm Association and the Heart Rhythm
Society, e101Ye198, 2011, with permission from Elsevier.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
448 Journal of Cardiovascular Nursing x September/October 2012
TABLE 2
Antithrombotic Therapy for Patients With Atrial Fibrillation
Risk Category
Therapy
No risk factors
1 moderate-risk factor
High-risk factor or 91 moderate-risk factor
Aspirin 81Y325 mg daily
Aspirin 81Y325 mg daily or warfarin (INR, 2.0Y3.0; target, 2.5)
Warfarin (INR, 2.0Y3.0; target, 2.5)a
Less Validated or Weaker Risk Factors
Moderate-Risk Factors
High-Risk Factors
Female gender
Age 65Y74 years
Coronary artery disease
Thyrotoxicosis
Age Q75 years
Hypertension
Heart failure
LV ejection fraction e35%
Diabetes mellitus
Previous stroke, TIA, or embolism
Mitral stenosis
Prosthetic heart valvea
Abbreviations: INR, international normalized ratio; LV, left ventricular; TIA, transient ischemic attack.
Reprinted from Journal of the American College of Cardiology, vol 57, no 11, Fuster V, Ryden LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused
updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with a trial fibrillation: a report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in partnership with the European
Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society, e101Ye198, 2011, with
permission from Elsevier.
a
If mechanical valve is present, target INR 92.5.
Dabigatran is a new oral direct thrombin inhibitor
that recently received US Food and Drug Administration (FDA) approval (2010). This new anticoagulant is designed for patients with nonvalvular AF.
Dabigatran is taken twice daily and has an elimination half-life of 12 to 17 hours.25 However, dabigatran
does not require periodic adjustment or monitoring
of the INR.25 Patients with AF receiving dabigatran
150 mg reported fewer major bleeds (3.1%) compared
with those receiving warfarin (3.4%).26 Dyspepsia
was reported more frequently with dabigatran.26 The
rate of myocardial infarction was found to be higher
with dabigatran compared with warfarin.26 The
2011 ACCF/AHA/HRS guideline update states that
dabigatran is useful as an alternative to warfarin for
the prevention of stroke and systemic thromboembolism in patients with paroxysmal to permanent
AF and risk factors for stroke or systemic embolization who do not have a prosthetic heart valve or
hemodynamically significant valve disease, severe renal failure, or advanced liver disease.8
Rate Control and Rhythm Control
The current established treatment options for patients
with AF are rate control and rhythm control.7 Under
the rate control strategy, the ventricular rate is controlled without restoration of sinus rhythm.7 The
aim of rate control is to reduce the ventricular rate
and reduce the symptoms of AF. The rhythm control
strategy attempts to restore and maintain sinus rhythm,
with attention to rate control.7 The treatment strategy
selected should be tailored to the individual patient.
Rate control may be a reasonable initial therapy in
older patients with persistent AF or in patients with
mild symptoms attributable to AF. Rhythm control
is often considered in younger patients with a shorter
duration of AF and in patients who can tolerate
antiarrhythmic drugs.7 The management of AF with
pharmacotherapy can be suboptimal because of the
complexity of treatment. Initial rhythm control drug
therapy in newly diagnosed patients is associated
with a high rate of discontinuation, especially early
in therapy (predictors of discontinuation of initial
drug therapy for AF included cardiac arrest before or
after the index date, history of coronary artery bypass graft surgery, valvular heart disease, ischemic
heart disease, and severity of illness).27 Persistence
with some antiarrhythmic agents (especially amiodarone) is poor, and patients who discontinue treatment are unlikely to restart therapy; lack of efficacy
and drug-related adverse effects may be important
reasons for the overall poor persistence.28 Clinical
studies show no significant difference in major clinical outcomes including total mortality, thromboembolic events, and symptomatic improvement between
rate and rhythm control strategies.2,29,30 In addition, several studies found no difference in reported
HRQOL when rhythm control was compared with
rate control.3,5,29
Pharmacologic Management of
Rate Control
The goal of rate control is to control the ventricular
rate during rest and exercise while avoiding excessive
tachycardia as well as excessive bradycardia. Adequate
rate control varies among clinical trials but is recommended to range between 60 and 80 beats/min at
rest and between 90 and 115 beats/min with exercise.7 However, lenient rate control may be a reasonable strategy in some patients with permanent AF.8
In the RACE II study (Rate Control Efficacy in Permanent Atrial Fibrillation: A Comparison Between
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Best Practice in the Management of Atrial Fibrillation 449
Lenient Versus Strict Rate Control II), lenient rate
control (resting heart rate G110 beats/min) was not
inferior to strict rate control (resting heart rate
G80 beats/min and heart rate during moderate exercise G110 beats/min).31 Current medications recommended for rate control of AF ("-blockers, calcium
channel blockers [CCBs], and digoxin), along with
mechanisms of action and considerations for nurses,
are presented in Table 3.7,32
The efficacy of "-blockers in controlling heart
rate is well established in this patient population. A
thorough patient assessment is necessary before implementation to ensure that there are no contraindications (eg, history of asthma). Common adverse effects
include bradycardia, hypotension, and fatigue.33 Caution should be used when starting "-blockers in patients with low blood pressure and/or heart failure.
The 2006 ACC/AHA/ESC guidelines recommend not
only "-blockers for long-term rate control management of AF but also implementation of "-blocker
therapy before cardiac surgery to prevent postoperative AF.7
Verapamil and diltiazem are nondihydropyridine
CCBs commonly used to control rapid heart rate during an acute event and may also be used in long-term
AF management. When given intravenously, nondihydropyridine CCBs have a rapid onset of action
(1Y5 minutes), and a continuous infusion is usually
given because of the short half-life of the drugs.32 Calcium channel blockers may be preferred in patients
with known respiratory disease but should be administered cautiously in heart failure patients.7 When
initiating CCBs, patients may experience peripheral
vasodilatation with associated hypotension and lightheadedness, as well as bradycardia.32 Careful monitoring of these patients is warranted. With long-term use
of CCBs, patients may report lower extremity edema
and constipation.32,33 Nondihydropyridine CCBs are
the only agents that have been associated with an im-
TABLE 3
provement in HRQOL and exercise tolerance in patients with AF.7
Digoxin is no longer considered a first-line therapy except in patients with left ventricular dysfunction because of controversial data concerning this drug
as well as the availability of more effective agents.7
The most common adverse effects of digoxin are ventricular arrhythmias, atrioventricular (AV) block, and
sinus pauses.7 Drug interactions and toxicity can be
problematic with digoxin. Therefore, close follow-up
and monitoring for signs of toxicity are necessary.
Because digoxin is almost completely eliminated by
the kidneys, changes in renal function and electrolytes
can significantly contribute to toxicity. In addition,
several drugs interact with digoxin, such as amiodarone, diltiazem, propafenone, spironolactone, and
verapamil, leading to increased digoxin levels.32 Dronedarone also increases digoxin levels 1.7- to 2.5-fold.34
When digoxin is given in conjunction with these
agents, a reduction in the digoxin maintenance dose
and testing is necessary to ensure that a therapeutic
dose is maintained and potential complications are
avoided. The frequency of testing will depend upon
the patient and drug given in conjunction with digoxin. A digoxin level should be considered within
1 week of initiation of therapy, when the dose of digoxin has been changed, or when the dose of drug
given in conjunction with digoxin is changed.
Pharmacologic Agents for
Rhythm Control
The decision to maintain sinus rhythm in the patient
with AF must be based on patient history, reported
symptoms, and the potential adverse effects of antiarrhythmic drugs. For patients who have recurrent paroxysmal or persistent AF, several drugs are available
for the maintenance of sinus rhythm. However, determining which drug to use should be individualized
Rate Control Medications for Atrial Fibrillation7,32
Drug
Mechanism of Action
Nursing Considerations
"-Blockers
Antagonizes "-adrenergic receptors and increases
refractory period of the AV node
Calcium channel blockers
Slows conduction through SA and AV nodes by
inhibiting calcium ion influx
Digoxin
Inhibits sodium-potassium ATPase and increases
vagal activity
Assess for contraindications
Monitor for bradycardia, hypotension, or AV block
Avoid abrupt withdrawal
Monitor for hypotension, bradycardia, or
AV block
Avoid use in patients with heart failure
Assess for lower extremity edema
Monitor renal function
Monitor potassium levels
Monitor for signs of toxicity
Therapeutic digoxin level (0.5Y2.0 ng/mL)
Abbreviations: AV, atrioventricular; SA, sinoatrial.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
450 Journal of Cardiovascular Nursing x September/October 2012
and based upon whether the patient has underlying
cardiovascular disease.7,8 Drugs such as flecainide,
propafenone, or sotalol can be used in patients who
do not have structural heart disease and in patients
with hypertension but without left ventricular hypertrophy.7,33 The use of these drugs decreased the
recurrence of AF (42%Y67% vs 71%Y84% for controls) but also increased the rate of adverse effects,
including proarrhythmias.35 Guidelines recommend
class IC and selected class III medications for rhythm
control.8 Table 4 contains a list of rhythm control
medications, mechanisms of action, pharmacokinetics,
and nursing considerations.7,32,36,37 Recommended
rhythm control medications for patients with paroxysmal or persistent AF include flecainide, propafenone, amiodarone, dronedarone, dofetilide, and sotalol
(Figure 2).8
In patients with no structural heart disease, class
IC agents (flecainide and propafenone) are considered first-line treatment based on the current guidelines.7,8 Both drugs can contribute to proarrhythmia
effects. The more common adverse effects of flecainide include dizziness, nervousness, headache, fatigue,
blurred vision, and nausea.32 The adverse effects of
propafenone include metallic taste in the mouth, constipation, nausea, vomiting, dizziness, fatigue, and conduction abnormalities.32 Careful continued assessment
for medications that may interact with the class IC
drugs, as well as monitoring the 12-lead ECG and renal, pulmonary, and hepatic functions, will serve to
reduce arrhythmia complications.
Amiodarone is a class III antiarrhythmic drug. It
reduces the automaticity of the sinus atrial node,
prolongs repolarization, increases conduction time
and the refractory period of the AV node, and reduces the conduction in the Purkinje fibers.32 Although amiodarone is not FDA approved for AF in
the United States, in a recent Cochrane review, it was
concluded that amiodarone is the most effective agent
for reducing the recurrence of AF.35
Amiodarone is a benzofuran derivative containing
iodine. Because amiodarone is lipophilic, it has an
extremely long half-life (average of 58 days). When
orally administered, amiodarone also has a highly
variable absorption.32 Chronic use of amiodarone is
limited by adverse effects including bradycardia, photosensitivity, pulmonary toxicity, thyroid dysfunction,
liver toxicity, and visual disturbances; in addition,
amiodarone is associated with prolongation of the
QT interval.32 Close follow-up of patients receiving amiodarone is warranted. Nurses following this
patient population should obtain liver, thyroid, and
pulmonary function tests at baseline. A baseline ophthalmologic evaluation should also be obtained in any
patient who has significant visual abnormalities. The
follow-up evaluation should include a yearly ECG and
chest x-ray film and, semiannually, a thyroid profile
and profile of liver enzymes.38 Regardless of the effectiveness of amiodarone, the potential adverse effects make it a second-line choice for AF patients who
do not have contraindications to other antiarrhythmic drugs.39
Dronedarone was approved by the US FDA in
2009 for reducing the risk of cardiovascular hospitalization in patients with paroxysmal or persistent
AF with a recent episode of AF/atrial flutter and associated cardiovascular risk factors who are in sinus
rhythm or who will be cardioverted. Similar to other
medications, dronedarone can be initiated during outpatient therapy.8 Dronedarone has pharmacological
properties similar to those of amiodarone but lacks
the iodine moiety, which is thought to be responsible
for amiodarone’s pulmonary, thyroid, hepatic, and ocular toxicity.39 Dronedarone inhibits potassium, sodium,
and calcium channels and has !- and "-adrenergicblocking activities.39 The half-life of dronedarone is
13 to 19 hours, with no significant accumulation in
the tissue.37 It has demonstrated an improved safety
profile over amiodarone.40 In a study that compared
the efficacy of dronedarone with that of amiodarone,
dronedarone was less effective than amiodarone in
decreasing AF recurrence.41 In the ATHENA trial (A
Placebo-Controlled, Double-Blind, Parallel Arm Trial
to Assess the Efficacy of Dronedarone 400 mg bid for
the Prevention of Cardiovascular Hospitalization or
Death From Any Cause in Patients With Atrial
Fibrillation/Atrial Flutter), dronedarone was shown
to reduce hospitalizations due to cardiovascular events
or death from any cause by 24% compared with placebo.42 A post hoc analysis of the ATHENA trial
showed that there was a significant reduction in the
risk of stroke with dronedarone compared with placebo.43 Given the favorable benefit-to-risk profile of
dronedarone, it may be considered for treatment of AF.
However, the ANDROMEDA trial (Antiarrhythmic
Trial With Dronedarone in Moderate to Severe CHF
Evaluating Morbidity Decrease), which included highrisk patients with heart failure, was discontinued early
after an interim safety analysis revealed an excess risk
of death in patients on active treatment.44 Therefore,
dronedarone is contraindicated in patients with New
York Heart Association class IV heart failure and in
patients with New York Heart Association class II or
III with a recent decompensation requiring hospitalization or referral to a specialized heart failure clinic.37
The 2011 ACCF/AHA/HRS guideline update does not
recommend the use of dronedarone in patients with
heart failure.8 Several cases of liver injury and hepatic
failure in patients receiving dronedarone have been
reported in the postmarketing setting, including 2 reports of acute hepatic failure requiring transplantation
and new-onset or worsening heart failure.45,46 The
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Selective potassium channel blocker;
increases the action potential duration
Potent sodium and calcium channel blocker;
prolongs repolarization and increases
conduction time; weak !- and
"-blocking activity
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Blocks "1 and "2 adrenergic receptors,
prolonging the action potential
Rapidly absorbed, biotransformed in liver,
excreted in urine
Low systemic bioavailability, extensive
first-pass hepatic metabolism, excreted mostly
in feces
Well absorbed orally, biotransformed in liver,
excreted in urine and feces
Variable absorption, biotransformed in liver,
excreted in bile
Complete oral absorption, bioavailability reduced
because of first-pass metabolism
Complete oral absorption, moderately bound to plasma
proteins, biotransformed in liver, excreted in urine
Pharmacokinetics
Monitor for adverse effects
Baseline liver, thyroid, and PFTs
Baseline ophthalmologic evaluation (patients with significant
visual abnormalities)
Follow-up evaluation: yearly ECG and chest x-ray film and,
semiannually, a thyroid profile and profile of liver enzymes
Monitor for increased effects of warfarin and digoxin
Monitor QT/QTc intervals
Review and follow manufacturer’s ECG monitoring
requirements
Monitor QT/QTc intervals
Calculate and monitor creatinine clearance
Assess and treat potassium and magnesium levels
Multiple drug interactions
Monitor for adverse effects
Monitor for development of or worsening heart failure
Baseline and periodically assess BMP and LFT
Monitor QT/QTc intervals and ECG rhythm
Maintain potassium and magnesium levels within
reference range
Monitor INR level after initiating dronedarone in patients
taking warfarin
Assess for contraindications
Monitor renal function and electrolytes
Monitor QT/QTc intervals
Assess for contraindications
Monitor vital signs
Withdraw previous antiarrhythmic therapy
Monitor ECG rhythm, PR and QRS intervals
Monitor QT/QTc intervals
Correct electrolytes
Avoid medications that are known to interact with class
IC drugs, such as digoxin and cimetidine
Monitor QT/QTc intervals
Nursing Considerations
a
Abbreviations: BMP, basic metabolic panel; ECG, electrocardiogram; INR, international normalized ratio; LFT, liver function test; PFT, pulmonary function test.
Updated prescribing information for Multaq can be found at http://www.fda.gov/Drugs/DrugSafety/ucm264059.htm.
Sotalol
Dronedaronea Inhibits potassium, sodium, and calcium
channels and has !- and "-blocking activities
Dofetilide
Class III
Amiodarone
Mechanism of action similar to that of
flecainide with weak "-blocking activity
Blocks inward movement of sodium: depresses
action potential phase 0, slows conduction
Mechanism of Action
Rhythm Control Medications for Atrial Fibrillation7,32,36Y38
Propafenone
Class IC
Flecainide
Drug
TABLE 4
Best Practice in the Management of Atrial Fibrillation 451
452 Journal of Cardiovascular Nursing x September/October 2012
FIGURE 2. Pharmacologic maintenance of sinus rhythm.7 *Recommended first-line medications. Drugs are listed alphabetically
and not in order of suggested use. Please refer to the 2011 American College of Cardiology Foundation/American Heart
Association/Heart Rhythm Society guideline update for a more detailed discussion.8 LVH indicates left ventricular
hypertrophy. Reprinted from Journal of the American College of Cardiology, vol 57, no 11, Fuster V, Ryden LE, Cannom
DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the
management of patients with a trial fibrillation: a report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines Developed in partnership with the European Society of Cardiology and
in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society, e101Ye198, 2011, with
permission from Elsevier.
updated prescribing information recommends obtaining periodic hepatic serum enzymes, particularly during
the first 6 months of treatment.37 Postmarketing cases
of increased INR with or without bleeding events have
also been reported in patients on warfarin initiated on
dronedarone.37,47
Dofetilide is a class III antiarrhythmic drug. In the
SAFIRE-D study (Symptomatic Atrial Fibrillation Investigative Research on Dofetilide), dofetilide demonstrated a 58% probability of maintaining sinus rhythm
1 year after cardioversion compared with 25% for
placebo.48 Dofetilide can contribute to prolongation
of the QT interval and lead to ventricular arrhythmias. Therefore, it is currently recommended that initiation of dofetilide occur in the hospital with doses
titrated to renal function and QT interval.7 Monitoring of the corrected QT interval, electrolytes, and creatinine clearance in follow-up can serve to further
reduce arrhythmia risk.
Sotalol is a class III antiarrhythmic drug that seems
to be equally as effective as propafenone for maintenance of sinus rhythm.49 The most common adverse
effects of sotalol include bradycardia and palpitations.32
Based on the current guidelines, sotalol can be initiated
on an outpatient basis.7,8 According to the 2011 guideline update, sotalol can be beneficial in outpatients in
sinus rhythm with little or no heart disease and prone
to paroxysmal AF if the baseline uncorrected QT interval is less than 460 milliseconds, serum electrolytes
are normal, and risk factors associated with class III
drug-related proarrhythmia are not present.8 If the
patient receives sotalol as an outpatient, continued
periodic monitoring of the QT interval, electrolytes,
and renal function is warranted.
Atrial fibrillation is usually a chronic arrhythmia,
and many patients will eventually experience a recurrence. According to guidelines, well-tolerated recurrence of AF is reasonable as a successful outcome of
antiarrhythmic drug treatment.8 Careful follow-up
and correction of modifiable risk factors are necessary along with periodic assessment to prevent potential adverse effects. When a medication does not
result in symptom improvement or results in adverse
effects, the medication should be discontinued and
an alternative treatment should be selected according to guidelines.7
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Best Practice in the Management of Atrial Fibrillation 453
New Pharmacologic Agents for the
Management of Atrial Fibrillation
Phase II clinical trials examining the maintenance of
sinus rhythm with celivarone (which is structurally
related to amiodarone) were recently completed. This
drug was compared with placebo in the maintenance
of sinus rhythm with an incidence of 90-day recurrence at 52% compared with 67% for placebo.50
Celivarone is also under investigation with amiodarone for the prevention of implantable cardioverter
defibrillator interventions or death.51 Another new
investigational drug is vernakalant, a sodium and potassium channel blocker with a very short half-life
(2Y3 hours).52 Intravenous vernakalant has recently
been approved (September 2010) in the European
Union, Iceland, and Norway for the rapid conversion of recent-onset AF to sinus rhythm in adult nonsurgery patients with AF of 7 or fewer days’ duration
and for adult postYcardiac surgery patients with AF
of 3 or fewer days’ duration.53 Vernakalant blocks
sodium and ultrarapid potassium currents in the myocardium.54 Phase 2 placebo-controlled studies demonstrated that oral vernakalant successfully maintained
sinus rhythm.54 Common adverse reactions included
dysgeusia, paresthesia, sneezing, and nausea.54
Nonpharmacologic Management of
Atrial Fibrillation
Direct-Current Cardioversion
Direct-current cardioversion is a well-established form
of treatment to restore sinus rhythm. The goal of cardioversion is to depolarize the atrial cells and prevent
reentry (convert the heart from AF to normal sinus
rhythm). Patients who present as hemodynamically
compromised with a rapid ventricular response not
responsive to pharmacologic measures or who are
symptomatic are recommended for treatment with
cardioversion.7 The effectiveness of direct-current cardioversion can be influenced by several factors, including the duration of AF, atrial size, and the presence
of other cardiac conditions.7 Patients may be treated
with antiarrhythmic medications before and after cardioversion to enhance the success of the procedure.7
Devices that use biphasic waveforms require less energy
and are recommended compared with the monophasicwaveform devices; devices with biphasic waveforms
have a median successful energy level of 100 joules
versus 200 joules for devices with monophasic waveforms.55 Paddle position with an anterior-posterior
configuration also enhances the success and reduces
the required energy.56
Patients with AF lasting longer than 48 hours or
those at increased risk for thromboembolism should
receive 3 weeks of oral anticoagulation (target INR
of 2.0Y3.0) before cardioversion is recommended, and
anticoagulation should be maintained for 4 weeks postcardioversion.7 However, transesophageal echocardiography may be used to exclude thrombi and allow
for immediate cardioversion with intravenous heparin.7 Patients must also be given warfarin for a period of time after transesophageal echocardiography
with cardioversion.
Atrial Pacing and Defibrillation
Studies have shown atrial pacing to be associated
with a reduced risk of AF and stroke when compared
with ventricular pacing.7 Atrial pacing can decrease
ectopic beats, which may trigger AF. Although atrial
pacing shows promise, its use as a primary treatment
in preventing recurrent AF has not been established.7
Large-scale studies are warranted to further examine
this treatment approach.
Currently, atrial defibrillators have limited utility
in the treatment of AF except for patients with left
ventricular dysfunction who are candidates for an
implantable ventricular defibrillator.7 Several devices
are available that combine both atrial cardioversion
and ventricular defibrillation capabilities and have
been designed to treat both atrial and ventricular arrhythmias by pacing before delivering a shock.7
Catheter Ablation
Ablation is an invasive procedure in which a catheter
is placed in the heart and targeted sites are destroyed
by radiofrequency. This technique has evolved in recent years from linear scars in the atrium to targeting
ectopic foci in the pulmonary vein. Patients undergoing this procedure have reported improvement in
their symptoms and HRQOL.57,58 Patients undergoing catheter ablation typically have symptomatic
paroxysmal AF and have failed treatment with 1 or
more antiarrhythmic drugs.8 The ThermaCool trial
reported significantly fewer episodes of recurrent AF
after catheter ablation compared with additional antiarrhythmic drugs.59 Therefore, catheter ablation may
be a reasonable treatment option for patients with
symptomatic persistent or paroxysmal AF.8 However,
there are insufficient data to support the long-term
efficacy of catheter ablation to prevent recurrent AF.7,8
Ablation of the AV node with implantation of a
permanent pacemaker, however, is a well-established
rate control treatment in select patients. Patients with
refractory AF who are symptomatic and unable to
tolerate pharmacologic treatment are most likely to
benefit from an AV node ablation and pacemaker. In
a meta-analysis of 21 studies involving 1181 patients,
significant improvements in HRQOL and clinical
outcomes were recorded after AV node ablation and
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
454 Journal of Cardiovascular Nursing x September/October 2012
What’s New and Important
h Treatment of atrial fibrillation (AF) should meet
3 general goals: (1) rate control, (2) reduction of
thromboembolic complications, and (3) establishment
and maintenance of sinus rhythm.
h The 2011 American College of Cardiology Foundation
(ACCF)/American Heart Association (AHA)/Heart
Rhythm Society (HRS) guideline update8 (update to
the 2006 ACC/AHA /ESC guidelines7) discusses
recommendations for strict versus lenient heart
rate control, combined use of antiplatelet and
anticoagulant therapy, use of dronedarone and
dabigatran, and catheter ablation.
h It is essential for nurses to stay apprised of current
guidelines and new evidence so that the assessment,
management, and education of AF patients and their
families are optimized.
pacing.60 Although there are clear benefits to this
treatment in select patients, limitations include the
long-term need for anticoagulation, loss of AV synchrony, and pacemaker dependency.7
Surgical Maze Procedure
The goal of this surgical procedure is to reestablish
or maintain sinus rhythm. The surgical approach was
based on the hypothesis that reentry is the primary
mechanism responsible for the development and maintenance of AF; as such, atrial incisions at critical locations would create barriers to conduction and prevent
sustained AF.7 The maze procedure involves encircling the pulmonary veins and linear atrial incisions
over both atria with radiofrequency, cryoablation, or
laser.61 This procedure forces atrial conduction through
designated atrial areas to the AV node. The reported
success rates range from 70% to greater than 97%.7,62
Despite its high success rate, the maze procedure requires the use of cardiopulmonary bypass, which is
the reason it has not been widely adopted except in patients undergoing other cardiac surgical procedures.7,62
Conclusions
Atrial fibrillation has a profound negative impact on
patients’ perceived HRQOL, mortality, and healthcare costs. Each patient presents with an individual
collection of symptoms and comorbid disease states
that must be taken into consideration when choosing
a management strategy. Established evidence-based
guidelines provide direction for treatment and management of the AF patient with the primary goals of
stroke prevention and amelioration of symptoms.
As the number of patients with AF increases, nurses
must be prepared to play a critical role in the care
and treatment of this patient population. It is essential for nurses to stay apprised of current guidelines and new evidence that can serve to optimize the
assessment, management, and education of AF patients and their families.
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