CE 3 HOURS

Continuing Education

Atrial Fibrillation:
Updated Management
Guidelines and Nursing
Implications
The focus is on symptom control, stroke prevention, and patient adherence.

OVERVIEW: Atrial fibrillation, the most common chronic cardiac arrhythmia, adversely affects the quality of
life of millions of people. The condition is frequently associated with advancing age, structural cardiac dys-
function, and preexisting comorbidities. The most common complications, stroke and heart failure, result in
significant morbidity and mortality. Indeed, atrial fibrillation is responsible for over 450,000 hospitalizations
and 99,000 deaths annually and adds up to $26 billion to U.S. health care costs each year. Given the aging of
the U.S. population, the incidence of atrial fibrillation is expected to double within the next 50 years. There is
evidence that nursing intervention in patient education and transition of care coordination can improve ad-
herence to treatment plans and patient outcomes.
This article reviews the recently updated guideline for the management of atrial fibrillation, issued jointly
by the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society. It
focuses on the prevention of thromboembolism and on symptom control, and stresses the importance of
patient adherence to treatment plans in order to ensure better outcomes.

Keywords: arrhythmia, atrial fibrillation, care coordination, older adults, patient education, stroke prevention,
treatment guidelines

A
trial fibrillation, the most common chronic
cardiac arrhythmia,1 is frequently associated
with advancing age, structural cardiac dys-
function, and preexisting comorbidities.2 Its esti-
mated that between 2.7 and 6.1 million Americans
currently live with this condition,2, 3 with nearly
75% of cases reportedly occurring in people over
65 years of age.4 According to results from the
Framingham Heart Study, the lifetime risk of de-
veloping atrial fibrillation is one in four.5 Given
the aging of the U.S. population, the incidence is
expected to more than double over the next 50
years.3, 6
Atrial fibrillation has significant financial implica-
tions for our health care system. Atrial fibrillation
related expenses alone add an estimated $6 billion
to U.S. health care costs annually; when other associ-
ated cardiovascular and noncardiovascular care costs
are factored in, this figure jumps to $26 billion.7 An
analysis of 2001 data found that in the United States,
atrial fibrillation accounted for about 350,000 hospi-
talizations, 5 million office visits, 276,000 ED visits,

26 AJN May 2015 Vol. 115, No. 5 ajnonline.com


and 234,000 ambulatory care visits annually.8 More
recent estimates put the number of hospitalizations
with atrial fibrillation as the primary diagnosis at over
450,000 per year.2 As the number of older Americans
rises, the costs associated with atrial fibrillation can
be expected to increase as well.
Adherence to treatment guidelines for atrial fibril-
lation can help to optimize treatment and reduce as-
sociated costs.9 Indeed, in general, the importance of
patient adherence to the prescribed treatment regimen
is well known. Nurses thus have a vital role to play in
ensuring that patients (or their caregivers) understand
and can follow the plan of care.
This article reviews the recently updated guideline
for the management of atrial fibrillation and discusses
the nursing implications. The guideline was issued
jointly last year by the American Heart Association
(AHA), the American College of Cardiology (ACC),
and the Heart Rhythm Society (HRS).2 Its recommen-
dations constitute the most current evidence-based
standardwhat the guideline refers to as guideline-
directed medical therapyfor the management of
atrial fibrillation. The primary therapeutic goals are
the prevention of thromboembolism and symptom
control.
The frequency with which treatment guidelines for
atrial fibrillation continue to be updated speaks to
both the prevalence and the serious health care impli-
cations of the condition. The 2014 AHA/ACC/HRS
guideline updates earlier versions published in 2006
and 2011.2 (The European Society of Cardiology has
also updated its guidelines, most recently in 2010 and
2012.6, 10) Notable themes in this newest guideline are
the importance of patient involvement in and adher-
ence to the prescribed plan of care and the value of
an individualized treatment plan. (See Table 12, 11-16 for
a summary of past and current guideline recommen-
dations.)
ATRIAL FIBRILLATION: AN OVERVIEW
Pathophysiology. Unlike other cells, cardiac cells are
capable of self-stimulation. Although this ability is
protective if the hearts conduction system fails, it can
also cause ectopic activity in the cardiac cells and re-
sult in atrial (or, worse, ventricular) fibrillation. In
atrial fibrillation, multiple atrial cells self-stimulate,
behaving as individual pacemakers and competing
ajn@wolterskluwer.com
By Christine L. Cutugno, PhD, RN
with the sinoatrial node for control of cardiac activity.
Normal atrial contractions are replaced by rapid
quivering movements, and the atria stop contracting
effectively.
This lack of coordinated atrial contractions can
result in two of the most common complications of
atrial fibrillationthrombi formation and heart fail-
ure. The formation of thrombi on the atrial walls and
within the left atrial appendage (LAA) occurs when
ineffective emptying allows blood to pool in these
chambers. Commonly referred to as mural thrombi,
these clots can dislodge and cause strokes and other
systemic thromboemboli. The lack of coordinated
atrial contractions can also result in less blood enter-
ing and leaving the left ventricle. The loss of what is
often called atrial kick can decrease cardiac output
by as much as 30%.17 If normal cardiac output can-
not be maintained, heart failure and pulmonary con-
gestion will result.
Atrial fibrillation often occurs in patients with
comorbidities and with structural cardiac defects. As
January and colleagues note in the current AHA/
ACC/HRS guideline, structural abnormalities such
as fibrosis and hypertrophy occur most commonly
in the setting of underlying heart disease associated
with hypertension, coronary artery disease, valvular
heart disease, cardiomyopathies, and [heart failure],
and these conditions tend to increase [left atrial]
pressure, cause atrial dilation, and alter wall stress.2
Comorbidities such as obesity, diabetes mellitus, and
hyperthyroidism; alcohol or drug use; and systemic
influences such as excessive autonomic nervous sys-
tem stimulation (causing catecholamine imbalances)
and excessive reninangiotensinaldosterone activa-
tion (causing sodium retention and hypertension) can
also cause abnormalities.2
An analysis of 2011 data from the Centers for
Medicare and Medicaid Services serves to illustrate
the incidence of various chronic comorbidities in two
groups of beneficiaries with atrial fibrillation: those
younger than 65 years and those ages 65 and older.2
In both groups, more than 80% had hypertension
and more than 50% had ischemic heart disease, hy-
perlipidemia, or heart failure. Other common comor-
bidities included anemia, arthritis, diabetes mellitus,
and chronic kidney disease. (Its also worth noting
the difference in the numbers of beneficiaries in the
AJN May 2015 Vol. 115, No. 5 27
 Normal sinus rhythm
Atrial fibrillation with rapid ventricular response
Atrial fibrillation with controlled ventricular response
Figure 1. Normal Sinus Rhythm and Two Types of Atrial Fibrillation. Images courtesy of ECGGuru.com.
two groups: 105,878 in the younger group and
2,426,865 in the older group.)
January and colleagues also point to aging and en-
vironmental stress as factors; both have been linked
to inflammation and may play a role in the onset of
atrial fibrillation.2 Inflammatory mediators (such as
C-reactive protein and interleukin-6) have been asso-
ciated with such physiologic stressors as pericarditis,
cardioversion, and cardiac surgery, and have been
implicated in the onset of atrial fibrillation.2 Because
of these multiple variables and potential complica-
tions, managing atrial fibrillation is challenging.
Disease classification. Atrial fibrillation is charac-
terized by the frequency and duration of episodes,
and is classified into five categories: paroxysmal,
persistent, long-standing persistent, permanent, and
nonvalvular. (For detailed descriptions of the five
categories, see Table 2.2) A single patient can have
both paroxysmal and persistent episodes. Categori-
zation has implications for various treatment proce-
dures (such as catheter ablation) and therapy decisions,
including the medications indicated and the diagnos-
tic procedures chosen (such as cardioversion), as dis-
cussed later in this article.
28 AJN May 2015 Vol. 115, No. 5 ajnonline.com
Risk factors. The incidence of atrial fibrillation is
strongly associated with having one or more risk fac-
tors, with one study finding that 57% of patients with
atrial fibrillation had one or more risk factors, hyper-
tension being the most common.18 Besides advancing
age, hypertension, and the aforementioned cardiac
diseases, other clinical risk factors include diabetes
mellitus; hyperthyroidism; obesity; obstructive sleep
apnea; and alcohol, tobacco, or drug use.2 Biomark-
ers include increased levels of C-reactive protein and
B-type natriuretic peptide.2
CLINICAL ASSESSMENT
A diagnosis of atrial fibrillation is confirmed by elec-
trocardiography (ECG) and other studies suggested
by the patients history and physical assessment.
These may include chest X-ray, transesophageal
echocardiography (TEE), various types of ambula-
tory rhythm monitoring (such as by using a Holter
monitor or a Zio patch, insertable loop recorder, or
event recorder), exercise testing, and electrophysio-
logical studies.2 Additional testing may be indicated
by the presence of risk factors and associated comor-
bidities.
Table 1. Major Changes in Guideline Recommendations for the Management of Atrial Fibrillation

Prior Current 2014 Evidence-based support for recommended

Category
recommendations11-13 recommendations2 changes
Recommended Resting HR < 80 bpm; HR < 110 bpm at rest for More patients achieved target HR with fewer
target heart rates exercise HR < 110 bpm asymptomatic patients drugs, lower doses, and fewer provider visits.15
(remains without signs of HF
controversial)
Benefit of rhythm- Rhythm control a long- Rhythm control indicated for No benefits seen for rhythm-control vs. rate-
control vs. rate- term goal persistent symptoms control strategies.2, 12, 14 Lenient rate control
control strategies didnot increase mortality; frequency of
hospitalizations and adverse events were
similar.15
Risk assessment CHADS2 used for CHA2DS2-VASc CHA2DS2-VASc adds age, sex differentiation,
for stroke and stroke risk assessment recommended for and vascular disease history to CHADS2
bleeding strokerisk assessment HAS-BLED evaluates patient based on hyper-
HAS-BLED recommended tension, abnormal liver or renal function,
to evaluate risk of bleeding stroke or bleeding history, labile INRs, elderly
(age > 65), drug and alcohol use

Antithrombotic Warfarin (Coumadin) Warfarin still Newer antithrombotics

agents recommended for have a wider therapeutic window than
AFpatients with warfarin
mechanical heart valves eliminate dietary restrictions and have
Newer antithrombotics fewer drug interactions
added for nonvalvular are more expensive
AF: dabigatran (Pradaxa), do not require blood testing (unlike
rivaroxaban (Xarelto), warfarin)16
apixaban (Eliquis)
Routine use of Recommended to Removed as a Lack of data linking aspirin use to reduced
ASA decrease stroke risk in recommendation owing to incidence of strokes
patients with low lack of supporting evidence
cardiovascular risk
Ablation therapy Not enough available Broader use encouraged for Procedure has been demonstrated useful and
data to determine certain symptomatic AF safe for some AF patients
scope of usefulness patients refractory to
medications and other
treatments
AF = atrial fibrillation; ASA = acetylsalicylic acid (aspirin); CHADS2 = congestive heart failure, hypertension, age 75 years, diabetes mellitus, prior stroke or transient ischemic
attack (TIA) or thromboembolism (TE) (doubled); CHA2DS2-VASc = congestive heart failure, hypertension, age 75 years (doubled), diabetes mellitus, prior stroke or TIA or TE
(doubled), vascular disease, age 6574 years, sex category; HAS-BLED = hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile interna-
tional normalized ratio, elderly, drugs/alcohol concomitantly; HF = heart failure; HR = heart rate; INR = international normalized ratio.

Signs and symptoms. Atrial fibrillation can be
asymptomatic and may go unrecognized. Common
symptoms include fatigue, palpitations, dyspnea, hy-
potension, and syncope. Less commonly, patients
may present with symptoms (such as shortness of
breath or evidence of systemic emboli) of serious
hemodynamic conditions (such as heart failure or
stroke, respectively). One study enrolled 2,580 older
adults with hypertension and no history of atrial
f ibrillation and monitored them continuously for
three months.19 Over the course of the study, the re-
searchers found a substantial incidence of subclini-
cal atrial tachyarrhythmias; the occurrence of such
tachyarrhythmias was associated with a significantly
higher risk of stroke.
On physical assessment, the heart rate of new on-
set or untreated atrial fibrillation is generally rapid,
because the ventricles are responding with relatively

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 Table 2. Classification of Atrial Fibrillation

Paroxysmal AF AF that terminates spontaneously or with intervention within 7 days of onset.
Episodes may recur with variable frequency.
Persistent AF Continuous AF that is sustained >7 days.
Long-standing Continuous AF of > 12 months duration.
persistent AF
Permanent AF Permanent AF is used when there has been a joint decision by the patient and
clinician to cease further attempts to restore and/or maintain sinus rhythm.
Acceptance of AF represents a therapeutic attitude on the part of the patient and
clinician rather than an inherent pathophysiological attribute of the AF.
Acceptance of AF may change as symptoms, the efficacy of therapeutic interventions,
and patient and clinician preferences evolve.
Nonvalvular AF AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart
valve, or mitral valve repair.
AF = atrial fibrillation.
Reprinted with permission from January CT, et al. The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation
2014;130(23):e199-e267.2

little impediment to excessive atrial activity. Patients
usually present with tachycardia, with rates often as
high as 130 beats per minute (or higher). Atrial fibril-
lation can frequently be detected when taking a pulse.
The patients pulse may be noticeably irregular and
vary in strength as a result of irregular ventricular fill-
ing times (and thus varying stroke volumes). Atrial
fibrillation can be recognized on ECG by its wavy, er-
ratic baseline; the absence of discreet and identifiable
P waves; and varying R-R intervals (reflecting vary-
ingventricular response.) (See Figure 1 for illustra-
tive ECG strips.)
Early evaluation of the effectiveness of cardiac ac-
tivity is essential. Sustained tachycardia can result in
cardiac ischemia, angina, and heart failure. Coronary
arteries are perfused during diastole (or between dias-
tole and systole); thus, the faster the heart rate, the less
diastolic filling time, limiting such perfusion. Ischemia,
seen on ECG as ST-segment and T-wave changes, can
be more readily observable during tachycardia.
MANAGEMENT: THE UPDATED GUIDELINES
Managing or preventing atrial fibrillation involves
addressing modifiable risk factors through lifestyle
changes, which might include smoking cessation, ex-
ercise, weight management, and treatment for alcohol
or drug abuse. Beyond this, treatment centers on pre-
venting thromboembolism and controlling heart rate.
Because of the effects of atrial fibrillation on cardiac
output, even when heart rate is within the normal
range, heart failure can occur. If atrial fibrillation
remains symptomatic despite rate control, more ag-
gressive measures such as ablation may be considered.
Stroke prevention: stroke and bleeding risk strat-
ification. People with untreated or undertreated atrial
fibrillation are at high risk for thromboembolism;
to lower that risk, anticoagulation therapy is recom-
mended.11 But this increases the risk of bleeding com-
plications and a potentially devastating outcome.
Risk stratification for both stroke and bleeding can
help guide informed decision making.20
Stroke risk stratification tools include the CHADS2
score (the acronym stands for congestive heart failure,
hypertension, age 75 years or older, diabetes mellitus,
prior stroke or transient ischemic attack or thrombo-
embolism [doubled]) and the more recently developed
CHA2DS2-VASc score (the acronym stands for con-
gestive heart failure, hypertension, age 75 years or
older [doubled], diabetes mellitus, prior stroke or
transient ischemic attack or thromboembolism [dou-
bled], vascular disease, age 65 to 74 years, sex cate-
gory). As the acronym shows, the latter tool considers
additional risk factors such as female sex and the pres-
ence of vascular disease; it also allows for some dif-
ferentiation by age, which is important because stroke
risk increases with every year over the age of 65.20 The
2014 AHA/ACC/HRS guideline discusses the broader
use of CHA2DS2-VASc for assessing stroke risk in pa-
tients with nonvalvular atrial fibrillation. Using the rec-
ommended CHA2DS2-VASc tool, adjusted stroke rate
scores have been found to range from 0% to 15.2%
per year.21 (See Table 3 at http://links.lww.com/AJN/
A67.2, 21)
Bleeding risk stratification scoring systems such as
HAS-BLED (the acronym stands for hypertension,
abnormal renal or liver function, stroke, bleeding his-
tory or predisposition, labile international normalized
ratio [INR], elderly, drugs or alcohol concomitantly)
evaluate bleeding risk based on several salient factors.
As the acronym suggests, the HAS-BLED system con-
siders hypertension, history of stroke or bleeding, labile
INRs, age over 65 years, use of drugs that promote

30 AJN May 2015 Vol. 115, No. 5 ajnonline.com

bleeding or alcohol use (or both), and renal and liver
function.2, 22 (See Table 4 at http://links.lww.com/AJN/
A68.22)
Stroke prevention: antithrombotic agents. An-
tithrombotic agents currently used to treat atrial fi-
brillation include established anticoagulants such as
warfarin (Coumadin, Jantoven), unfractionated hepa-
rin, and low-molecular-weight heparin; newer throm-
bin and factor Xa inhibitors; and antiplatelet drugs
such as clopidogrel (Plavix). Aspirin alone is no lon-
ger recommended as data of effectiveness are lacking.2
The U.S. Food and Drug Administration has recently
approved several newer antithrombotics, including
dabigatran (Pradaxa), rivaroxaban (Xarelto), and
apixaban (Eliquis), and these may be considered in
certain cases.2 Like warfarin, these newer drugs re-
quire strict adherence in order to be effective. More-
over, they have not been tested for use in patients
with mechanical heart valves or hemodynamically
significant mitral stenosis; these patients should be
treated with warfarin.2
The choice of agent will be based on an assessment
of the patients clinical status, ability to adhere to the
medication regimen, and bleeding risk; the drugs elim-
ination route; potential drugdrug interactions; pro-
vider preference; and cost considerations. Although
warfarin is an established and effective antithrom-
botic, it has several disadvantages, including the need
for dietary restrictions, its potential for multiple drug
interactions, and the need for frequent INR testing to
determine adequate therapeutic levels. A recently pub-
lished meta-analysis of eight trials of patients on war-
farin found that, on average, patients spent only 55%
to 68% of the trial period in the therapeutic INR
range.23 Warfarin has the advantage of having a re-
versal agent, vitamin K; but the other antithrombotics
have much shorter half-lives. Aspirin alone has not
been found effective for preventing stroke in patients
with atrial fibrillation.2 For more on pharmacologic
therapy for atrial fibrillation, see Table 5.2. 24, 25
Rate control. For patients who are asymptomatic
and show no signs of heart failure, the 2014 AHA/
ACC/HRS guideline recommends a resting heart rate
of less than 110 beats per minute.2 This relatively le-
nient target allows patients to achieve the target rate
with fewer drugs, lower doses, and fewer provider vis-
its. But for symptomatic patients, the recommended
heart rate target is less than 80 beats per minute; and
when patients have underlying cardiac disease or other
comorbidities, the target rate must be individualized.
Rate control reduces the morbidity associated with
sustained tachycardia (such as cardiomyopathy) and
decreases the distressing cardiac and hemodynamic
symptoms associated with rapid heart rates.
Recommended and commonly used drugs for
rate control include -adrenergic antagonists (also
called -blockers) and calcium channel antagonists
(also called calcium channel blockers); digoxin (Lan-
ajn@wolterskluwer.com
oxin) and amiodarone (Cordarone and others) may
be indicated in particular clinical situations. The Atrial
Fibrillation Follow-Up Investigation of Rhythm Man-
agement (AFFIRM) study evaluated the effectiveness
of such drugs in controlling heart rate in 2,027 pa-
tients.26 Heart rate control was achieved in 70% of
patients receiving -blockers (alone or with digoxin),
in 54% of those receiving calcium channel blockers
(alone or with digoxin), and in 58% of those receiv-
ing digoxin alone.
With any drug, the potential for unwanted
sideeffects must be considered relative to (or bal-
anced against) the patients clinical condition. Both
-blockers and calcium channel blockers can cause
arrhythmias, heart failure, and hypotension. Heart
failure can result from the negative inotropic effects
of these drugs; and hypotension can result from their
blocking of the vasoconstrictive effects of the sym-
pathetic nervous system. Patients with asthma may
be at higher risk for bronchospasm; the use of cardio
selective -blockers will mitigate this risk. In acutely
ill patients, iv administration of these medications
is indicated. Patients must be closely monitored for
unwanted side effects. Since some of these medica-
tionscan cause sustained bradycardia, in cases of
long-term use prophylactic pacemaker insertion may
be indicated.
Rhythm control. The conversion of atrial fibril
lation to normal sinus rhythm has been shown to
decrease symptoms.2 Rhythm control is most often
used in patients with new-onset atrial fibrillation;
in younger patients; and in patients whose symp-
toms remain unresponsive to, or who are intolerant
of, rate-control medications. Atrial fibrillation of long
duration is much more difficult to convert. Rhythm
control may involve the use of antiarrhythmics, electri-
cal cardioversion, ablation, or a combination of these.
Treatment choices vary depending on the patients
age, the patients clinical presentation, and the du
ration and classification of the atrial fibrillation. No
benefits for rhythm-control versus rate-control strate-
gies have been found; and neither approach has shown
superiority in decreasing mortality.2, 12, 14
Pharmacologic cardioversion. Several antiar-
rhythmic agents (amiodarone, dofetilide [Tikosyn],
flecainide [Tambocor], propafenone [Rythmol], and
ibutilide iv [Corvert]) have demonstrated effective-
ness in converting atrial fibrillation.2 But most have
contraindications and will not be appropriate for
all patients. Moreover, each has significant and life-
threatening adverse effects that require some duration
of ECG assessment for bradycardia or prolongation
of the QT interval.2
A meta-analysis of 39 randomized controlled trials
found that amiodarone was the most effective drug for
maintaining normal sinus rhythm once atrial fibrilla-
tion had been converted; but it was also associated
with the highest rate of adverse events.27 Dronedarone
AJN May 2015 Vol. 115, No. 5 31
 Table 5. Pharmacologic Therapy for Atrial Fibrillation (Evaluation Ongoing)a

32
Generic name Brand name Drug category Precautions
Antithrombotic therapy
ASA (aspirin) Antiplatelet No studies showed effectiveness of ASA alone2
Clopidogrel Plavix Antiplatelet Some studies showed effectiveness in combination with low-dose ASA2, 24
Warfarin Coumadin, Jantoven Vitamin K antagonist Recommended for AF patients with mechanical heart valves2
(antidote available: Narrow therapeutic window25

AJN May 2015

vitamin K) Varying dose response

Dietary restrictions
Multiple OTC and prescription drug interactions
Bridge therapy to oral antithrombotics

Vol. 115, No. 5

Unfractionated Inactivator of several iv administration route
heparin clotting factors Monitor for signs of bleeding, monitor PTT
(antidote available:
protamine sulfate)
LMWH Lovenox sc administration route
Monitor for signs of bleeding
Newer antithrombotics
Dabigatran Pradaxa Direct thrombin inhibitor Not recommended for patients with mechanical heart valves2
(no antidote, but has Not recommended for patients with liver disease2
faster onset and shorter Can be used in patients with CKD with a dose adjustment, except in cases of severe or
duration of action than end-stage renal disease2
warfarin) Strict adherence is critical2
Rivaroxaban Xarelto Direct factor Xa inhibitor Not evaluated in patients with mechanical heart valves or heart failure2
(no antidote) Can be used in patients with CKD with a dose adjustment, except in cases of severe or
end-stage renal disease2
Strict adherence is critical2
Apixaban Eliquis Direct factor Xa inhibitor Not evaluated in patients with mechanical heart valves2
(no antidote) Can be used in patients with CKD with a dose adjustment, except in cases of severe or
end-stage renal disease2
Strict adherence is critical2

ajnonline.com
 Antiarrhythmics: rate control
Metoprolol Lopressor -adrenergic Caution and periodic assessment in patients with heart failure or bradycardia
antagonists, also called Caution with asthma
Atenolol Tenormin
-blockers (lower heart

ajn@wolterskluwer.com

Nadolol Corgard rate, conduction speed,
force of LV contraction)
Propranolol Inderal and others
Esmolol Brevibloc
Sotalol Betapace, Sorine
Verapamil Calan and others Calcium channel Caution and periodic assessment in patients with hypotension
antagonists, also called
Diltiazem Cardizem and others calcium channel blockers
(act as antiarrhythmics,
antihypertensives)
Antiarrhythmics: rhythm conversion and maintenance
Digoxin Lanoxin Inotropic agent Should not be used as first-line treatment for AF; when used in combination with other
drugs, titrate to avoid bradycardia2
One of the few agents with positive inotropic effects
Amiodarone Cordarone and others Antiarrhythmic Phlebitis, hypotension, arrhythmias, increased INR levels2
Dronedarone Multaq Antiarrhythmic Not recommended for patients with heart failure or in permanent AF24
Flecainide Tambocor Antiarrhythmic Arrhythmias, hypotension
Reasonable for out-of-hospital use, once observed to be safe in a monitored setting2
Dofetilide Tikosyn Antiarrhythmic Arrhythmias
Should not be initiated out of the hospital2
Propafenone Rythmol Antiarrhythmic Arrhythmias, hypotension
Avoid with CAD and structural heart disease2
Reasonable for out-of-hospital use, once observed to be safe in a monitored setting2

AJN May 2015

Ibutilide Corvert Antiarrhythmic Arrhythmias, hypotension

iv administration route2
AF = atrial fibrillation; ASA = acetylsalicylic acid; CAD = coronary artery disease; CKD = chronic kidney disease; INR = international normalized ratio; LMWH = low-molecular-weight heparin; LV = left ventricle; OTC = over the
counter; PTT = partial thromboplastin time; sc = subcutaneous.
a
Treatment of precipitating factors and reversible causes of atrial fibrillation is recommended prior to other treatment measures when possible. Consider specific drug-related risks, mode of elimination, and patient contrain-

Vol. 115, No. 5

dications when choosing medications. Selections vary for patients with mechanical heart valves.

33
 Table 6. Summary of Recommendations for Thromboembolism Prevention and Electrical Cardioversion
of Atrial Fibrillation and Atrial Flutter
Thromboembolism prevention
With AF or atrial flutter of 48 hours or unknown duration, anticoagulate with warfarin for at least 3
weeks before and 4 weeks after cardioversion.
With AF or atrial flutter of 48 hours or unknown duration requiring immediate cardioversion, anticoagulate
as soon as possible and continue for at least 4 weeks.
With AF or atrial flutter < 48 hours and high stroke risk, iv heparin or LMWH, or factor Xa or direct thrombin
inhibitor, is recommended before or immediately after cardioversion, followed by long-term anticoagulation.
With AF or atrial flutter for 48 hours or unknown duration and no anticoagulation for preceding 3 weeks,
it is reasonable to perform TEE before cardioversion and then cardiovert if no LA thrombus is identified,
provided anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks.
With AF or atrial flutter 48 hours or unknown duration, anticoagulation with dabigatran, rivaroxaban,
or apixaban is reasonable for 3 weeks before and 4 weeks after cardioversion.
With AF or atrial flutter < 48 hours and low thromboembolic risk, iv heparin, LMWH, a new oral anticoagulant,
or no antithrombotic may be considered for cardioversion.
Direct-current cardioversion
Preferred in patients with decompensated heart failure, ongoing myocardial ischemia or hypotension,
though this may raise the risk of thrombotic emboli in patients inadequately anticoagulated or for whom
AF is of uncertain duration.
Current ACLS guidelines recommend synchronized cardioversion using the initial biphasic energy level
of 120 to 200 joules.28
Cardioversion is recommended for AF or atrial flutter, or for AF or atrial flutter with RVR that does not
respond to pharmacologic therapies, to restore sinus rhythm. If unsuccessful, repeat cardioversion attempts
may be made.
Cardioversion is recommended for AF or atrial flutter and preexcitation with hemodynamic instability.
It is reasonable to repeat cardioversions in persistent AF when sinus rhythm is maintained for a clinically
meaningful time period between procedures.
ACLS = advanced cardiovascular life support; AF = atrial fibrillation; LA = left atrial; LMWH = low-molecular-weight heparin; RVR = rapid ventricular
response; TEE = transesophageal echocardiography.
Adapted with permission from January CT, et al. The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation
2014;130(23):e199-e267.2

(Multaq) was associated with the lowest rate of ad-
verse events. Other drugs shown to be effective in
maintaining normal sinus rhythm following cardio-
version include dofetilide, flecainide, propafenone,
and sotalol (Betapace, Sorine).2, 27
Electrical cardioversion. The purpose of electrical
cardioversion is to depolarize all of the cardiac cells si-
multaneously in an effort to prompt a normal cardiac
rhythm. This involves delivering an electrical shock
synchronized to the QRS complex (in order to avoid
delivering current during the T wave, which could
cause ventricular fibrillation). Cardioversion is per-
formed under moderate sedation with ECG moni-
toring; advanced cardiac life support (ACLS)trained
staff should be present and resuscitation equipment
available. The standard of care for hemodynamically
unstable patients remains immediate electrical cardio-
version.2
The 2014 AHA/ACC/HRS guideline mentions
several factors that can increase the effectiveness of
electrical cardioversion (such as the initial use ofa
higher-energy shock), although more specific recom-
mendations arent given.2 Current ACLS guidelines
recommend using an initial biphasic energy level of
120 to 200 joules.28 A higher initial energy level may
reduce both the number of shock attempts and the
duration of sedation needed. Its also important to
determine whether the cardioversion attempt re-
sulted in normal sinus rhythm, even transiently. If
itdid, but atrial fibrillation has recurred, treatment
with an antiarrhythmic medication before making
subsequent attempts is recommended.2 If the rhythm
wasnt converted, then measures to maximize en-
ergydelivery are recommended. These include using
abiphasic defibrillator, using anteroposterior elec-
trode placement, and pretreating the patient with a

34 AJN May 2015 Vol. 115, No. 5 ajnonline.com

medication that lowers the defibrillation threshold
(such as ibutilide).
Under nonemergent conditions, and depending
onthe patients clinical presentation, anticoagula-
tion pretreatment for at least three weeks may be
recommended before either pharmacologic or elec-
trical cardioversion.2, 29 When emergency cardiover-
sion is performed, antithrombotics should be started
before or during the procedure, if possible, and con-
tinued afterward; regardless, emergency cardioversion
should not be delayed.29 When cardioversion is elec-
tive, TEE can provide an alternative to anticoagulation
pretreatment.2, 29 TEE allows visualization of the inner
chambers of the atria and can help in the detection
of mural thrombi. If the atrial fibrillation has lasted
48 hours or less, neither TEE nor antithrombotic pre-
treatment is generally indicated, but antithrombotics
should be given at full venous thromboembolism
treatment doses during and after cardioversion.29 If
the atrial fibrillation has lasted longer than 48 hours,
or if the duration is unknown, evaluation with TEE
and antithrombotic pretreatment are recommended.2, 29
Anticoagulation treatment should continue for at least
four weeks after cardioversion.
For a summary of current AHA/ACC/HRS recom-
mendations for cardioversion, see Table 6.2, 28
Supplemental treatment modalities include the
following.
Occlusion of the LAA. The LAA is the primary
source of thromboembolism in patients with nonval-
vular atrial fibrillation.2, 30 It can be excluded as such a
source either with devices inserted percutaneously or
during cardiac surgery. The percutaneously inserted
devices, which occlude or tie off the opening of the
LAA, are still under investigation, but may be consid-
ered for use in patients who dont respond to pharma-
cologic anticoagulation. There is a lack of consensus
regarding the use of surgical procedures to exclude the
LAA during concomitant cardiac surgery. Removal
has yielded inconsistent results; and the data reveal
highly variable rates of successful LAA occlusion.2
Radiofrequency catheter ablation and the Cox
maze procedure. The 2014 AHA/ACC/HRS guideline
recommends radiofrequency catheter ablation for
symptomatic patients who are refractory to or can-
not tolerate other treatments.2 The procedure involves
inserting catheters to locate areas of atrial tissue that
are causing fibrillation and then scarring the pulmo-
nary veins in those areas to prevent the conduction
of ectopic stimuli.31 In a study of 323 patients treated
with catheter ablation and followed for two years,
72% maintained normal sinus rhythm without anti-
arrhythmics; an additional 15% maintained it with
antiarrhythmics.32 Improvement in atrial fibrillation
related symptoms and quality of life were also noted.
A recent literature review concluded that catheter
ablation appears to be safe for use in appropriately
screened elderly patients, with one study reportedly
ajn@wolterskluwer.com
finding an average complication rate of 4.5%.33 And
a large study of adults who had undergone an initial
ablation procedure found that 5% had serious peri-
procedural complications, including perforation,
cardiac tamponade, and stroke.34 Other potential
complications include atrial-esophageal fistula, myo-
cardial infarction, pericarditis, pulmonary vein steno-
sis, vascular complications, and death.
Early versions of the Cox maze procedure (often
called simply the maze procedure) required sur-
geons to surgically ablate atrial tissue using cut and
sew methods. Of these, the Cox maze III is still some-
times performed. In the most recent version, known
as the Cox maze IV, surgeons use radiofrequency ab-
lation or cryoablation techniques to achieve the same
end. The Cox maze procedure may be appropriate for
select patients undergoing concomitant cardiac surgery
for other reasons or for highly symptomatic patients
whose atrial fibrillation isnt well managed.2 In a study
of 112 patients undergoing the most recent procedure,
50% to 87% of patients were free from atrial fibril-
lation at six months follow-up.35 (The range reflects
variation according to the duration of atrial fibrilla-
tion and whether patients required continuing treat-
ment with antiarrhythmics.) The overall complication
rate was 10%.
Pacemakers and nodal ablation. Pacemakers are
indicated primarily for patients who develop symp-
tomatic bradycardia as a result of pharmacotherapy
for atrial fibrillation.2 (These patients often have
underlying sick sinus syndrome.) Pacemakers are
also used in patients with refractory atrial fibrilla-
tion who have been treated with nodal ablation.2 In
nodal ablation, radiofrequency catheter ablation is
used to obliterate the atrioventricular node, thus pre-
venting the atrias rapid, irregular impulses from reach-
ing the ventricles.
Aside from such cases, neither pacemakers nor im-
plantable cardioverterdefibrillators have been shown
to be effective in preventing or treating atrial fibrilla-
tion, and are not recommended.2
NURSING IMPLICATIONS
The importance of nursing interventions to improv-
ing patient care outcomes has been well documented.
With any illness, patient education and care coordina-
tion are vital to effective disease management. Multi-
ple studies have evaluated nursing interventions used
in the management of atrial fibrillation or of compli-
cations often associated with atrial fibrillation (such
as heart failure), and found numerous benefits.36-40
For example, in an Australian study by Inglis and
colleagues of 152 patients with atrial fibrillation and
with or without concurrent heart failure, patients re-
ceived either a nurse-led, multidisciplinary home-based
intervention or usual postdischarge care.40 Those in the
intervention group had fewer readmissions, shorter
hospital stays, and fewer fatal events than those in the
AJN May 2015 Vol. 115, No. 5 35
 Table 7. Patient Education for Atrial Fibrillation Patients: Content to Cover 45

Topic Content
Atrial fibrillation Causes, risks if untreated, complications, signs and symptoms
Treatment plan Goals of treatment
For each medication: purpose, dosage, time of day it should be taken, normal and
adverse effects, importance of monitoring and therapeutic range, frequency of
laboratory tests, signs and symptoms to report (for example, with anticoagulation
agents, signs of bleeding), importance of not stopping medications
Follow-up care: treatments, how often to schedule laboratory tests and provider
visits
Dietary and Dietary restrictions and medication interactions, permitted and restricted activities,
activity restrictions pulse taking
Risk factor Smoking cessation, exercise, weight and cholesterol management, alcohol and drug use
modifications
Stroke symptoms Headache, blurred or double vision, face droop, one-sided weakness, dizziness
Safety precautions Home safety-check elements: loose floor rugs, poor lighting
to prevent injury Personal elements: assistive devices, vision and hearing checks, well-fitting shoes,
gait testing
Important Signs and symptoms such as palpitations, syncope, weight gain, shortness of
information to breath, fatigue, edema, signs of bleeding (bruising, bleeding gums, blood in urine,
report black stools)
Use of supplements (such as St. Johns wort, ginseng) and of over-the-counter drugs
(especially NSAIDs, ASA, and any medication containing ASA, such as Alka-Seltzer)
ASA = acetylsalicylic acid (aspirin); NSAIDs = nonsteroidal antiinflammatory drugs.

control group, although significance varied. Gillis and
colleagues looked at data for Canadian patients who
were referred to a nurse clinicianbased atrial fibrilla-
tion clinic and found they had markedly shorter
wait times to see a specialist than were usual for that
region.37 In a Dutch study, a nurse-driven, guideline-
based, integrated chronic care program was imple-
mented for 111 patients with atrial fibrillation.39
Guideline adherence for patients in the program
was 96%, compared with 70% for controls.
In a study by Benatar and colleagues, conducted
among 216 patients with heart failure, patients re-
ceived either home nurse visits from cardiac nurses or
interdisciplinary home telemanagement implemented
by an advanced practice nurse.36 After three months,
the researchers found that compared with patients
managed through traditional home care, those man-
aged by home telemanagement had significantly fewer
hospital readmissions (13 versus 24), shorter readmis-
sion lengths of stay (49.5 versus 105 days), and lower
hospital charges ($65,023 versus $177,365). And in a
study by Cowan and colleagues conducted among
1,207 hospitalized general medicine patients, patients
received either usual care management or an inter-
vention that included the involvement of an NP dur-
ing hospitalization and for 30 days after discharge.41
The results showed that compared with controls,
patients in the intervention group had shorter hospital
stays and associated cost reductions. Further studies
investigating the financial impact of implementing
more nursing interventions and adding more nursing
hours in order to improve outcomes and prevent re-
admissions are warranted.
Managing atrial fibrillation has traditionally
been challenging for both providers and patients.
Aquantitative study by Aliot and colleagues involv-
ing 825 patients with atrial fibrillation and 810 car-
diologists in 11 European countries found that the
patients (who often had associated diseases) visited a
physician an average of nine times per year, and that
the physicians considered atrial fibrillation difficult
and time consuming to manage.1 Achieving adequate
anticoagulation offers a prime example of such dif-
ficulty. Strict adherence to the medication regimen is
essential and may require frequent blood tests and
dietary restrictions (as is the case for patients on war-
farin). Inadequate anticoagulation of high-risk atrial
fibrillation patients has been found to be associated
with a significantly worse cardiovascular prognosis
over the course of one year.42
All chronic diseases are known to affect quality of
life, and this can influence patients desire or ability
to follow prescribed treatment plans. Aliot and col-
leagues found that 24% of patients rated their ability

36 AJN May 2015 Vol. 115, No. 5 ajnonline.com

to explain atrial fibrillation as poor and more than
one-third were worried or fearful about the disease.1
Another study involving 101 patients with atrial fi-
brillation and 97 controls with hypertension found
that about one-third of the atrial fibrillation patients
had elevated levels of depression and anxiety, which
persisted at six months.43 Depressive symptoms were
found to be the strongest independent predictor of
their future quality of life.
The 2014 guideline invites a
recommitmentto the effective
management of patients with
atrialfibrillation.
Care coordination and guideline adherence. The
care of patients with atrial fibrillation is complex and
can be confusing even for health care providers. Care
coordination among providers is essential, as is ad-
herence by patients and providers to both guideline
recommendations and individual treatment plans. As
the 2014 AHA/ACC/HRS guideline makes a point of
noting, Prescribed courses of treatment . . . are effec-
tive only if followed.2
A systematic review of seven studies utilizing care
pathway management for 3,690 patients with heart
failure found that the use of care pathways decreased
mortality and readmission rates.44 In another study,
Hendricks and colleagues randomized 712 patients
with atrial fibrillation to either a nurse-led care group
or a usual care group; the nurse-led care group was
guideline based and included more detailed patient
education and the use of dedicated decision-making
software.38 The researchers found that compared with
patients in the usual care group, patients in the nurse-
led care group were better informed and adherence to
guideline recommendations by providers and patients
was markedly improved.
Patient education. Since patient education is a
common regulatory requirement, most patient health
records document this. But providing information
doesnt guarantee understanding. The content that pa-
tients with atrial fibrillation need to be taught about
the condition and their treatment plan is generally rec-
ognized (for a summary, see Table 745). Ensuring that
patients understand this content is more difficult and
requires more than a cursory discussion.
Its well known that patients need time to access
information and to clarify with providers anything
they dont fully understand. Indeed, its an accepted
principle in education that repeating what one has
been taught improves comprehension and retention.
ajn@wolterskluwer.com
But time is a scarce resource in busy, often under-
staffed, hospitals.
The effectiveness of evidence-based, RN-led, follow-
up care plans has also been demonstrated.36,38, 40, 41 Yet
such plans usually require more nurses and nursing
hours, and unfortunately predominate only in the lit-
erature. Its my observation, based on nearly 40 years
in hospital nursing, that the usual discharge instruc-
tions typically delivered just once by a harried staff
nurse or medical resident dont begin to meet patient
education needs. And follow-up care must consist of
more than scheduling a follow-up appointment with
a provider. Sustained follow-up by an outpatient or
home care nurse can provide opportunities for pa-
tients to have their questions answered and can rein-
force the goals of treatment.
Given that U.S. expenditures for the treatment of
atrial fibrillation and associated conditions stand at
$26 billion annually,7 and with nearly 75% of these
costs associated with inpatient care,8 it also makes
financial sense to make sure that patients are well-
informed and understand their treatment plans. Fo-
cused efforts to prepare patients for care transitions
may prevent unnecessaryand often unreimbursed
readmissions.
LOOKING AHEAD
The 2014 AHA/ACC/HRS guideline invites a recom-
mitment to the effective management of patients with
atrial fibrillation. Its recommendations, which are
based on the most recent evidence available, focus
particularly on measures to prevent thromboembo-
lism and control symptoms. The guideline also stresses
the importance of patient adherence to treatment plans
in achieving improvedoutcomes. And there is evidence
that nursinginterventions in patient education and in
care coordination, particularly at transition points,
can also improve patient outcomes and decrease costs.
More resources must be dedicated if these goals are to
be realized.
Christine L. Cutugno is an assistant professor of nursing and
graduate coordinator for the Adult-Gerontology Clinical Nurse
Specialist Program at the Hunter-Bellevue School of Nursing in
New York City. A critical care nurse for over 30 years, she was
most recently the director of the Critical Care Division at St.
Josephs Regional Medical Center in Paterson, NJ, from 2003
to 2009, and at Jacobi Medical Center, Bronx, NY, from 1999
to 2003. Contact author: ccutugno@hunter.cuny.edu. The au-
thor and planners have disclosed no potential conflicts of in-
terest, financial or otherwise.
For more than 60 additional continuing nursing
education activities on cardiovascular topics, go
to www.nursingcenter.com/ce.
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AJN May 2015 Vol. 115, No. 5 37
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