Matters of the Heart - A-fib/A-flutter
Matters of the Heart: Atrial Fibrillation (Afib) and Atrial Flutter (AFlutter).
So I’m sure many of you have seen those commercials for the medication Eliquis (Apixaban). You know, the one that says it’s used to treat Afib “an irregular heart rhythm” or something like that. Well, today I wanted to talk about that “irregular” heart rhythm and what nurses need to know to care for patients experiencing it.
So we are going to keep this sweet and simple.
What is Atrial Fibrillation (Afib)?
Simply put, atrial fibrillation is when the upper chambers of the heart (atria) develop an irregular and erratic beating pattern. So the commercial hit that on the head.
Many times it may present at accelerated rates, or may go undetected until the rate goes above 100 bpm for some people.
Fun Fact: The centers for disease control and prevention (CDC) estimate that 2.7 to 6.1 million Americans experience AFib (CDC, 2017).
Many times people who come to the hospital come with the complaint of having a “racing heart”, acute shortness of breath, or feeling dizzy or like “I’m going to pass out”.
When we hook patient’s up to the ECG monitor, we often see a heart rate that is jumping all over the place with the rate, going from 65 to 92 and then to 80 in the course of 2-3 seconds.
Atrial fibrillation is typically characterized by obvious QRS complexes with a jumble of waves, that look like minuscule scribble scrabble, in between each QRS complex on the ECG/EKG. That “scribble scrabble” is the rapid misfiring of atrial impulse sites.
The firing rate of these atrial impulses can range from 300-600 times a minute, while the ventricular rates can vary anywhere from 50bpm to over 150bpms.
What does Afib look like?
Let's start off with a quick reminder of what a Normal Sinus Rhythm (NSR) ecg strip may look like.
Normal Sinus Rhythm (NSR) example
(Source)
Remember, in Afib, the upper chambers (atria) of the heart are doing slightly more than just quivering. The cardiac muscle isn’t appropriately contracting due to “electrical” conduction issues. It looks like this at a slower rate, typically anywhere from 65-100 bpm.
Afib example
(Source)
At faster rates, 100bpm or higher, people begin to experience atrial fibrillation with rapid ventricular response (Afib RVR, see below), and the morphology and presentation of Afib on a ECG strip can look a little different.
Like this…
Afib with RVR Example
(Source)
So, the important thing here is to not let the wave after the QRS complex fool you into thinking it’s a P-wave, it’s not. Those little humps are the T-wave that normally follows the QRS, but because of the ineffective conduction and contraction of the SA node (pacemaker of the heart) and the accelerated rate, (greater than 120 bpm) the T-wave becomes more visually dominant and the little “scribble lines we see in slower rates of Afib are hardly, if at all, visible.
Now, when looking at this on an actual live ecg, there will often be a lot of what some of us call “rate jumping” (i.e the ecg may show a rate of 80 bpm 1 second and then a rate of 118 bpm the next second) which can be a big clue identifying AFib in accelerated rhythms. This rate jumping is also visually apparent in the ecg morphology itself, with frequently irregular spacing between QRS complexes, as seen in the image above.
What’s Atrial flutter (AFlutter)?
If Atrial arrhythmia were a family, Atrial fibrillation and Atrial Flutter would be first cousins that looked remotely similar.
Despite how similar they may seem to be in concept, there are a few differences between the 2 arrhythmias.
Atrial flutter, or Aflutter as many refer to it, is a rhythm that comes from the incorrect conduction path of atrial impulses that travel, normally in an organized fashion, along a pathway or circuit around the right atrium. Thus, this causes fast Atrial beats that are regular and organized, unlike the irregularity that occurs in Afib.
What does AFlutter look like?
(Source)
Note: Pay attention to the sawtooth appearance of AFlutter, it is a defining characteristic, but may not always be as clearly evident as pictured above. The little identifiable “humps” are what help us visually differentiate between Afib and AFlutter.
When describing atrial flutter, we typically include the number of flutter waves (also called f-waves) to QRS complexes in a ratio format. Thus, in the image above we would say that the rhythm is A-flutter with 4 flutter waves to each QRS complex, or 4:1 Atrial flutter.
What’s the big deal?
Well, a lot actually. Afib and Aflutter are the types of conditions that can lead to a lot of other nasty problems down the road, some of which I’ll list below:
Blood clot formation due to more stagnant blood
CVA (Stroke)
Heart Failure
Shortness of Breath
Hypotension
Dizziness and syncope - Passing out.
Increased feelings of tiredness
Many other issues that are too numerous to list.
Now do you see why it’s a big deal?
What can we do about it?
Of course, the answer to this question will depend on many factors such as
What is the rate of the Afib and aflutter? Slow? Fast? Controlled?
Is this the first time this has occurred with a patient? Is this a chronic issue?
Is the blood pressure stable?
What resources are available at the facility?
What’s the patient’s general health status? What other issues exist?
Nursing Considerations and treatment for Afib/AFlutter
Those factors aside, I’ll list some of the nursing interventions and medical treatment regimens typically implemented in the course of treatment of Afib.
In many cases, if the patient is stable and asymptomatic, treatment focuses on controlling the ventricular response/rate of the Atrial Arrhythmia.
ECG/EKG - Obtain to evaluate the electrical characteristics of the Rhythm
Oxygen - Irregular heart rhythms can mean less than optimal performance and circulation.
- Medications (both IV and PO) - AKA chemical cardioversion. Often the goal with Afib is to obtain a controlled rate and prevent the formation of a thrombus. Of course, there is also the goal to revert the heart back to normal sinus rhythm (NSR).
- Beta-blockers: Many of which end in “lol”, like Metoprolol, Carvedilol, and atenolol.
Calcium Channel Blocker: Diltiazem and verapamil
Antidysrhythmics: Amiodarone and Multaq (dronedarone)
Antithrombolytics/Anticoagulant therapy: To prevent or control blood clot formation. Coumadin (Warfarin) and Eliquis (Apixaban) are very popular anticoagulants. If a thrombus forms and a cerebrovascular accident (CVA or Stoke) has a occurred, a thrombolytic, like t-PA (class of drugs that includes Activase) might be administered.
- Radiography: 2-Dimensional Echocardiogram and Chest X-ray (CXR) are the most common.
Cardioversion: Shocking the heart. Kind of like when your mom slaps you when you say something disrespectful. The shock, aka slap, helps the attitude get it’s attitude together. Lol!
Surgery: For severe and chronic conditions. 2 popular procedures are the catheter ablations and the MAZE procedure.
Nursing Tidbits:
So here are a few extra nursing-specific things to know about Afib.
Sometimes it can present with almost imperceptible “fibrillation” and the ecg can look like an almost flat line between QRS complex, but heart rate variation will typically be evident. Absence of a p-wave or presence of an inverted, or u-shaped, p-wave is a likely another dysthymia known as a junctional or accelerated junctional rhythm.
Patient’s with new onset Afib and those who are currently experiencing accelerated rates of Afib (call Afib with rapid ventricular response/afib rvr) shouldn’t do a lot of walking and moving around, as this can worsen the problem.
New Afib or a return of Afib, regardless if the patient has a history of it or if the rate is controlled (e.g between 60-100 bpm)should always be reported to a provider (MD, NP, PA etc…) unless parameters are otherwise stated by the managing provider. Often an EKG will be ordered to verify this assessment.
There are cases where patients may be discharged while still in Afib, but this is usually with individuals who are experiencing chronic issues or those who are having difficulty staying converted (or remaining in normal sinus rhythm/NSR) after pharmacological, procedural, or surgical intervention.
These patients should always be discharged with their Afib in a controlled rate as defined by the provider, organizational protocol, and care standards, preferably for greater than 24 hours.
A daily aspirin, alone, is not an adequate treatment for the prevention of thrombus in a new onset or acute complication of chronic Afib patient and this should be stressed in admission and discharge teaching.
Long-term anticoagulant therapy needs will be assessed with the CHADS2 assessment tool, by a healthcare provider.
Afib can be hard to differentiate between a couple of other rhythms at really fast rates, greater than 120-130 bpm. Many times an IV bolus of different medications will be given and then maintenance medications or IV drips will be given to help regulate and stabilize the patient.
Measuring BP, especially an automatic bp, can sometimes be difficult and misleading with Afib patients. Compare abnormal BP findings with a manual bp measurement.
If the patient has a controlled rate and they are asymptomatic, ask yourself whether the abnormal BP measurement fits their BP trend and their disease process.
If you are suspicious that cardiovascular compromise or decompensation is occurring, call the provider and have bp, heart rate, and rhythm trend information available to report.
Also be prepared to report whether the patient is symptomatic (Feeling like their heart rate is increasing, dizziness, shortness of breath, acute anxiety, chest pain etc…)
References:
Critical Care Nursing Demystified
Pocket Guide for ECGs Made Easy, 6th Edition
ECG Interpretation Made Incredibly Easy Pocket Guide
Disclaimer: This material should be used to supplement your understanding of the cardiovascular system. Any use of the information given in this post series is at your own risk and should be verified prior to making it a part of your nursing practice. There may be affiliate links associated with some products but we promise that we will never recommend anything that we don’t use ourselves.
Written by: Patrick McMurray of PatMacRN is a full-time critical and intermediate care nurse at Level I academic trauma center. In his spare time, Patrick enjoys reading, traveling, and improving his French language skills.
