Anticoagulant options in atrial fibrillation: When new treatments become standard practice

Direct oral anticoagulants (DOACs) have expanded options for treating patients with atrial fibrillation (AF). However, DOACs are not warfarin substitutes, and NPs need to be aware of the difference. DOACs are first-line agents when treating AF, yet warfarin has not been replaced. Individualized patient characteristics drive current guidelines.

[Oral administration of medicines in elderly patients and adaptation of galenic forms]

Physiological ageing and pathologies can have an influence on the pharmacology of numerous medicines, leading to serious iatrogenic accidents, polypharmacy and incorrect use of a medicine in elderly people. An observational study carried out in a short-stay geriatric unit focused on the issues surrounding the difficulties the elderly may encounter when taking medicines and the prevalence of the manipulation of galenic forms.

Uncertainty and Its Antecedents in Patients With A trial Fibrillation

The aim of this descriptive, correlational, and cross-sectional survey was to explore uncertainty in patients with atrial fibrillation and to examine the relationships between uncertainty and its antecedents, including education, social support, and perceived seriousness of illness in patients newly diagnosed with atrial fibrillation. The theoretical framework of the study was Mishel’s middle-range nursing theory of uncertainty in illness. A convenience sample of 81 participants recruited from two academic medical centers over 10 months was interviewed. Uncertainty was moderately high in patients with atrial fibrillation compared to other clinical populations. Among antecedents of uncertainty, higher education was significantly associated with less uncertainty (= -.21 to -.25). Except for tangible support, persons with greater social supports perceived less uncertainty (= -.25 to -.27), and individuals with greater perceived seriousness of illness reported greater uncertainty (= .30 to .33).

Atrial fibrillation case study

This article discusses the irregular heart rhythm caused by atrial fibrillation (AF). A brief overview of the pathophysiology will be provided. A case study is discussed to highlight the treatment and management of AF. The care provision describes common signs and symptoms and also the treatment and management of AF within the maternity care setting. The importance of maintaining the mother-baby dyad is highlighted. For the purpose of maintaining confidentiality the woman will be referred to as Shama.

Education and practice gaps on atrial fibrillation and anticoagulation: a survey of cardiovascular nurses

BACKGROUND

Patients' knowledge of their atrial fibrillation (AF) and anticoagulation therapy are determinants of the efficacy of thromboprophylaxis. Nurses may be well placed to provide counselling and education to patients on all aspects of anticoagulation, including self-management. It is important that nurses are well informed to provide optimal education to patients. Current practice and knowledge of cardiovascular nurses on AF and anticoagulation in the Australian and New Zealand (ANZ) context is not well reported. This study aimed to; 1) Explore the nurse's role in clinical decision making in anticoagulation in the setting of AF; 2) Describe perceived barriers and enablers to anticoagulation in AF; 3) Investigate practice patterns in the management of anticoagulation in the ANZ setting; 4) Assess cardiovascular nurses' knowledge of anticoagulation.

METHODS

A paper-based survey on current practices and knowledge of AF and anticoagulation was distributed during the Australian Cardiovascular Nursing College (ACNC) Annual Scientific Meeting, February 2014. This survey was also emailed to Cardiovascular Trials Nurses throughout New South Wales, Australia and nursing members of the Cardiac Society of Australia and New Zealand (CSANZ).

RESULTS

There were 41/73 (56%) respondents to the paper-based survey. A further 14 surveys were completed online via nurse members of the CSANZ, and via an investigator developed NSW cardiovascular trials nurse email distribution list. A total of 55 surveys were completed and included in analyses. Prior education levels on AF, stroke risk, anticoagulation and health behaviour modification were mixed. The CHA2DS2VASc and HAS-BLED risk stratification tools were reported to be underused by this group of clinicians. Reported key barriers to anticoagulation included; fears of patients falling, fears of poor adherence to medication taking and routine monitoring. Patient self-monitoring and self-management were reported as underutilised. ANZ cardiovascular nurses reported their key role to be counselling and advising patients on therapy regimens. Anticoagulant-drug interaction knowledge was generally poor.

CONCLUSION

This study identified poor knowledge and practice in the areas of AF and anticoagulation. There is scope for improvement for cardiovascular nurses in ANZ in relation to AF and anticoagulation knowledge and practice.

The Role of Nurses in E-Health: The MobiGuide Project Experience

Leveraging the experience of the European project MobiGuide, this paper elaborates on the nurses' role in developing, delivering and evaluating e-health based services. We focus on the home monitoring of atrial fibrillation. Patients enrolled in our study are provided with a smartphone and an ECG sensor, and receive recommendations, reminders and alerts concerning medications and measurements that they should perform through a mobile decision support system that is constantly updated by a backend system. Patients' data are sent to health care personnel that may visualize them, and act accordingly. Nurses play a central role in such setting. After being involved in the design of the caregiver interface, they are responsible for the patients' enrollment phase (which includes patients' training), for the daily checking of incoming data, for the triage of patients' complaints, and for the final phase of the study where patients are interviewed about their experience with the system.

Stroke prevention in nonvalvular atrial fibrillation: update on target-specific oral anticoagulants

Atrial fibrillation is the most common arrhythmia in adults, and the risk for stroke is increased five-fold. Efforts should be made to educate health care providers to understand the importance of using risk stratification tools. New oral anticoagulants are available for thromboembolic stroke prevention, and knowledge of their clinical indications and use is essential.

Standard versus atrial fibrillation-specific management strategy (SAFETY) to reduce recurrent admission and prolong survival: pragmatic, multicentre, randomised controlled trial

BACKGROUND

Patients are increasingly being admitted with chronic atrial fibrillation, and disease-specific management might reduce recurrent admissions and prolong survival. However, evidence is scant to support the application of this therapeutic approach. We aimed to assess SAFETY--a management strategy that is specific to atrial fibrillation.

METHODS

We did a pragmatic, multicentre, randomised controlled trial in patients admitted with chronic, non-valvular atrial fibrillation (but not heart failure). Patients were recruited from three tertiary referral hospitals in Australia. 335 participants were randomly assigned by computer-generated schedule (stratified for rhythm or rate control) to either standard management (n=167) or the SAFETY intervention (n=168). Standard management consisted of routine primary care and hospital outpatient follow-up. The SAFETY intervention comprised a home visit and Holter monitoring 7-14 days after discharge by a cardiac nurse with prolonged follow-up and multidisciplinary support as needed. Clinical reviews were undertaken at 12 and 24 months (minimum follow-up). Coprimary outcomes were death or unplanned readmission (both all-cause), measured as event-free survival and the proportion of actual versus maximum days alive and out of hospital. Analyses were done on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTRN 12610000221055).

FINDINGS

During median follow-up of 905 days (IQR 773-1050), 49 people died and 987 unplanned admissions were recorded (totalling 5530 days in hospital). 127 (76%) patients assigned to the SAFETY intervention died or had an unplanned readmission (median event-free survival 183 days [IQR 116-409]) and 137 (82%) people allocated standard management achieved a coprimary outcome (199 days [116-249]; hazard ratio 0·97, 95% CI 0·76-1·23; p=0·851). Patients assigned to the SAFETY intervention had 99·5% maximum event-free days (95% CI 99·3-99·7), equating to a median of 900 (IQR 767-1025) of 937 maximum days alive and out of hospital. By comparison, those allocated to standard management had 99·2% (95% CI 98·8-99·4) maximum event-free days, equating to a median of 860 (IQR 752-1047) of 937 maximum days alive and out of hospital (effect size 0·22, 95% CI 0·21-0·23; p=0·039).

INTERPRETATION

A post-discharge management programme specific to atrial fibrillation was associated with proportionately more days alive and out of hospital (but not prolonged event-free survival) relative to standard management. Disease-specific management is a possible strategy to improve poor health outcomes in patients admitted with chronic atrial fibrillation.

FUNDING

National Health and Medical Research Council of Australia.

Atrial electrogram interpretation improves after an innovative education program

BACKGROUND

To avoid adverse patient outcomes from inappropriate treatment, it is recommended that an atrial electrogram (AEG) be recorded whenever atrial arrhythmias develop in patients after cardiac surgery. However, AEGs are not commonly performed because nurses lack knowledge about differentiating atrial rhythms on AEGs.

OBJECTIVE

To investigate whether completing a novel online evidence-based education program on interpreting AEGs would improve critical care nurses' AEG interpretation.

METHODS

Specialized critical care nurses were taught about obtaining and interpreting atrial rhythms on AEGs using a 42-minute online mini-movie. AEG interpretation was assessed pre and two and eight weeks post-intervention.

RESULTS

AEG interpretation increased two weeks post intervention and was retained at eight weeks. Some participants used this newly acquired knowledge to interpret arrhythmias that were not taught during the education program.

CONCLUSION

Accurate interpretation of AEGs is an easy skill for specialized critical care nurses to learn via an online education program.

Recognising and managing atrial fibrillation in the community

Atrial fibrillation (AF) is the most common cardiac arrhythmia and has greater prevalence in the increasing ageing population, with an estimated 10% of those over 80 years having AF. Symptoms associated with AF include palpitations, dizziness, shortness of breath and fatigue. Those presenting with these symptoms need to be investigated and the appropriate treatment should be initiated if AF is detected. For those with AF, there is a significant risk of stroke if patients are not adequately anti-coagulated. This article outlines methods for detecting AF in the community and provides an overview of current treatment options, including the newer anti-coagulant agents. The importance of assessing stroke risk and conveying this risk to those with AF is essential. Community health professionals play an important role in monitoring, treating and managing AF within the community setting and supporting and educating the patient in minimising the risk of serious thromboembolic complications such as stroke.

Nursing and quality of life in patients with atrial fibrillation before and after radiofrequency ablation

The importance of nursing and patient quality of life is a top concern for medical professionals. Therefore, participation by medical professionals in raising awareness and continuously supporting improvements in nursing care is an essential part of improving patient quality of life. Modern medical techniques and procedures are changing rapidly, particularly in the field of cardiology. This has resulted in changing roles and increased responsibility for nurses and confirms the necessity for changing the perception of nurses relative to their role in the medical environment and to patient care. This paper presents the results from the first phase of a research project and focuses on quality of life and problematic areas associated with the needs of patients with atrial fibrillation before and after radiofrequency catheter ablation. Atrial fibrillation is one of the most common supraventricular arrhythmias. Its incidence in the general population has risen significantly over the last twenty years. The objective of this research was to assess those areas, which are considered by patients to be problematic before therapeutic intervention. The research was realized through a quantitative survey using a modified questionnaire. Results showed that AF reduced the quality of life both physically and psychologically (i.e. increased levels of anxiety and depression). Results also showed that radiofrequency catheter ablation was able to alleviate symptoms associated with AF and was also able to increase patient quality of life.

Preventing stroke in patients with atrial fibrillation

Adults with atrial fibrillation are at an increased risk for stroke. New oral antithrombotic agents are now available to help prevent stroke and other thromboembolic events. This article provides an update on factors to consider when determining various treatment options for these high-risk patients in hopes of improving outcomes.

Opportunistic screening for atrial fibrillation

Atrial fibrillation is the most common arrhythmia and the likelihood of having it increases with age. If left untreated it can lead to heart failure and is a significant risk factor for stroke but risk can be greatly reduced with oral anticoagulation. Many people with AF remain asymptomatic, but the risk of stroke remains the same. Simple screening methods will help detect those at risk. Many of those with a diagnosis and at high risk of stroke remain untreated. This two-part series aims to raise awareness of the importance of early detection and appropriate treatment. Part one discusses the complications linked to AF and explores the nurse's role in screening; part two will look at management.

Atrial fibrillation

My first placement as a nursing student was on a cardio-thoracic surgical ward, where patients frequently present with atrial fibrillation (AF). The learning zone article has helped to improve my knowledge and understanding of AF, including symptoms, risk factors, diagnosis and treatment.

[Five scenarios for five… and many more drugs]

The report of the National Observatory on drug is the occasion for a reflection on the different perspectives offered from data on populations and the analysis of patients stories. Five scenarios are presented and briefly commented on of real-life drug prescriptions to elderly patients. Irrational-not evidence based prescriptions, open questions related to the compatibility of some drugs associations, and the limitedness of an answer to patients problems based mainly on drugs, are the main take home messages. A close surveillance oriented to problems and not to drugs, could be the strategy for reconsidering and restoring dignity to what should be a priority research area.

Factors associated with 'caregiver burden' for atrial fibrillation patients

BACKGROUND

The burden on caregivers providing support to atrial fibrillation (AF) patients has not been evaluated.

OBJECTIVE

To examine the interrelationship between unpaid caregiver, patient and thromboprophylaxis characteristics and caregiver burden in AF.

METHODS

We conducted a cross-sectional survey study of AF patient-caregiver dyads recruited from cardiology clinics at an urban teaching hospital. Eligible patients had a diagnosis of AF, received thromboprophylaxis to prevent stroke, lived in the community and had an adult, unpaid, English-speaking caregiver. Hierarchical multivariate regression was used to evaluate the association between caregiver, patient and thromboprophylaxis characteristics and caregiver burden as measured by the 'Caregiver Reaction Assessment' (CRA).

RESULTS

Eighty patient-caregiver dyads were surveyed. The mean ± standard deviation scores for each CRA domain were 'Disrupted schedule' (2.4 ± 1.0), 'Financial problems' (2.1 ± 0.8), 'Lack of family support' (1.9 ± 0.7), 'Health problems' (1.9 ± 0.7) and 'Self-esteem' (0.9 ± 0.5). Significantly greater caregiver burden due to 'Disrupted schedule' was seen in those spending > 4 h/week providing care and when caring for frail, sick or disabled patients, with higher CHADS2 scores and requiring help with their medications. 'Financial problems' burden scores were significantly associated with caring for frail patients and those requiring more frequent office follow-up. 'Lack of family support' scores were inversely associated with having somebody else to help provide care and increased as patients CHADS2 score increased. Lower 'Health problem' burden scores were associated with female gender and higher scores with the need to spend > 4 h/week providing care.

CONCLUSION

The greatest burden to caregivers of AF patients occurs due to schedule disruption.

Radiofrequency catheter ablation for atrial fibrillation

Radiofrequency catheter ablation can lead to improvements in morbidity and mortality rates and quality of life for individuals with atrial fibrillation.

Provider perceptions of implementation of integrated care pathways for patients with chronic heart conditions

Integrated care pathways (ICPs) for atrial fibrillation and congestive heart failure have been examined in the literature. Systematic study, however, of provider experiences with implementation of pathways for these conditions is lacking. Given the pivotal role of nurses in the care of these chronic heart conditions, this information may be valuable for cardiovascular nurses who use pathways for these chronic heart conditions. In this study, qualitative methods were used to systematically examine providers' experiences with the implementation of integrated care pathways for these conditions. Nurses, physicians, and pharmacists provided feedback on their experiences. Analyses revealed that pathways were perceived by providers to have strengths (e.g., improved communication, knowledge, transition, patient involvement and review), but also multiple challenges (e.g., education, timelines, complexity, interest, ownership, coordination, and documentation) when implemented for these complex chronic medical conditions. Provider recommendations for pathway implementation with these conditions are shared in this study. This information may facilitate cardiovascular nurses in implementing ICPs in other centres.

Surgical approaches for atrial fibrillation

The Cox Maze procedure, a cardiac intervention that was developed by James Cox, MD, was first performed in 1988 to surgically cure atrial fibrillation. Over the years, changes in techniques of the classic maze were made, culminating in the Cox Maze III procedure, the Gold Standard. Modifications in the original procedure included simplifying the procedure to a minimally invasive approach. As a result of some of these modifications, the initial maze-like series of surgical atrial incisions has been reduced with the use of alternate energy sources that create hyperthermic lesion lines of conduction block that isolate and interrupt the abnormal impulses. The minimize, a minimally invasive thorascopic approach, can be performed off pump, thus avoiding a median sternotomy and cardiopulmonary bypass and cardioplegic arrest intraoperatively and ensuring a shorter, less painful recovery.

Surgery for atrial fibrillation

Atrial fibrillation (AF) is the most common sustained disturbance of cardiac rhythm, affecting an estimated 2.3 million people in North America and 4.5 million people in the European Union. Although af is associated with significant morbidity, mortality, and increased health care costs, more-precise and less-invasive surgical ablation procedures have been developed. Specific cardiac sites emitting the aberrant, premature electrical signals that induce AF are ablated, which results in excellent cure rates and allows normal sinus rhythm to resume. These procedures can be performed with or without the use of cardiopulmonary bypass, through either traditional sternotomy or minimally invasive thoracotomy incisions.

Supraventricular Dysrhythmias

Cardiovascular nursing practice includes accountability for the clinical and organizational processes to ensure positive outcomes for patients having cardiac dysrhythmias. For patients with supraventricular dysrhythmias, nurses have studied patient outcomes related to mortality, morbidity, quality of life, psychological and physical functioning, and symptoms. Nurses have also explored these same outcomes associated with the management of supraventricular dysrhythmias. In addition, nurses have contributed to understanding organizational outcomes such as healthcare utilization and costs associated with these patients. For patients with atrial fibrillation after cardiac surgery, nurses have studied patient and organizational outcomes related to mortality, morbidity, symptoms, psychological and physical functioning, and economic outcomes. This research has included numerous interdisciplinary studies, and most of it has been descriptive or observational in design. Areas for future nursing outcomes research, including more interventional studies, are discussed.

Spheres of clinical nurse specialist practice influence evidence-based care for patients with atrial fibrillation

PURPOSE

The purpose of this article is to review atrial fibrillation (AF) and its consequences, to present sources of published evidence-based guidelines for management of AF, and to highlight multifaceted clinical nurse specialist (CNS) interventions that promote positive outcomes for patients with AF.

RATIONALE

The number of people with AF is expected to increase from 2.3 million to more than 5 million in the next 50 years. AF is associated with increased mortality, morbidity, healthcare expenditures, and decreased quality of life. Recognition of the growing number of AF cases and adverse consequences of AF led to development of evidence-based guidelines for AF management. Although nurses in diverse settings are accountable for providing evidence-based care for patients with AF, the guidelines have not been widely disseminated to nurses.

DESCRIPTION

This discussion includes a review of the adverse consequences of AF and a summary of management of recently detected AF with a focus on recommendations for nursing activities/interventions that are supported by evidence-based guidelines. Multifaceted strategies directed toward nurses and nursing practice, patients/clients, and organizations/systems that are linked to published CNS competencies and outcomes are highlighted.

OUTCOMES

CNS influence in all 3 spheres of CNS practice promotes positive outcomes that include improved patient/client functioning and self-management, reduced complications of treatment, decreased fragmentation of care, advancement of professional nursing practice, adherence to regulatory standards, and development of patient care processes that are supported by published guidelines.

CONCLUSIONS

With the use of the strategies discussed, clinical nurse specialists, whose spheres of influence include nursing and nursing practice, patients/clients, and organizations/systems, promote improved patient outcomes through implementation of evidence-based guidelines for AF management.

Four years experience of a nurse-led elective cardioversion service within a district general hospital setting

AIMS

External direct current cardioversion is an effective method of restoring sinus rhythm (SR) in patients with persistent atrial arrhythmias. Increasing demand for hospital beds, together with a reduction in junior doctors' hours, has adversely affected cardioversion provision. A regular nurse-led cardioversion service conducted in a dedicated hospital day-unit was introduced to resolve these constraints. There are limited data on the safety or efficacy of such a service.

METHODS AND RESULTS

All cardioversions between October 2000 and October 2004 were performed by an appropriately trained specialist nurse, under general anaesthesia. Patients attended a pre-assessment clinic. Energy requirements for initial and subsequent defibrillations were guided by a local protocol in accordance with the guidelines from American Heart Association, American College of Cardiology, and the European Society of Cardiology. Rectilinear biphasic defibrillation was introduced in January 2004 with an appropriate protocol amendment. In the absence of complications, the aim was to discharge patients the same day. A total of 578 cardioversions (475 monophasic; 103 biphasic) were performed on 464 patients [72.1% male, mean (+/- SD) age 67.8 +/- 9.4 years] with atrial fibrillation (AF) (89.7%) and atrial flutter (10.3%). SR was restored in 84.0 and 100% of patients with AF and atrial flutter, respectively, which increased to 90.2 and 100% following the introduction of biphasic defibrillation. Biphasic shocks cardioverted AF with less energy (163 +/- 22 vs. 289 +/- 81 J) and less cumulative energy (230 +/- 139 vs. 455+/-255 J) than monophasic (P < 0.001 for both), despite no difference in the duration of AF (P = 0.26) or patient age (P = 0.78). Two patients required hospital admission due to transient bradycardia; both were discharged within 72 h, without the need for permanent pacing. A total of 99.6% of patients was discharged home the same day; there were no deaths.

CONCLUSION

The provision of a nurse-led elective cardioversion service is feasible and effective, without compromising safety.

Introduction of nurse led DC cardioversion service in day surgery unit: prospective audit

PROBLEM

Atrial fibrillation is the most common persistent arrhythmia in adults and carries an increased risk of thromboembolism and stroke. Electrical (DC) cardioversion is an effective treatment, but logistical difficulties in many institutions lead to problems providing a prompt service. This reduces the rate of long term success, delays relief of symptoms, and increases the burden on anticoagulation clinics.

DESIGN

Prospective audit of introduction of a collaborative, nurse led DC cardioversion service in a day surgery unit.

SETTING

Day surgery unit 5 km from an acute hospital in southeast London.

KEY MEASURES FOR IMPROVEMENT

Waiting times, success of procedures, and complication rates.

STRATEGIES FOR CHANGE

Collaborative working across traditional specialty boundaries; empowerment of patients within the process; using a nurse consultant as a single point of reference to coordinate the service.

EFFECTS OF CHANGE

Sinus rhythm was restored in 131 (92%) of the first 143 patients treated. Three patients needed hospital admission; all were discharged uneventfully within 24 hours. No important complications occurred. Waiting times were reduced from 27 weeks to eight weeks for patients eligible for the service.

LESSONS LEARNT

Elective DC cardioversion under general anaesthesia can be safely done by an appropriately trained nurse in a day surgery unit remote from an acute general hospital. This model of care is effective and can reduce waiting times and relieve pressure on acute beds and junior doctors.

Initiation and monitoring of class III antiarrhythmic agents

Initiation and Monitoring of Class III Agents. Dofetilide is a Class III antiarrhythmic agent that is approved by the United States Food and Drug Administration (FDA) for use in the conversion of atrial fibrillation, as well as in the maintenance of normal sinus rhythm. Because of the risk of torsades de pointes associated with dofetilide, the FDA mandated in-hospital initiation of therapy and initially restricted dofetilide's availability to institutions and prescribers who completed appropriate educational forums. The use of dofetilide within health care systems requires specific procedures for prescribing, dispensing, and monitoring, as well as a format for educating personnel who will be involved in the care of these patients. Several models have demonstrated success in initiating dofetilide and are also used for sotalol, which also can cause torsades de pointes. The utilization of nonphysician personnel, such as nurse practitioners and clinical pharmacists, in conjunction with a team approach were essential components for the success of these models. Preprinted order forms or procedural guidelines, as well as computer-assisted dosing programs, can be utilized to prevent inappropriate or miscalculated dosing of these agents, which potentially can cause life-threatening ventricular arrhythmias.

Knowledge level and coping strategies according to coagulation levels in older persons with atrial fibrillation

The present study examined the knowledge level and the coping strategies of older persons with atrial fibrillation, who were on oral anticoagulant therapy. The relationship among knowledge level, problem and affective-oriented coping strategies, and the level of anticoagulant effectiveness were examined. We also compared differences between subjects who were within a therapeutic range for International Normalized Ratio levels with those who were not. The research design was descriptive and correlational. One hundred older persons completed the Jaloweic Coping Scale (a knowledge questionnaire) and socio-demographic, contextual and clinical characteristic questions. The findings suggested that the knowledge levels were low (53%), and problem-oriented coping strategies were most often used (32.62%) compared to affective-oriented coping strategies (18.96%). Other than praying and putting one's trust in God (P = 0.05), it appeared that no other significant coping strategies differentiated the subjects regarding their level of anticoagulant effectiveness. It is recommended that further examination of the reasons for older persons' low knowledge level, in regard to their oral anticoagulant therapy, occurs and that use of problem-oriented coping strategies, to improve self-care measures, be encouraged.

Atrial fibrillation: the newest frontier in arrhythmia management

At least 2.3 million people in the United States have atrial fibrillation. Since the risk for developing atrial fibrillation increases with age, the number of people with atrial fibrillation is expected to rise sharply. Atrial fibrillation is a complex condition that adversely influences mortality, morbidity, quality of life, and use of health care resources. Knowledge generated from extensive research has led to innovative management strategies. As the number of individuals with atrial fibrillation increases and treatment options expand, nurses in a variety of settings will be challenged to respond to the multifaceted needs of this population. This review discusses the significance of atrial fibrillation and summarizes research findings influencing current management strategies. Pharmacologic therapies are reviewed and new technologies for atrial fibrillation treatment are introduced. Nursing assessment and treatment of patients' response to atrial fibrillation are discussed. Recommendations for patient education are offered. A plan describing specific nursing diagnoses, outcomes, interventions, and activities for care of patients with atrial fibrillation is presented.

The maze III surgical procedure

The maze III procedure is a surgical treatment for atrial fibrillation (A fib), a rhythm problem in which the heart's upper chambers (i.e., atria) beat rapidly and irregularly, sometimes beating more than 400 times per minute. Approximately 10% of Americans older than 60 years of age suffer from A fib. The maze procedure was designed to create a maze on the atria with multiple incisions that allow sinus rhythm to be conducted to the atrioventricular node without creating a reentry circuit. Currently, it is not a widely used procedure, but its popularity continues to increase. The maze III procedure generally is reserved as a treatment of last resort for a patient with A-fib that is unresponsive to medication therapy, electrical cardioversion, surgical ablation, or pacemaker implantation. The maze III procedure, performed as open-heart surgery, has a high success rate for sustaining normal heart rhythms, usually without the need for a pacemaker; however, all other medical and nonsurgical treatment options are exhausted before the maze III procedure is performed.

Randomised trial of two approaches to screening for atrial fibrillation in UK general practice

BACKGROUND

Atrial fibrillation is a common and treatable cause of stroke that often remains unrecognised. Screening has been suggested but there is very little evidence concerning the uptake of screening in the elderly population at risk, nor of the optimal method of screening in a general practice setting

AIM

To compare the uptake and effectiveness of two methods of screening for atrial fibrillation in general practice--systematic nurse-led screening and prompted opportunistic case finding.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

Patients aged 65 to 100 years (n = 3,001) from four general practices within the MRC general practice framework.

METHOD

Each of the four study practices were selected from one quartile, after ranking all framework practices according to the small area standardised mortality ratio of the geographical area served. Patients were randomised either to nurse-led screening or to prompted opportunistic casefinding. The proportion of patients assessed and the proportion found to have atrial fibrillation were compared. The sensitivity and specificity of clinical assessment of pulse are also reported.

RESULTS

Substantially more patients had their pulse assessed through systematic screening by invitation (1,099/1,499 [73%]) than through opportunistic case finding (439/1,502 [29%], difference = 44%, 95% confidence interval [CI] = 41% to 47%). Atrial fibrillation was detected in 67 (4.5%) and 19 (1.3%) patients respectively (difference = 3.2%, 95% CI= 2.0 to 4.4). Invitation to nurse-led screening achieved significantly higher assessment rates than case finding in all practices; however, the proportion of patients assessed in the case-finding arm varied markedly between practices (range = 8% to 52%). The number needed to screen to identify one additional patient with atrial fibrillation was 31 (95% CI = 23 to 50). The proportion of screened patients with atrial fibrillation receiving anticoagulation treatment was 25%, although in the majority (53/65 [82%]) atrial fibrillation had been previously recorded somewhere on their medical record. If the nurse used any irregularity of the pulse as the screening criterion, the sensitivity of screening was 91% and the specificity was 74%; sensitivity fell to 54% but specificity increased to 98% if the criterion used was continuous irregularity.

CONCLUSIONS

Nurse-led screening for atrial fibrillation in UK general practice is both feasible and effective and will identify a substantial number of patients who could benefit from antithrombotic therapy. Although the majority of patients detected at first screening could be identified by careful scrutiny of medical records, review of record summaries was insufficient in the practices involved in this study and screening may be a more cost-effective option.