Atrial Fibrillation (AF)

Atrial Fibrillation (AF)

1. 5. The nurse then tells Ms. Smith that she has high blood pressure (hypertension), and has had it for many years, she explains how this likely caused her to develop atrial fibrillation. Stress may have also triggered it

   • CAUSES
     • Stimulants
       • Medications and caffeine. Aripiprazole, a second-generation antipsychotic drug, is used for psychiatric conditions. It is a dopamine D2 receptor partial-agonist, interacting with serotonin receptors and a longer elimination half-life than other antipsychotic drugs. Cases of acute AF have been reported many days after an infection of the long-acting aripiprazole (Stefatos et al., 2018). Caffeine increases heart rate and blood pressure subsequently exacerbating AF.
     • Diabetes
       • Increases your risk of developing high blood pressure, atherosclerosis, coronary artery disease and stroke, thus increasing your chances of developing AF (Heart and Stroke Foundation of Canada, 2018)
     • Increased age
       • AF is more common in older individuals. 1 in 4 people over the age of 40 have AF, and due to the aging population this number is expected to double in the next 30 years (Hargroves & Ward, 2015)
     • Diseases that damage the valves of the heart (rheumatic fever, untreated bacterial infections)
       • Disrupts the maintenance of one way continuous flow, therefore damaged valves can lead to poor oxygenation, causing AF (Heart and Stroke Foundation of Canada, 2018)
         • Figure 24
     • Stress
       • Major contributor to dysrhythmias. Recent studies suggest that AF symptoms can develop and worsen due to stress and mental health issues (Mayo Clinic, 2019)
         • Ways to manage stress (Mayo Clinic, 2019)
           • Meditation
           • Yoga
             • Figure 3
           • Relaxation techniques
           • Support from family and friends
           • Regular physical activity
           • A positive attitude
           • A healthy diet
     • Lung disease
       • The lack of tissue oxygenation to the heart from inadequate oxygen intake, for example in COPD
       • Pulmonary embolism
         • Thromboembolism that has been dislodged in the lungs, due to the abrupt increase in pulmonary vascular resistance from the occlusion in the pulmonary vessels, thus causing AF (Ptaszynska-Kopczynska, Kiluk, & Sobkowicz, 2019; Hargroves & Ward, 2015)
           • Figure 11
     • Sleep apnea
       • When individuals are startled awake, due to oxygen deprivation, this puts stress on the heart while causing chemical changes, contributing to the development of AF (Heart Rhythm Society, n.d.)
     • Myocarditis or Pericarditis
       • Swelling and damage in the heart will impair the heart’s ability to contract, this cell damage causes AF (Heart and Stroke Foundation of Canada, 2018).
     • Hyperthyroidism
       • Causes tachycardia, leading to palpitations and irregularity in rhythm, subsequently causing AF (Heart and Stroke Foundation of Canada, 2018).
     • High blood pressure (BP)
       • Most common risk factor*, Keep BP at low risk < 120/80 to avoid complications related to stroke, and prevent the heart from working harder than it has too. Control with medication if required for example Angiotensin-converting enzyme (ACE) inhibitors: Enalapril (Heart and Stroke Foundation of Canada, 2018).
     • Coronary artery disease
       • Compromised blood vessels leading to impaired or inadequate blood flow, oxygen and nutrients to the heart, contributing to AF (Heart and Stroke Foundation of Canada, 2018)
     • Alcoholism
       • Heavy consumption of alcohol increases blood pressure, further increasing the risk of heart disease like dysrhythmias and stroke -- Women: no more than 2 drinks a day and 10 drinks a week. • Men: no more than 3 drinks a day and 15 drinks a week (Heart and Stroke Foundation of Canada, 2018).
     • Idiopathic cause
       • if you receive a diagnosis before age 60 and do not have any form of heart disease, the cause may be termed idiopathic. In this instance, there may be certain familial genes that predispose people to atrial fibrillation (Heart and Stroke Foundation of Canada, 2018).
     • Coronary artery bypass surgery
       • AF is a common complication post cardiac surgery Cardiomyopathy- A cardiac disease of the heart muscle that compromises its ability to pump oxygen-rich blood to the body, subsequently causing AF (Heart and Stroke Foundation of Canada, 2018)
     • Atrial septal defect
       • Congenital cardiac anomaly, AF is a late complication.
     • Heart failure
       • Damaged or altered heart structure can affect cardiac conduction. The heart beats faster in AF, therefore inadequate filling of the heart chambers or decreased blood pumping ability out of the chamber may occur (Heart and Stroke Foundation of Canada, 2018).
     • Unhealthy weight
       • Poor eating habits and lack of exercise leads to weight gain, ultimately putting more stress on the heart muscle. Focus on eating more fruits and vegetables, and whole grains to keep full, avoid foods with saturated fat, sugar and sodium, as well as processed foods. Portion control all meals and do not overeat. Get at least 30 minutes of physical activity per day (Heart and Stroke Foundation of Canada, 2018).
   • Atrial Fibrillation Classifications (Moyer, 2018 & Snofi, 2013; Heart and Stroke Foundation of Canada, 2015)
     • Paroxysmal
       • Sudden episode caused by lifestyle choices such as illegal drugs, smoking, alcohol, obesity, and excessive exercise
       • Self-terminating or intermittent recurrent episodes
       • Terminate spontaneously within seven days
       • Overtime, AF damages heart’s tissues and lead to persistent AFib
     • Persistent
       • Require intervention to terminate AF
       • Episodes lasting longer than 7 days
       • Untreated persistent AF can lead to permanent AF
       • Key outcome is to make sure it does not progress into permanent stage
     • Permanent
       • Unable to restore regular rhythm
       • Continuous and does not respond to treatment
       • Use of long term medication to control heart rate and decrease risks of stroke

2. 1. Ms. Kelly Smith is a 76 year old patient that has presented in the emergency department with what she says, “feels like her heart is skipping beats” , she also complains of a pounding heart. She informs the nurse she has been having these episodes for over a year. In addiotion, this causes her to feel shortness of breath and anxiety. Vital signs are as follows: T-37.1 degrees celsius, P- 258 beats per minute, R- 28 breaths per minute, BP- 152/94, O2 sat- 92% on room air. The nurse receives the patient, introduces herself, makes eye contact, and asks Ms. Smith if she may obtain a health history and perform a head to toe assessment. The nurse then asks Ms. Smith a series of open ended questions in order to understand what is going on from Ms. Smith’s perspective.

   • SIGNS
     • Weaken heart (heart failure). Seen on any echocardiogram by determing the ejection fraction (Kotak, 2018).
     • Sweating
     • Abnormal EKG indicative of AF
   • SYMPTOMS
     • Symptoms can be disruptive and debilitating in the patient's life. They may withdraw from normal daily activities as a form of protection due to worry of triggering a symptom. Fear of an unanticipated symptom attack such as a stroke is common, causing a great deal of stress, subsequently disturbing ones quality of life (Tan, Koh, Wu, Lim, & Wang, 2018).
       • Figure 12
     • 60% of patients don’t know that they are having an Afib episode (Snofi, 2013)
     • Fatigue (lack of energy)
     • Anxiety
     • Light headed or dizzy
     • Palpitation (fish flopping around in their chest or feel like their heart will explode)
     • Subtle or severe and they may come and go
     • Rapid, irregular heart rate
     • Some patients may not experience any symptoms at all
     • Chest discomfort/ pain
     • Trouble concentrating
     • Activity intolerance
     • Dyspnea (shortness of breath)
     • MANIFESTATIONS
   • RISK FACTORS
     • Obesity
       • Obesity is the second biggest attributable risk factor after hypertension. The Atherosclerosis Risk in Communities (ARIC) study suggests that obesity is a major factor in the rise of atrial fibrillation cases worldwide (ARIC, 2019).
       • An increase in pressure on the heart is needed to compensate for the high BMI, causing abnormal relaxation and enlargement of the left atrium. Consequently, it causes scarring of the atrium and leads to an erratic heartbeat (Vyas, 2019).
     • Hypertention
       • Hypertension can cause cardiac structural changes that influence the development of atrial fibrillation such as atrial remodelling and increase in arterial wear and tear. Atrial wear and tear will weaken and narrow arterial wall which will impede normal blood flow (Ogunsua, 2015; Jacob, 2017).
     • Old Age
       • Aging accompanies degeneration of cells, in addition to reduce the effect of most biochemical and physiological functions. This includes in accumulation of fibrous tissue, arterial stiffness and left ventricle diastolic dysfunction as part of the normal aging process (European Society of Cardiology, 2019; Mayo Clinic, 2019).
     • Diabetes mellitus
       • Studies have indicated that inflammatory response caused by diabetes play a role in the generation, maintenance, and perpetuation of AF. Glucose and insulin can affect the myocardium in the atrium and ventricle that may lead to atrial fibrillation. Moreover, there is a close relationship between insulin resistance and left ventricle thickness, which increases the risk of developing atrial fibrillation (Sun, 2010).
     • Family History
       • Generally, AF has not been considered a genetic condition though studies show there are some genes with mutations that influence the likelihood of developing AF. Some of these genes influence fetal organ development or heart cells (Mayo Clinic, 2019).
         • Figure 23
     • Heart Failure
       • Heart failure stretches atria causing tissue to thicken and scar, which disrupts electrical signals increasing risk for AF (Heart and Stroke Foundation of Canada, 2019; Heart Rhythm Society, n.d.).
     • Obstructive sleep apnea
       • In a prospective analysis by Gami et al (2004), about 50% of AFib patients complained of obstructive sleep apnea, compared to 32% of the population in the control group (Jacob, 2017).
     • Alcoholism
       • Data collected from the Framingham cohort study demonstrated a relation between levels of alcohol intake of greater than 3 standard units per day and atrial fibrillation. This is evidenced by ARREST- AF cohort study, which demonstrated that avoidance of alcohol or even alcohol consumption of no more than 30 grams per week (roughly 2.5 to 3 standard units) was directly proportional to improved patient outcomes when alcohol was viewed as a major risk factor for cardiovascular, particularly Afib risk factor (Jacob, 2017).
     • Stress
       • Stressful situations and panic disorders are linked to a higher risk of atrial fibrillation (Heart and Stroke Foundation of Canada, 2019).
     • Cigarette Smoking
       • Smoking damages blood vessels, increases blood pressure and heart rate, contributing to risk of AF (Heart and Stroke Foundation of Canada, 2019; Rawshani, 2019).
     • Cardiac Disease
       • Association with a wide range of different cardiovascular disease can contribute to abnormalities and damage to the heart’s structure (Mayo Clinic, 2019)

3. 2. The nurse is fully present with Ms. Smith, giving her her full attention in a non judgemental manor, allowing Ms. Smith to lead the conversation while building a trusting relationship with her, comforting her as the nurse understands this is a scary time for Ms. Smith

   • COMMON AGE GROUP AFFECTED (Jacob, 2017 & Kheiri et al., 2018)
     • Common in older patients (35% of the patients with AF are above 80 years old)
     • Elders are at risk of experiencing AF, without any underlying cardiac diseases
     • This population are at risk due to age driven alterations in heart structure and functions, such as increased stiffness
     • Moreover, Afib in the older population is related with a higher risk of stroke

4. 3. The nurse, with an order from the doctor, does blood work, a chest X-ray, and connect Ms. Smith to an electrocardiogram (ECG) to identify her heart rhythm, her ECG strip is as follows:

   • Figure 1
   • DIAGNOSTIC TESTING (Lewis, 2015)
     • 12 Lead ECG (A representation of the heart's electrical activity recorded from electrodes on the body surface).
     • Holter Monitor (48 hours cardiac electrical conduction monitor)
     • Electrocardiography (A quick, simple, painless procedure in which the heart's electrical impulses are amplified and recorded).
     • Chest Radiograph (X- ray)
     • Echocardiogram (An echocardiogram uses sound waves to form a visual representation of the heart. This commonly utilized test allows doctors to view the heart beating and pumping blood. Doctors can use the images from an echocardiogram to confirm any heart disease.)
     • Electrophysiology study (Provides a detailed visualization of the electrical signals in the heart and identify the source of any arrhythmias).
     • Prothrombin time (A type of blood test which measures how long it takes blood to clot. A prothrombin time test can be used to check for bleeding problems).
     • Auscultation (Listen to heart sounds- Apical for a full minute)
     • Cardiac monitoring
     • Physical Exam (Test for complications of A Fib)
     • Blood Tests (Look at Cardiac enzymes and markers in specific)
     • Stress test (also known as exercise stress test), demonstrate how the heart pumps during on physical exertion . Since exercise makes the heart beat harder and faster, an exercise stress test can identify issues related to blood flow within the heart. A stress test usually involves walking on a treadmill or riding a stationary bike and the heart rhythm, blood pressure and breathing are monitored continuously. However, for those who cannot tolerate exercise, they will receive a drug (dobutamine) that mimics the effects of exercise. Caffeine should be avoided the day before and the day off the test (Mayo Clinic, 2019).
     • Early diagnosis is key to prevent complications of Afib and improve the patient’s quality of life (Snofi, 2013)

5. 4. Her atrial impulses appear small, squiggly, and chaotic, there is no presence of P waves and no identifiable PR interval, but the QRS complex is normal at 0.04-0.10 seconds. The nurse is then able to determine that Ms. Smith is experiencing atrial fibrillation through the ECG strip. The nurses next action is to start an IV on Ms. Smith in order to administer her a drug known as metoprolol to slow her heart rate down, and amiodarone to normalize her heart rhythm.

   • DEFINITION
     • Atrial fibrillation (AF) is the most common type of dysthymia among the rhythm disturbances, which may ultimately persist continuously and is life-threatening. It causes the heart to race and beat in an irregular rhythm (Stefatos, Baranchuk, Baldessarini & Vazquez, 2018; Hargroves & Ward, 2015)
     • Electrical signals may start in the pulmonary veins rather than the sinoatrial node, the electrical impulse may still reach the atrioventricular node but some will remain blocked leading to a decreased number of impulses reaching the ventricles, causing more impulses to remain in the atria causing chaotic, disorganized contraction (Heart and Stroke Foundation of Canada, 2015; Jacob, 2017 & Kheiri et al., 2018)
       • Figure 25
     • Prevalence increases with age (Kheiri et al., 2018), affecting 1.5-2% of the general population (Hohnloser et al., 2016)
   • PATHOLOGY (Banasik, 2013; Copstead, 2013 & Snofi, 2013).
     • Normal heart rhythm, electrical conduction and blood flow
       • The heart is a muscle-like organ that functions like a pump
       • With each beat, it compresses or contacts to eject blood to the rest of the body
       • The heart has four chambers; the two upper chambers are called the atrium, while the two lower chambers are called the ventricles
       • Under normal circumstances, the upper and lower chambers of the heart work collectively to pump blood throughout the body
       • The bloodstream enters the atrium where blood is pumped to the ventricles in a regular and organized way. From there, blood is ejected from the ventricles to various parts of the body
       • A healthy heart beats in a regular, steady rhythm or pattern. And beats evenly and uniformly
       • Electrical signals travel through the heart in a regular pattern. These impulses begin in the sinoatrial node (small bundle of specialized cells) of the atrium and travel through the heart in a regular pattern, and each signal ultimately causes the heart to contract
       • Figure 10
     • Afib heart rhythm, electrical conduction and blood flow
       • The atria quiver and are uncoordinated. Due to this irregular rhythm, the atria (top chambers) do not coordinate with the ventricles (lower chambers) and as a result, the heart beats out of rhythm
       • Afib occurs when electrical signals begin from an abnormal place and misfires (something in the sequence fails)
       • The faulty signals cause the atria to quiver and not contact completely
       • Signals spread in a rapid and disorganized manner, which is clearly illustrated in the ECG monitor
       • Heart has to work harder and as a result, the heart tissues may get damaged. The heart increases in size and the walls thicken
       • Characterized by multiple reentrant “wavelets” that consistently and continually changing in size and direction. A large portion of atrial depolarizations are blocked at the atrioventricular node, causing few to reach the ventricles and initiate a ventricular contraction. The atria then enters a state of quivering rather than contracting forcefully, this leads to a pooling of blood in the atria, leading to the potential formation of thrombi (Copstead & Banasik, 2013). The nurse should be aware of the pathophysiological changes to the heart and intervene appropriately through drug administration or preparing the patient for cardioversion with electrical shock
     • Characterized by multiple reentrant “wavelets” that consistently and continually changing in size and direction. A large portion of atrial depolarizations are blocked at the atrioventricular node, causing few to reach the ventricles and initiate a ventricular contraction. The atria then enters a state of quivering rather than contracting forcefully, this leads to a pooling of blood in the atria, leading to the potential formation of thrombi (Copstead & Banasik, 2013). The nurse should be aware of the pathophysiological changes to the heart and intervene appropriately through drug administration or preparing the patient for cardioversion with electrical shock.
       • Figure 9

6. 6. After the nurse stabilizes Ms. Smith, the nurse explores with the patient what quality of life means to her before deciding on a treatment plan. After this is done, Ms. Smith decides she wants to follow medical advice precisely in order for her to experience minimal symptoms as possible.

   • COMPLICATIONS (National Lung and, Blood Institute, 2019).
     • Sudden Death
       • Increased risk in sudden cardiac arrest and lead to sudden death
     • Cognitive Impairment and Dementia
       • Studies suggest that impaired cognition such as Alzheimer’s disease and vascular dementia can occur due to blockages in the blood vessels of the brain or reduces blood flow to the brain
     • Cardiogenic Shock
       • When the heart’s pumping action is not sufficient, therefore causing a decrease in cardiac output and ultimately leading to imapaired tissue perfusion and cell metabolism
     • Fatigue
       • The body needs an adequate supply of oxygen-rich blood in order to function. An individual may feel fatigue due to the fact that the heart cannot pump enough blood. Moreover, fluid buildup in the lungs can occur due to heart failure, which can add to exhaustion
     • Pulmonary Embolism
       • Since the heart is unable to pump the blood out properly, it can cause it to pool and form an abnormal blood clot which can travel to different parts of the body, blocking blood flow to the brain, lungs, intestine, spleen, or kidneys
     • Heart Failure
       • ↑ in resting HR & shorter diastolic filling time → reduction in cardiac output → further affected by irregularity of ventricular response → reduction in left ventricular filling → no compensation by increased filling → ↓ blood flow to heart → heart failure (American Heart Association, 2019).
       • Heart being overworked becomes enlarged, ineffective and weak and is unable to efficiently pump oxygenated blood throughout the body
     • Stroke
       • Stroke is the number one complication in AF patients . Patients with Afib are 5 times higher risk having a stroke
       • Afib leads to decreased cardiac output due to lack of atrial kick or rapid ventricular response → Clots may form and obstruct arteries in the brain→ Increased risk for stroke
         • Figure 8
       • Afib can lead to stroke even when patients don’t have symptoms
       • Stroke due to Afib are more severe than regular strokes
     • Tachycardia
       • Due to the fast, irregular and disorganized electrical signals of the heart, it can lead to a heart rate of more than 150 beats per minute, known as tachycardia

7. 7. The doctor prescribes Ms. Smith blood thinners, this is to ensure that if blood is pooling in the left atrium and form small clots, one of these small clots does not break away and travel to the brain causing a stroke. He also prescribes her a beta blocker to control her heart rate, and an antiarrhythmic to control the rhythm. She is then placed on a holter monitor for 48 hours in order to further solidify her diagnosis of AF.

   • MEDICATIONS
     • Blood thinning medication to prevent the complication of stroke (Kotak, 2018)
     • May not be fully effective and may have side effects (Kotak, 2018)
     • Maintain sinus rhythm → Amiodarone, Flecainide & Sotalol
     • Keep a recent list of medications, both prescription and non prescription, you are taking and keep it on hand at doctors appointments. Record all allergies, side effects and intolerances and notify the doctor of them (Heart and stroke Foundation of Canada, 2015)
     • Do not double up doses if you forget, take the next dose at the next allotted time (Heart and stroke Foundation of Canada, 2015)
     • Anticoagulants- Commonly known as blood thinners and used as prophylaxis of blood clot formation (Heart and stroke Foundation of Canada, 2015)
       • Apixaban (Eliquis)
       • Dabigatran (Pradaxa)
       • Rivaroxaban (Xarelto)
         • Figure 5
       • Warfarin (Coumadin)
     • Antiplatelets- prevent platelet aggregation and subsequently blood clot formation (Heart and stroke Foundation of Canada, 2015)
       • Acetylsalicylic acid (Aspirin)
       • Clopidogrel (Plavix)
       • Prasugrel (Effient)
       • Ticagrelor (Brilinta)
     • Antiarrhythmics- prevent and treat abnormal heartbeats also known as arrhythmias, they work by slowing down the electrical impulses in the heart in order for it to beat regularly again (Heart and stroke Foundation of Canada, 2015)
       • Sodium channel blockers slow down electrical impulse conduction of the heart muscle
       • Disopyramide (Rhythmodan)
       • Quinidine
       • Mixelitine (Teva-Mixelitine)
       • Flecainide (Apo-Fleicanide)
       • Propafenone (Rythmol)
     • Potassium channel blockers slow down electrical impulse conduction in heart cells (Heart and stroke Foundation of Canada, 2015)
       • Amiodarone – the most commonly used drug in this class.
         • Figure 21
       • Dronedarone (Multaq)
       • Sotalol (Pro-Sotalol)
     • Calcium channel blockers slow down your heart rate, this is done by slowing the electrical impulse conduction at the sinoatrial and atrioventricular nodes (Heart and stroke Foundation of Canada, 2015)
       • Amlodipine (Norvasc)
       • Diltiazem (Cardiazem)
       • Felodipine (Plendil)
       • Nifedipine XL (Adalat XL)
       • Verapamil (Isoptin)
     • Beta-blockers make your heart not have to work as hard, this is done by lowering your heart rate and blood pressure (Heart and stroke Foundation of Canada, 2015)
       • Atenolol (Tenormin)
       • Bisoprolol (Monocor)
       • Metoprolol (Lopressor, Betaloc)
       • Esmolol (Brevibloc)
     • Cardiac glycosides help the heart pump with more force, it also slows your heart rate subsequently helping you to not feel as tired while decreasing shortness of breath (Heart and stroke Foundation of Canada, 2015)
       • Digoxin (Lanoxin, Toloxin)
   • GOAL OF TREATMENT
     • Listen to your patients concerns, and provide adequate support. Educate the patient at their level of understanding to reduce anxiety related to diagnosis (Heart and Stroke Foundation of Canada, 2018)
     • Empower the patient to make healthy lifestyle choices that focus on smoking cessation, promoting physical activity, eat a healthy diet to maintain a healthy weight, decrease alcohol intake and explore ways to help the patient manage stress (Heart and Stroke Foundation of Canada, 2018)
       • Figure 15
     • Manage high blood pressure through changes in diet, sodium restrictions, and medication, in order to avoid the risk of stroke (Heart and Stroke Foundation of Canada, 2018)
       • Figure 14
     • Encourage patient to join a cardiac rehabilitation program that is personalized and focuses on exercise, education, and counselling (Heart and Stroke Foundation of Canada, 2018)
     • Maintain the patients quality of life as determined by the patient. The patients perception of quality of life should be considered when discussing treatment options (Tan, Koh, Wu, Lim, & Wang, 2018)
     • Guide interventions around symptom management through medication and procedures
     • Advise patients to journal and document symptoms they experience to discuss further and encourage patients to ask questions (Mayo clinic, 2019)
       • Prevent the patient from experiencing thromboembolic complications, rate control and rhythm control (Ceyhan, Tasci, ElmalI, & Dogan, 2019)
       • Restoring and maintaining sinus rhythm (Ceyhan, Tasci, ElmalI, & Dogan, 2019)
       • Controlling the rate in treatment are the primary method preferred for many patients. Starting with the mild treatment first, then gradually increase the intensity of the treatment (Ceyhan, Tasci, ElmalI, & Dogan, 2019)
       • Talk to your healthcare provider if you find any changes in your body after being diagnosed with Afib (Snofi, 2013)
       • Early intervention (Snofi, 2013)
       • Comprehensive treatment plan (Snofi, 2013)
       • Administration of adequate anticoagulation to prevent thromboembolic complications (Tereshchenko, Henrikson, Cigarroa, & Steinberg, 2016; Heart and Stroke Foundation of Canada, 2018).
       • Teach patient how to avoid symptomatic attacks, this includes connecting your patient with resources to help combat anxiety and depression related to atrial fibrillation (Akintade, Chapa, Friedmann, & Thomas 2015).
       • Work with patient to maintain a healthy mental status, often symptoms of anxiety and depression are associated with worse atrial fibrillation related symptoms and severity. Combat depression as it is associated with poor quality of life, as well as anxiety, as it is the strongest predictor of the severity and frequency of symptoms in patients with atrial fibrillation (Akintade, Chapa, Friedmann, & Thomas 2015).

8. 8. Ms. Smith has been told to eat a diet high in vegetables, fruits, and whole grains and low in saturated fat, sugar and sodium, in order to control her hypertension, ultimately controlling symptoms of atrial fibrillation

   • Figure 2
   • NURSING INTERVENTIONS (Rawshani, 2019 & Heart and Stroke Foundation of Canada, 2018)
     • Preform physical examinations
       • Assess for airway, breathing and circulation
       • Ensure patient is hemodynamic stable
     • Recognizing atrial fibrillation on an echocardiogram
       • Atrial impulses appear as small, squiggly waves of various sizes and shapes (Copstead & Banasik, 2013; Hargroves & Ward, 2015)
       • P waves are not present
       • PR interval is not identifiable due to lack of P wave
         • Figure 20
       • QRS complex is normal at 0.04-0.10 seconds
       • Atrial rate is 350-600 beats per minute
       • Irregularly irregular ventricular rate (100-180 beats per minute)
       • Baseline characterized by fibrillatory waves (small waves with high frequency, each wave tends to vary in appearance, irregular rate between 300-600 beats per minute) or minute oscillations
       • Rapid ventricular rhythm (>100 beats per minute)
       • Ashman’s phenomenon, an abnormal ventricular conduction may be seen, indicated when a bundle branch block occurs due to an abrupt change in cardiac cycle length
     • Assessing psychosocial status of the patient is imperative, anxiety and depression are significant predictors of the patient’s health related quality of life in atrial fibrillation, therefore adequate assessment and intervention by the nurse is vital to improve patient outcomes. (Akintade, Chapa, Friedmann, & Thomas 2015).
     • Obtain orders from healthcare practitioner:
       • Complete blood count
       • Medication
       • EKG
     • Introduce and educate patients on artificial intelligence, for example, the handheld iPhone-based lead-I ECG (iECG) through the AliveCor Heart Monitor. This device helps patients feel involved in their care while enjoying the ease of use this device provides (Lowres et al., 2015; Hargroves & Ward, 2015)
     • Figure 4
     • AF Presentation
       • Asymtomatic
         • Identify and treat cause
         • Observe patient
         • Control ventricular rate
         • Convert rhythm from A fib to normal cardiac function
       • Symptomatic / Hemodynamically Stable
         • identify and treat cause
         • Control ventricular rate-
         • Administer medication
           • If cardiac function is normal, administer calcium channel blockers or beta- blockers
           • If cardiac function is impaired, administer digoxin, diltiazem, or amiodarone, especially when symptoms have persisted < 48 hours
             • Figure 16
         • Convert rhythm
           • Administer the drug Amiodarone
           • If symptoms persist < 48 hours, perform synchronized electrical cardioversion
             • Figure 18
           • If symptoms persist > 48 hours duration, anticoagulate first, then perform synchronized electrical cardioversion
             • Figure 19
       • Symptomatic / Hemodynamically Unstable
         • Immediate synchronized cardioversion using anesthetic and analgesia
     • Figure 22
   • MANAGING A FIB AT HOME (Heart and Stroke Foundation of Canada, 2015 & Jacob, 2017)
     • Long term longitudinal study (LEGACY) came into conclusion that a long-term constant weight loss was directly related to significant reduction of AF burden and maintenance of normal sinus rhythm
     • Healthy eating and portion control- Will improve overall well-being and will contribute to a healthy body weight. Keep a diet low in saturated fat, trans fat, cholesterol, and salt, and high in whole grains, fruits, and vegetables.
       • Figure 7
     • Exercise - Do not be scared to exercise due to a diagnosis of AF, rather speak with your doctor on what exercises will work best for you. Also works to reduce stress and controls body weight. Aim for 150 minutes of physical activity per week
       • Figure 17
     • Smoking cessation will not only decrease your risk of AF, but will also decrease your risk of the most common complication of AF being a stroke
     • Alcohol cessation- will decrease frequent episodes of AF
     • Weight reduction
     • Decrease stress- Find out the sources for stress and create a plan to manage them
     • Community-based nurse-led clinics are a clinically and cost-effective delivery method which brings healthcare more accessible to patients. These nurse-led clinicals are described by nurses managing their own patient workload with greater autonomy, utilizing advanced skills of physical assessment, diagnosis and management of drugs. These nurse-led clinics makes healthcare professionals more accessible to patients and allow monitoring of the patient’s healthcare status and condition systematically, in order to determine if the patient is improving or doing worse. Moreover, they also provide holistic care by providing additional educational and psychological support by empowering patients to be the boss of their own healthcare management (Jacob, 2017).
     • Speak with your doctor prior to taking herbal and complementary medication, as they may interfere with AF medication
     • Check your blood pressure regularly, keeping blood pressure <120/80 is optimal and will decrease the risk of AF because the heart will not have to work as hard

9. 9. After 3 weeks of taking her blood thinner, Ms. Smith is asked to come back to the hospital to receive scheduled cardioversion therapy. This is done to ensure that her heart is beating effectively, pumping at a regular rate and rhythm. She is advised not to have anything to eat or drink 8 hours prior to the procedure as she will be put under sedation. Through collaboration of Ms. Smith and the whole healthcare team, Ms. Smith’s cardioversion therapy was a success

   • SURGICAL INTERVENTIONS
     • ATRIAL ABLATION
       • Surgical procedure and it’s minimally invasive, which means cuts and stitches are not required. Utilized advanced 3D technology, by which we can accurately navigate to the regions of the heart and treat the distruped signals. Patient’s recovery duration is short and they usually are discharged the next morning. By this procedure, patients can be symptom-free and have an enhanced quality of life, and not worrying about the side effects of medication and the disease process. Ultimately, it prevents serious complications that comes along with Afib (Snofi, 2013 & Hohnloser et al., 2016).
         • Figure 13
     • ATRIAL PACEMAKER
       • Device typically implanted through the right femoral vein and into the right atrium of the heart using a guidewire under general anesthesia in order to regulate the rate and rhythm of the heart. Heparin is administered in order to maintain an active clotting time between 200 and 300 seconds (Regoli, Moccetti, Pasotti, Auricchio, & Moccetti, 2016; Kotak, 2018)
     • CATHETER ABLATION
       • Procedure that involves threading a catheter using a fluoroscope into the veins to the heart in order to burn abnormal tissue around the openings of the four pulmonary veins in order to create scar tissue. This is done because scar tissue does not conduct electricity therefore electrical firing cannot exit the veins and continue to misfire in the atria ultimately fixing the short-circuit (Providência et al., 2019; Rawshani, 2019)
     • CARDIOVERSION THERAPY
       • Procedure done to correct an arrhythmia and restores pumping efficiency for appropriate blood flow to the body. Two pads are placed over the patient’s skin anteriorly and posteriorly chest wall over the heart, an electrical current (energy jolts) is then administered while the patient is under sedation. This procedure corrects a heart in atrial fibrillation back to normal sinus rhythm. Educate patient to take an anticoagulant 3 weeks prior to the procedure to avoid thromboembolic complications (Hohnloser et al., 2016; Mayo Clinic, 2019)
         • Figure 6
     • Involve multidisciplinary team
       • Anesthesiologist- administers sedative prior to procedure
       • Cardiologist (Medical doctor)- facilitates entire procedure and administers medications
       • Nurse- monitors vital signs and ensures patient comfort
       • Pharmacist- dispenses medication to be used, counsels adverse effects in medication
       • Respiratory therapist- may be required if patients oxygen saturation falls too low <92% or patient adversely goes into respiratory arrest to intubate the patient or attain arterial blood

10. 10. Although she takes medication for AF, there are still times when Ms. Smith feels that her heart is skipping beats. Now that she knows the cause and takes the appropriate medication, having atrial fibrillation does not impact her quality of life, and she is able to enjoy her favourite activities without any barriers caused by AF. Understanding that she has AF alongside with high blood pressure, recognizing the clinical manifestations of stroke, taking new medication, and making lifestyle changes to lower her blood pressure have all been big alterations for Ms. Smith. But now, she follows a new routine, sees her family doctor regularly, and is determined to avoid another trip to the hospital related to AF (Heart and Stroke Foundation of Canada, 2015).

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