CHAPTER 2 Jennifer Cruz, MN, NP, CCN(C), and Paul Dorian, MD, MSc Atrial fibrillation (AF) is the most common type of arrhythmia and its prevalence is steadily increasing around the world. Over 350,000 Canadians,1 3 million Americans,2 and 6 million Europeans3 live with AF. Although AF may be viewed as a complex disorder, it would be useful for clinicians from various health disciplines to develop a streamlined, systematic way of assessing, evaluating, and managing patients with AF. The extensive amount of detail included in multiple published national guidelines can be confusing—especially to a novice clinician. Guideline interpretation or adherence may also vary in the actual clinical setting, owing to available resources, diverse patient circumstances, and individual patient preferences. Furthermore, clinicians are required to ask patients a multitude of questions to determine appropriate AF management, which can be viewed as complicated or cumbersome. Thus, this chapter will outline a simplified and systematic (“checklist-based”)4 approach for clinical evaluation, history taking, and determining appropriate diagnostic testing during a patient’s initial presentation with AF. It is important to identify and manage symptoms of AF to decrease potential complications and improve a patient’s quality of life. Guideline adherence can lead to improved patient outcomes, and it plays an important impact on health systems globally. The European Heart Survey on AF showed that guideline adherence reduces morbidity and mortality of AF patients and reduces costs related to AF.5 However, the best approach to management of AF care is still unclear. A systematic approach that includes a checklist may offer a solution to improving overall AF care, because “a checklist is a simple concept: rather than depending on the memory of those involved, it ensures that all the desired actions are accomplished.”6 A checklist approach has been used effectively in other areas of health care, such as preoperative surgical procedures. The development of a clinical checklist has several goals and benefits including the following: • help clinicians obtain accurate pertinent information and avoid errors of omission, • recommend safe and effective therapy, • improve guideline adherence, • reduce variations in clinical practice, • improve standards of care and patient treatment outcomes, • improve clinic productivity and work efficiency. To develop a systematic checklist approach to AF care, a core data set needs to be considered. The data set on the following pages is based on national guidelines along with clinician preferences that are according to experience and individual clinical setting. The following questions, illustrated in Table 2.1, may be used as a foundation to formulate data fields within the checklist.
Clinical Evaluation of the Atrial Fibrillation Patient
INTRODUCTION
A SYSTEMATIC, PROTOCOL-BASED APPROACH TO PATIENT EVALUATION
Clinical Category | Part 1: Four Simple Questions That the Clinician Should Answer | Part 2: Detailed Questions That the Clinician Should Consider in the Background |
Detection/ documentation Establish type of AF pattern | 1) Does the patient have AF? | • What is the AF pattern? • Are there any other types of arrhythmia present that require investigation or treatment? • Is there symptom–rhythm correlation? |
Determine etiology Diagnostic evaluations | 2) Why does the patient have AF? | • Are there identifiable causes of AF? • Can predisposing factors of AF be treated to reduce AF recurrence? |
Clinical evaluation/ assessment Rate and rhythm management | 3) Is AF affecting the patient’s quality of life? | • What symptoms does the patient have? • Are the symptoms due to AF or its treatment? • Are there activity restrictions or exercise limitations during AF episodes? • Are there medication side effects? |
Clinical evaluation/ assessment Antithrombotic management | 4) What is the patient’s stroke risk? | • Is the patient on appropriate anticoagulant for stroke prevention? • Are there any restrictions limiting patient anticoagulant use? (e.g., contraindications, drug coverage, financial burden, ability to undergo regular monitoring) |
The questions illustrated in Table 2.1 outline the management flow that is essential in AF care. The illustrations below will provide answers to the questions in Table 2.1, including:
• a sample of a clinical checklist with rationale provided (Table 2.2)
• a sample of screen shots from an electronic software system to illustrate integration of clinical assessment checklist (Appendix A)
✓ | Clinical Assessment | Rationale for Obtaining Data |
History of present illness (to obtain from patient interview/history taking) | ||
• When did you first notice symptoms possibly related to your heart rhythm disturbance? | • Helps determine onset of AF | |
• What symptoms did you actually feel? (examples: palpitations or irregular heart beating, chest pain/tightness, shortness of breath/dyspnea, dizziness/lightheaded, fatigue/weakness, or syncope/fainting spells) | • Every patient feels different symptoms during AF; others may be asymptomatic | |
• When do the episodes usually happen—at rest or during activity? | • Helps establish AF pattern (paroxysmal versus persistent) or type of AF (e.g., “vagally mediated” AF usually happens at rest). *Note: ‘triggers’ are usually not asked about, as patients will correlate all kinds of coincidences. | |
• Did you seek medical attention? How was AF diagnosed or documented? (e.g., ECG, Holter, Loop monitor) | • Helps determine first documentation of AF (versus other types of arrhythmia); verification of AF diagnosis | |
• How was it treated? Did the treatment help improve your symptoms? | • Helps determine type of therapy that has been effective or ineffective in improving symptoms (medical therapy—rate versus rhythm control; or procedures—electrical cardioversion or ablation) | |
• How much do you think AF is affecting your overall quality of life—mild, minor, moderate or severe? (An example of mild effect would be: AF is not at all bothersome; an example of severe effect would be: during AF, the symptoms are so debilitating that you have to stay in bed all day and cannot perform activities of daily living.) | • Helps establish impact on Quality of life (QOL) of severity of AF (SAF) symptoms and its treatment—SAF Score: · Class 0: Asymptomatic · Class 1: Minimal effect on QOL · Class 2: Minor effect on QOL · Class 3: Moderate effect on QOL · Class 4: Severe effect on QOL *Note: Very important information since treatment (rate versus rhythm control) is based on severity/impact on QOL. | |
Cardiac history (to obtain from patient interview/history taking) | ||
• Have you been admitted to a hospital for heart failure symptoms? Do you have a history of high blood pressure (HTN), diabetes, stroke/mini stroke (TIA), CAD, or have had a heart attack (MI), peripheral arterial disease? • If patient has history of CAD or heart failure, may ask more questions about related symptoms | • Helps establish stroke risk factors—CHADS2/CHA2DS2VASc score • If patient has heart failure, document NYHA class; if patient has CAD, document CCS Angina class · May need to alter choice of drug therapy | |
• Have you had any cardiac procedure? (PCI, CABG, Valve surgery, device implant, other cardiac surgery) | • Helps determine potential cardiac causes and risks of developing AF | |
Other AF risk factors (to obtain from patient/partner interview/history taking) | ||
• Do you have any sleep-related symptoms? Snoring, daytime somnolence/sleepiness, observed to stop breathing at night? • Have you been tested for sleep apnea? If sleep study is positive, is CPAP recommended? | • Helps determine noncardiac causes of AF (such as sleep apnea) and treatment could decrease AF recurrence | |
• Do you drink excessive amounts of alcohol? (e.g., >4 units a day in men and >2 units a day in women) | • Helps determine noncardiac causes/triggers of AF • Helps determine potential risks of bleeding (HAS-BLED) | |
• Do you perform competitive, intensive endurance exercises? | • Competitive long-term endurance exercise is associated with increased AF risk (but decreased CAD risk) | |
• Any history of rheumatic heart disease or valve disease? | • Helps determine potential cardiac causes and risks of recurrent AF | |
Other relevant past medical history (to obtain from patient interview/history taking) | ||
• Did you smoke in the past, or do you currently smoke? | • Helps determine risks of developing CAD or COPD (patient counseling regarding smoking cessation for improvement of overall cardiovascular respiratory health, but may not necessarily prevent AF episodes) | |
• Do you have any family history of heart disease such as heart attack (MI) or CAD? • Have any of your family members been diagnosed of AF? • Has there been any family history of sudden cardiac death (SCD) (dying suddenly or dying of unknown cause before age 40)? | • Helps determine risk of developing CAD or AF • Family history of SCD helps determine potential risks of developing life-threatening arrhythmias | |
• Do you have any past medical history of thyroid disease, COPD, asthma, chronic kidney disease, liver disease, history of major bleeding? • Other relevant past history? | • Thyroid disease, COPD: helps determine noncardiac causes of AF and treatment of reversible causes can decrease AF recurrence • Asthma: condition may be considered if using β-blocker (due to risks of exacerbations) • Chronic kidney and liver disease: helps determine potential medication options and risks of bleeding (HAS-BLED score) • History of major bleeding: helps determine risks of bleeding (HAS-BLED score) | |
