Exam (elaborations)
NUR 6111 Adv Nursing Practice 1 NUR 6111 Week 5 Cardiovascular Disorders
- Institution
- William Paterson University
NUR 6111 Adv Nursing Practice 1
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● Atrial Fibrillation○ Impact of Atrial Fibrillation
■ It increases a person’s risk of stroke by 4 to 5 times.
■ AFib causes about 25% of ischemic strokes by causing blockage of blood
flow to the brain.
■ AFib doubles the risk of heart-related deaths.
■ The absence of contraction of the atria can result in a loss of cardiac
output anywhere from 15 - 30% due to the absence of an "atrial kick,"
contributing to heart failure.
○ Risk Factors
■ Advancing age*
■ High blood pressure*
■ Coronary artery disease*
■ Cardiomyopathy
■ Obesity
■ European ancestry
■ Athletes
■ Diabetes
■ Heart failure
■ Hyperthyroidism
■ Chronic kidney disease
■ Heavy alcohol use
■ Rheumatic heart disease
■ Valvular heart disease
■ Enlargement of the chambers on the left side of the heart
■ Pericarditis/myocarditis
■ Sleep Apnea
○ Valvular vs Non-Valvular AFib
■ Valvular: AF in the presence of moderate-to-severe mitral stenosis
(potentially requiring surgical intervention) or in the presence of an
artificial (mechanical) heart valve
■ Non-valvular: AF in the absence of moderate-to-severe mitral stenosis or
a mechanical heart valve
○ Clinical Presentation
■ Many people do not experience any symptoms and are unaware of their
diagnosis – Sometimes it is an incidental finding upon examination
■ Symptomatic presentation:
● General fatigue
● Rapid and irregular heartbeat
● Fluttering or “thumping” in the chest
● Dizziness
● Shortness of breath and anxiety
● Weakness
● Faintness or confusion
, ● Fatigue when exercising
● Sweating
● *Chest pain or pressure- (Call 911)
○ Physical Exam
■ On PE: Irregular heart rhythm – this is the hallmark finding of AFib,
tachycardia (typically 110s-140s), hypotension
■ Possible findings in someone with AF include:
● JVD, rales or effusions from HF
● Murmurs suggest stenosis or regurgitation.
● LE edema (HF or DVT),
● Exophthalmia (*bulging eyes)
● Signs of stroke, including facial droop, arm weakness, and slurred
speech
■ Possible PE findings correspond with diseases coexisting with AF or
being high risk for AF rather than the disease presentation itself
○ EKG
■ There are no visible P waves (no measurable PR interval) & an irregularly
irregular QRS complex. The ventricular rate is frequently fast.
■ *GOLD standard
■
■
○ Classifying AFib
■ 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 persistent AF
● Continuous AF >12 months in duration
■ Permanent AF
● The term “permanent AF” is used when the patient & clinician
decide to stop further attempts to restore &/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 AF
● Acceptance of AF may change as symptoms, efficacy of
therapeutic interventions, & patient & clinician preferences evolve.
■ Nonvalvular AF
● AF in the absence of rheumatic mitral stenosis, a mechanical or
bioprosthetic heart valve, or mitral valve repair.
○ Labs
■ CBC
■ CMP
■ TSH
■ BNP
■ PT/PTT/INR
○ Other Diagnostic Tests
■ Echocardiogram - evaluation of size & function of atria & ventricles;
detection of valvular heart disease, left ventricular hypertrophy, &
pericardial disease.
■ Transesophageal Echocardiogram (TEE) - the most sensitive & specific
technique to detect LA thrombi.
■ Event Recorders (Implantable loop recorders, Holter monitors) -
identify arrhythmia if intermittent, correlate symptoms, or use rate control
strategies
■ Stress test
■ EP study
○ Management
■ Goals of Treatment for AF
● Prevention of Thromboembolism – utilize the Chadsvasc score
to determine stroke risk
● Rate Control (preferred over rhythm control)
○ Beta-Adrenergic Receptor Blockers
■ atenolol, metoprolol, nadolol, propranolol, & sotalol
○ Nondihydropyridine Calcium Channel Blockers
■ diltiazem and verapamil
○ Digitalis Glycoside
■ Digoxin
● Rhythm Control
, ○ for patients who don’t tolerate loss of atrial kick
(hemodynamic instability):
■ Synchronized cardioversion
■ Pharmacologic cardioversion: dofetilide, flecainide,
propafenone, ibutilide, or amiodarone (consider
long half-life, pulmonary toxicity, thyroid
dysfunction)
■ Chadsvasc - To determine stroke risk
●
●
■ Anticoagulation
● Vit K antagonist
○ Warfarin (serum monitoring: goal INR 2-3)
● Direct Thrombin Inhibitor
○ Dabigatran (Pradaxa) - 150 mg PO BID (no serum
monitoring)
● Factor Xa Inhibitors
○ Rivaroxaban, Edoxaban, & Apixaban (no serum
monitoring)
○ Xarelto (Rivaroxaban) - 20 mg PO QD
■ (if switching from warfarin to Xarelto, d/c warfarin &
start Xarelto when INR < 3)
○ Eliquis (Apixaban) - 5 mg PO BID
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