Atrial Fibrillation - BMH/Tele

Atrial Atrial Fibrillation:Fibrillation:Too Many Atrial Too Many Atrial

Chiefs!!!Chiefs!!!

Natalie Bermudez, RN, BSN, MSNatalie Bermudez, RN, BSN, MS

Clinical Educator for Cardiac Clinical Educator for Cardiac TelemetryTelemetry

TelemetTelemetry ry

CourseCourse

Course ObjectivesCourse Objectives Discuss prevalence of atrial Discuss prevalence of atrial

fibrillation in the United Statesfibrillation in the United States Discuss pathophysiology of atrial Discuss pathophysiology of atrial

fibrillationfibrillation Discuss the main goals for treatment Discuss the main goals for treatment

of atrial fibrillationof atrial fibrillation Discuss the electrical cardioversion Discuss the electrical cardioversion

versus chemical cardioversionversus chemical cardioversion Review medications that are used to Review medications that are used to

treat atrial fibrillationtreat atrial fibrillation

StatisticsStatistics““More than 2.2 million Americans – nearly More than 2.2 million Americans – nearly 15% of those older than age 85 – experience 15% of those older than age 85 – experience

this arrhythmia” this arrhythmia” (Prudente, 2008, p. 21)(Prudente, 2008, p. 21)

“…“…An estimated 150,000 new cases will be An estimated 150,000 new cases will be diagnosed each year.” diagnosed each year.” (Zak, 2010, p. 68)(Zak, 2010, p. 68)

““Experts expect the prevalence to increase to 5 Experts expect the prevalence to increase to 5 million by 2050 as the population ages” million by 2050 as the population ages”

(Prudente, 2008, p. 21)(Prudente, 2008, p. 21)

More StatisticsMore Statistics

““Occurs in 11% to 64% of patients Occurs in 11% to 64% of patients after a CABG, valvular after a CABG, valvular replacements, and heart replacements, and heart

transplantation”transplantation”

(Smeltzer et al, 2008, p.832)(Smeltzer et al, 2008, p.832)

Electrical Electrical ChaosChaos

Chaotic, irregular, rapid Chaotic, irregular, rapid depolarization in atrial depolarization in atrial

tissue due increased tissue due increased atrial irritabilityatrial irritability

Firing Rate = 300 – 600 Firing Rate = 300 – 600 times/minutetimes/minute

Causes the atria to Causes the atria to quiverquiver

Atrial Atrial CharacteristicsCharacteristicsNo P waves are visible on an EKGNo P waves are visible on an EKG

Fibrillatory waves Fibrillatory waves (Fine or Coarse)(Fine or Coarse)

Characteristics of Characteristics of AFAF

Fine or CourseFine or Course

The GatekeeperThe GatekeeperAV node AV node

controls the controls the # of # of

electrical electrical impulses that impulses that

reach the reach the ventriclesventricles

AV ConductionAV ConductionHowever, the AV However, the AV conduction rate conduction rate is more often is more often

tachycardic with tachycardic with atrial fibrillationatrial fibrillation

Dependent on the Dependent on the AV node AV node

Refractory Refractory PeriodPeriod

Ventricular Ventricular ResponseResponse

Ventricular rhythm is irregularly, Ventricular rhythm is irregularly, irregular!!!irregular!!!

Origins of AFOrigins of AF

Paroxysmal Paroxysmal Onset is suddenOnset is sudden

May be self-limitingMay be self-limiting

May represent a single, isolated May represent a single, isolated incidentincident


Paroxysmal Paroxysmal Transient rhythm disturbances are Transient rhythm disturbances are

commonly caused by:commonly caused by:

ThyrotoxicosisThyrotoxicosis

Heart Failure ExacerbationHeart Failure Exacerbation

S/P Cardiac or Thoracic SurgeryS/P Cardiac or Thoracic Surgery

Excessive Alcohol IntakeExcessive Alcohol Intake

(Prudente, 2008)(Prudente, 2008)

Origins of AFOrigins of AF

Origins of AFOrigins of AF““Lone AF” Lone AF”

Primary rhythm Primary rhythm disturbance without disturbance without

underlying heart underlying heart diseasedisease


Origins of AFOrigins of AFSecondary AFSecondary AF

AF is secondary to a AF is secondary to a cardiac disease or other cardiac disease or other

disease that causes disease that causes atrial remodelingatrial remodeling


Secondary AFSecondary AFAtrial RemodelingAtrial Remodeling

HypertensionHypertensionCADCAD

Valvular DiseaseValvular DiseasePulmonary DiseasePulmonary Disease

Sleep ApneaSleep ApneaObesityObesity


Secondary AFSecondary AF

““Nearly two-thirds of AF Nearly two-thirds of AF patients have patients have

underlying heart underlying heart disease that may disease that may

contribute to structural contribute to structural remodeling”remodeling”


Etiology in a Etiology in a NutshellNutshell

Cardiac SurgeryCardiac Surgery MVR, MVSMVR, MVS HyperthyroidismHyperthyroidism InfectionInfection AMI, CADAMI, CAD PericarditisPericarditis HypoxiaHypoxia

Coffee, ETOH, Coffee, ETOH, CigarettesCigarettes

Fatigue or StressFatigue or Stress Meds (Digoxin or Meds (Digoxin or

Aminophylline)Aminophylline) Catecholamine Catecholamine

release during release during exerciseexercise

3 P’s: Types of AF3 P’s: Types of AFParoxysmal AFParoxysmal AF

Persistent AFPersistent AF

Permanent AFPermanent AF(Prudente, 2008, p. 21)(Prudente, 2008, p. 21)

Paroxysmal AFParoxysmal AF

Episodes come and go, Episodes come and go, typically lasting less than typically lasting less than

24 hours, and convert 24 hours, and convert spontaneously within 7 spontaneously within 7

daysdays


Persistent AFPersistent AF

Episodes last more than 7 Episodes last more than 7 days and require days and require

cardioversion with cardioversion with drugs, electrical shock, drugs, electrical shock,

or bothor both


Permanent AFPermanent AF

A longstanding episode A longstanding episode in which cardioversion in which cardioversion

fails or no fails or no cardioversion effort is cardioversion effort is

mademade


AF and Atrial KickAF and Atrial KickWhat is atrial kick???What is atrial kick???

A-fib causes loss of Atrial KickA-fib causes loss of Atrial Kick

Uncontrolled A-fib in combo with loss of Uncontrolled A-fib in combo with loss of Atrial Kick results in Atrial Kick results in ↓ CO ↓ CO

(as much as 30% less)(as much as 30% less)

May result in Heart Failure, Angina, and/or May result in Heart Failure, Angina, and/or SyncopeSyncope

Treatment of Treatment of AFAF

Controlled or Uncontrolled???Controlled or Uncontrolled???

Dependent upon AV conduction or ventricular Dependent upon AV conduction or ventricular responseresponse

Without heart rate controlling medications, Without heart rate controlling medications, atrial fibrillation is typically uncontrolled atrial fibrillation is typically uncontrolled

(rapid ventricular response)(rapid ventricular response)

Ventricular Ventricular ResponseResponse

HR 60 – 100 HR 60 – 100 Controlled Ventricular ResponseControlled Ventricular Response

HR > 100 HR > 100 uncontrolleduncontrolledOr Rapid Ventricular Response (RVR)Or Rapid Ventricular Response (RVR)

HR < 50HR < 50Slow Ventricular Response (SVR)Slow Ventricular Response (SVR)

Uncontrolled AFUncontrolled AFIf left untreated can lead to:If left untreated can lead to:

Cardiovascular CollapseCardiovascular Collapse

Thrombus FormationThrombus Formation

Systemic Arterial or Pulmonary EmboliSystemic Arterial or Pulmonary Emboli

““In AF patients, the yearly risk of ischemic In AF patients, the yearly risk of ischemic stroke ranges from 3% to 8%”stroke ranges from 3% to 8%”


Signs & SymptomsSigns & Symptoms

None with Controlled A-fibNone with Controlled A-fibIrregular RhythmIrregular Rhythm

Uncontrolled or SVR:Uncontrolled or SVR:Irregular RhythmIrregular Rhythm

HypotensionHypotensionLight-headednessLight-headedness

WeaknessWeaknessPalpitationsPalpitations

SOBSOB

Goals for Goals for Treatment Treatment

Convert to NSRConvert to NSR

oror

Rate Control with Prevention of Rate Control with Prevention of Blood Clots & Atrial RemodelingBlood Clots & Atrial Remodeling

TREATMENTTREATMENT::

Asymptomatic versus Asymptomatic versus SymptomaticSymptomatic

If < 48 hours, synchronized If < 48 hours, synchronized cardioversioncardioversion

If > 48 hours, anticoagulation therapy If > 48 hours, anticoagulation therapy and rate control 1and rate control 1stst

Then chemical or synchronized Then chemical or synchronized cardioversion, if desired by physiciancardioversion, if desired by physician

Rhythm ControlRhythm Control

Medications that Act as Medications that Act as Chemical CardiovertersChemical Cardioverters by by prolonging refractory periods:prolonging refractory periods:

Antidysrhythmics:Antidysrhythmics:Cordarone (amiodarone)Cordarone (amiodarone)

Corvert (ibutilide)Corvert (ibutilide)Rhythmol (propafenone)Rhythmol (propafenone)

Tambocor (flecainide)Tambocor (flecainide)Tikosyn (dofetilide)Tikosyn (dofetilide)

Rhythm ControlRhythm Control

Medications that Act as Chemical Medications that Act as Chemical Cardioverters by prolonging action Cardioverters by prolonging action

potential in myocardial fibers without potential in myocardial fibers without affecting conduction:affecting conduction:

Betapace (sotalol): non-selective beta-Betapace (sotalol): non-selective beta-blocker/antidysrhythmicblocker/antidysrhythmic

Rhythm ControlRhythm ControlPatients likely to receive chemical Patients likely to receive chemical

cardioversion:cardioversion:

First Episode of AFFirst Episode of AF Paroxysmal AFParoxysmal AF

Younger Patients with Structural Younger Patients with Structural RemodelingRemodeling

Patients with Pronounced AF SymptomsPatients with Pronounced AF Symptoms


Preparing Patients for Preparing Patients for

Synchronized Synchronized CardioversionCardioversion May occur at the bedside or in the Cath May occur at the bedside or in the Cath

Lab!Lab! Cardiologist MUST be present for Cardiologist MUST be present for

interventionintervention Sedation is usually ordered prior to Sedation is usually ordered prior to

delivering electrical shockdelivering electrical shock Attach patient to pulse generator pads and Attach patient to pulse generator pads and

the 3-lead wire systemthe 3-lead wire system Pulse generator should be set to “SYNC” (R Pulse generator should be set to “SYNC” (R

waves are marked)waves are marked) Shock delivery: 100J, 150J, 200JShock delivery: 100J, 150J, 200J

Synchronized Synchronized CardioversionCardioversion

If the patient’s rhythm converts to If the patient’s rhythm converts to NSR, then the heart rate control NSR, then the heart rate control and antiagulation therapy is not and antiagulation therapy is not neededneeded

If the cardioversion is If the cardioversion is unsuccessful, then the patient will unsuccessful, then the patient will need medications!need medications!

Catheter AblationCatheter Ablation It is the delivery of low-frequency, It is the delivery of low-frequency,

alternating current through a catheter alternating current through a catheter electrode that produces thermal electrode that produces thermal myocardial injury at the tip of the 4-myocardial injury at the tip of the 4-mm cathetermm catheter

These areas of injury, or lesions, create These areas of injury, or lesions, create electrically unexcitable tissue, a electrically unexcitable tissue, a situation that prevents depolarization situation that prevents depolarization and conduction of electrical impulseand conduction of electrical impulse

(Zak, 2010, p. 70)(Zak, 2010, p. 70)

Catheter AblationCatheter AblationIndications for Ablation:Indications for Ablation: Primary Indication:Primary Indication:

Symptomatic AF that is refractory or Symptomatic AF that is refractory or intolerant to at least one class I or intolerant to at least one class I or class III antiarrhythmic medicationclass III antiarrhythmic medication

Documented HF or decreased EF who Documented HF or decreased EF who have increasing symptoms of HF in AFhave increasing symptoms of HF in AF

Do not take antiarrhythmic medsDo not take antiarrhythmic meds Long-term anticoagulation treatmentLong-term anticoagulation treatment

(Zak, 2010, p. 70)(Zak, 2010, p. 70)

Catheter AblationCatheter AblationContraindicated for:Contraindicated for:

Left atrial thrombus indicated by Left atrial thrombus indicated by TEETEE

Active bleeding or the inability to Active bleeding or the inability to achieve anticoagulationachieve anticoagulation

(Zak, 2010, p. 70)(Zak, 2010, p. 70)

Catheter AblationCatheter Ablation

The duration of the procedure The duration of the procedure is about 3 to 5 hoursis about 3 to 5 hours

Under moderate sedation or Under moderate sedation or general anesthesiageneral anesthesia

Performed in an EP labPerformed in an EP lab

(Zak, 2010, p. 70)(Zak, 2010, p. 70)

Rate ControlRate ControlMedications that Slow the Heart Rate:Medications that Slow the Heart Rate:

May or May Not act as a Chemical Cardioverters!!!May or May Not act as a Chemical Cardioverters!!!

Beta-BlockersBeta-Blockers (decrease contractility)(decrease contractility)

Calcium Channel BlockersCalcium Channel Blockers (nondihydropyridine - decrease contractility)(nondihydropyridine - decrease contractility)

Cardiac GlycosidesCardiac Glycosides (increase contractility)(increase contractility)

AntiarrhythmicsAntiarrhythmics

Medications for Medications for Treatment of New Onset Treatment of New Onset or Sudden Onset Atrial or Sudden Onset Atrial

FibrillationFibrillation

Cardizem (diltiazem)Cardizem (diltiazem) – – nondihydropyridine CCBnondihydropyridine CCB

Cordarone (amiodarone)Cordarone (amiodarone) – – antiarrhythmic agentantiarrhythmic agent

Lanoxin (digoxin)Lanoxin (digoxin) – – cardiac glycoside cardiac glycoside

CardizemCardizem(diltiazem hydrochloride)(diltiazem hydrochloride)Nondihydropyridine Calcium Channel BlockerNondihydropyridine Calcium Channel Blocker

““Diltiazem IV is the drug of choice for Diltiazem IV is the drug of choice for urgent rate control in patients with AFurgent rate control in patients with AF

A constant IV infusion brings ventricular A constant IV infusion brings ventricular response under control reliablyresponse under control reliably

Sinus rhythm is achieved in only 15% and Sinus rhythm is achieved in only 15% and hypotension occurs in up to 33% of hypotension occurs in up to 33% of patientspatients

(Khan, 2007, p. 260)(Khan, 2007, p. 260)

CardizemCardizem(diltiazem hydrochloride)(diltiazem hydrochloride)

Nondihydropyridine Calcium Channel BlockerNondihydropyridine Calcium Channel Blocker

Inhibits calcium ion influx across Inhibits calcium ion influx across cell membrane during cardiac cell membrane during cardiac

depolarizationdepolarization

Slows SA/AV node conduction Slows SA/AV node conduction timestimes

Cardizem DripCardizem Drip

How is it ordered???How is it ordered???

Ordered to control heart rateOrdered to control heart rate

Titrate to keep HR between 60 – 100Titrate to keep HR between 60 – 100

Need to monitor HR, B/P, & EKG Need to monitor HR, B/P, & EKG rhythm closelyrhythm closely


IV Bolus administered firstIV Bolus administered first

5 – 20 mg IVP 5 – 20 mg IVP

Supplied as: 25 mg/5 mlSupplied as: 25 mg/5 ml


Physician will order drip in mg/hrPhysician will order drip in mg/hr

Usually starting @ 5mg/hrUsually starting @ 5mg/hr

May titrate up to 15 mg/hr maximumMay titrate up to 15 mg/hr maximum

How Supplied: 100 mg/100 mlHow Supplied: 100 mg/100 ml

(1 mg/ml)(1 mg/ml)


If HR < 60 or SBP < 90If HR < 60 or SBP < 90

Call physician for further orders (Do Call physician for further orders (Do not stop or discontinue without not stop or discontinue without

physician orders!!!)physician orders!!!)

An order with titrating does not An order with titrating does not include orders to discontinue a include orders to discontinue a medication; unless otherwise medication; unless otherwise

specified!!!specified!!!


Before drip is discontinued, Before drip is discontinued, make sure patient is on oral make sure patient is on oral Cardizem, or another rate Cardizem, or another rate control medication, firstcontrol medication, first

To wean or not to wean???To wean or not to wean???

AmiodaroneAmiodarone(Cordarone)(Cordarone)

Acts as a chemical cardioverter Acts as a chemical cardioverter

Prolongs refractory period of all cardiac Prolongs refractory period of all cardiac cellscells

Nurses responsible for preparing IV bolus Nurses responsible for preparing IV bolus and first bottle for maintenance doseand first bottle for maintenance dose


150 mg in 100 ml D150 mg in 100 ml D55W bolus over 10 minutes W bolus over 10 minutes

Rate = 600 ml/hrRate = 600 ml/hr


Concentration: 450 mg (150 mg vials x 3) in Concentration: 450 mg (150 mg vials x 3) in 250 ml D250 ml D55W W

(glass bottle)(glass bottle)

Amiodarone InfusionAmiodarone Infusion

Maintenance Drip:Maintenance Drip:

1 mg/min (33 ml/hr) x 6 hours 1 mg/min (33 ml/hr) x 6 hours

followed byfollowed by

0.5 mg/min (17 ml/hr) x 18 hours or until 0.5 mg/min (17 ml/hr) x 18 hours or until discontinueddiscontinued

Important: To avoid medication infiltration, Important: To avoid medication infiltration, use use 0.22 Micron Filter0.22 Micron Filter (white)!!! (white)!!!

Amiodarone InfusionAmiodarone Infusion

Maintenance Drip:Maintenance Drip:

This is not a drip that is titrated!!!This is not a drip that is titrated!!!

Digoxin Digoxin (Lanoxin)(Lanoxin)

The most commonly cardiac The most commonly cardiac glycoside to be usedglycoside to be used

The only one that is used in the The only one that is used in the United StatesUnited States

Functional Classification: Cardiac glycoside, Functional Classification: Cardiac glycoside, inotropic, antidysrhythmicinotropic, antidysrhythmic

(Lilley, Harrington, and Snyder, 2007)(Lilley, Harrington, and Snyder, 2007)

Digoxin (Lanoxin)Digoxin (Lanoxin)Increased Contractility:Increased Contractility:

Positive Inotropic EffectsPositive Inotropic Effects

It boosts intracellular calcium and sodium It boosts intracellular calcium and sodium at the cell membrane, enabling stronger at the cell membrane, enabling stronger

heart contractions **(requiring heart contractions **(requiring increased Oincreased O22 consumption)** consumption)**

Digoxin (Lanoxin)Digoxin (Lanoxin)Decreased Electrical Conduction Velocity:Decreased Electrical Conduction Velocity:

Negative Dromotropic EffectsNegative Dromotropic Effects

Decreases the velocity (rate) of electrical Decreases the velocity (rate) of electrical conduction conduction

Mainly at the SA and AV nodesMainly at the SA and AV nodes

Prolongs the refractory period in the Prolongs the refractory period in the conduction systemconduction system

Atrial and Ventricular cardiac cells remain in Atrial and Ventricular cardiac cells remain in a state of depolarization longer and are a state of depolarization longer and are

unable to start another electrical impulseunable to start another electrical impulse

Digoxin (Lanoxin)Digoxin (Lanoxin)Decreased Heart Rate:Decreased Heart Rate:

Negative Chronotropic EffectNegative Chronotropic Effect

Blocks the reuptake of Blocks the reuptake of norepinephrine at the norepinephrine at the

adrenergic nerve terminaladrenergic nerve terminal

Digoxin (Lanoxin)Digoxin (Lanoxin)Improved Cardiac Output:Improved Cardiac Output:

Parasympathetic effectsParasympathetic effects

Augments vagal tone Augments vagal tone (cholinergic or (cholinergic or

parasympathetic)parasympathetic)

Slower heart rates allow for Slower heart rates allow for increased cardiac filling timeincreased cardiac filling time

Adverse Reactions/Side Adverse Reactions/Side EffectsEffects

Digoxin Toxicity Digoxin Toxicity [has a narrow therapeutic index – (0.5 – 2 ng/ml)][has a narrow therapeutic index – (0.5 – 2 ng/ml)]

BradycardiaBradycardia Arrhythmias, complete heart blocksArrhythmias, complete heart blocks

Nausea, vomitingNausea, vomiting Abdominal pain, diarrheaAbdominal pain, diarrhea Headache, vision changesHeadache, vision changes

Irritability, insomnia, depressionIrritability, insomnia, depression

(Eckman, Labus, and Thompson, 2009, p. 184)(Eckman, Labus, and Thompson, 2009, p. 184)

Herbal Drug Herbal Drug InteractionInteraction

St. John’s wortSt. John’s wort and and ginsengginseng inhibit the metabolism of inhibit the metabolism of

digoxin increasing the risk digoxin increasing the risk of toxicityof toxicity

(Eckman, Labus, and Thompson, 2009)(Eckman, Labus, and Thompson, 2009)

Anticoagulation Anticoagulation Therapy for Patients Therapy for Patients

with Atrial Fibrillationwith Atrial Fibrillation What is the difference between an What is the difference between an

anticoagulant, such as warfarin, and anticoagulant, such as warfarin, and an antiplatelet agent, such as an antiplatelet agent, such as clopidogrel???clopidogrel???

Why are anticoagulants used for Why are anticoagulants used for atrial fibrillation and not an atrial fibrillation and not an antiplatelet agent???antiplatelet agent???

Anticoagulation Anticoagulation Therapy for Patients Therapy for Patients

with Atrial Fibrillationwith Atrial Fibrillation Thrombolytic events are the most Thrombolytic events are the most

feared complication of AFfeared complication of AF

Patients with AF are up to 7 Patients with AF are up to 7 times more likely than the times more likely than the general population to have a general population to have a strokestroke

(Zak, 2010, p. 68)(Zak, 2010, p. 68)

Heparin SodiumHeparin SodiumAnticoagulantAnticoagulant

““Blood Thinner”Blood Thinner”

Prevents conversion of fibrinogen to Prevents conversion of fibrinogen to fibrin and prothrombin to thrombinfibrin and prothrombin to thrombin

Main use is prevention of blood clot Main use is prevention of blood clot formation!!!formation!!!

Heparin SodiumHeparin Sodium

Common Administration Routes:Common Administration Routes:

Subcutaneously or IntravenouslySubcutaneously or Intravenously

Heparin DripHeparin Drip

IV Bolus administered first according IV Bolus administered first according to patient’s weightto patient’s weight

How Supplied: 10,000 units/mlHow Supplied: 10,000 units/ml

Followed by continuous drip Followed by continuous drip

(dose determined by pharmacy)(dose determined by pharmacy)

How Supplied: 25,000 units/250 ml DHow Supplied: 25,000 units/250 ml D55WW

(100 units/ml)(100 units/ml)

Monitoring Monitoring HeparinHeparin

PTT measured on a regular PTT measured on a regular basis; 6 hours initially and basis; 6 hours initially and

after any rate changes; after any rate changes; otherwise every 12 hours or otherwise every 12 hours or

once dailyonce daily

Platelet Count daily – H.I.T.Platelet Count daily – H.I.T.

Heparin Induced Heparin Induced Thrombocytopenia (HIT)Thrombocytopenia (HIT) Aka Heparin Associate Thrombocytopenia Aka Heparin Associate Thrombocytopenia

(HAT)(HAT)

An allergic reaction that is mediated by by the An allergic reaction that is mediated by by the production of immunoglobulin (Ig)G antibodiesproduction of immunoglobulin (Ig)G antibodies

The greatest risk of this condition is the The greatest risk of this condition is the paradoxical occurrence of thrombosis, paradoxical occurrence of thrombosis, something that heparin normally prevents or something that heparin normally prevents or alleviatesalleviates

(Lilley, Harrington, and Snyder, 2007, p. 422)(Lilley, Harrington, and Snyder, 2007, p. 422)

Heparin Induced Heparin Induced Thrombocytopenia (HIT)Thrombocytopenia (HIT)

Incidence is 5% to 15% of patientsIncidence is 5% to 15% of patients

Is higher bovine versus porcine heparinsIs higher bovine versus porcine heparins

Argatroban and lepirudin (Refludan) are Argatroban and lepirudin (Refludan) are indicated for treating HITindicated for treating HIT

(Lilley, Harrington, and Snyder, 2007, p. 422)(Lilley, Harrington, and Snyder, 2007, p. 422)

Monitoring Monitoring HeparinHeparin

Monitor:Monitor:

S/S of Bleeding S/S of Bleeding → gums, hematuria, black tarry → gums, hematuria, black tarry stoolsstools

Labs → PTT (Target PTT = 60 – 80 seconds or 2 – Labs → PTT (Target PTT = 60 – 80 seconds or 2 – 2.5 greater than baseline2.5 greater than baseline

Platelet Count > 100Platelet Count > 100

Heparin: Too Heparin: Too Much?Much?

ATTENTION!!!ATTENTION!!!

Reversal agent for Heparin is…Reversal agent for Heparin is…

Protamine SulfateProtamine Sulfate1 gram per 100 units of heparin (IV)1 gram per 100 units of heparin (IV)

Heparin Heparin DiscontinuationDiscontinuation

Before heparin drip is discontinued, Before heparin drip is discontinued, patient needs to be on Coumadin patient needs to be on Coumadin (warfarin) and INR needs to be (warfarin) and INR needs to be

therapeutic (2.0 – 3.0)therapeutic (2.0 – 3.0)

This is not a nursing or pharmacy This is not a nursing or pharmacy judgment – physician will order judgment – physician will order

discontinuation of heparin or write discontinuation of heparin or write standing ordersstanding orders

CoumadinCoumadin

(warfarin sodium)(warfarin sodium)AnticoagulantAnticoagulant

““Blood Thinner”Blood Thinner”

Depresses hepatic synthesis of vitamin K-Depresses hepatic synthesis of vitamin K-dependent coagulation factors (II, VII, IX, dependent coagulation factors (II, VII, IX,

X)X)

Main use is prevention of blood clot Main use is prevention of blood clot formation!!!formation!!!

Coumadin DosingCoumadin DosingCoumadin is usually ordered on a Coumadin is usually ordered on a

daily basisdaily basis

Dose is adjusted by prescribing Dose is adjusted by prescribing physician according to INR level.physician according to INR level.

Upon D/C, patient will need to be Upon D/C, patient will need to be instructed to keep follow-up instructed to keep follow-up appointments for INR level appointments for INR level

monitoringmonitoring

Coumadin Coumadin

Monitor:Monitor:

S/S of Bleeding S/S of Bleeding → gums, hematuria, → gums, hematuria, black tarry stoolsblack tarry stools

Labs → PT/INR (Target INR = 2.0 – 3.0)Labs → PT/INR (Target INR = 2.0 – 3.0)

Avoid IM injectionsAvoid IM injections

Herbal Drug Herbal Drug InteractionInteraction

St. John’s wort, ginseng,St. John’s wort, ginseng, and and gingkogingko inhibit the inhibit the

metabolism of warfarin metabolism of warfarin increasing the risk of toxicityincreasing the risk of toxicity

(Micromedex)(Micromedex)

Coumadin: Too Coumadin: Too Much?Much?

Anticoagulant TherapyAnticoagulant Therapy

ATTENTION!!!ATTENTION!!!

Reversal agent for Coumadin is…Reversal agent for Coumadin is…

Vitamin K (Oral, SQ, or IV)Vitamin K (Oral, SQ, or IV)

ReferencesReferencesDonofrio, J., Haworth,K., Achaeffer, L., & Thompson, G. (2005). Donofrio, J., Haworth,K., Achaeffer, L., & Thompson, G. (2005).

Cardiovascular care made incredibly easy. Cardiovascular care made incredibly easy. Ambler, PA: Lippincott Ambler, PA: Lippincott Wilkins & WilliamsWilkins & Williams

Eckman, M., Labus, D., & Thompson, G., (Eds). (2009). Eckman, M., Labus, D., & Thompson, G., (Eds). (2009). Nursing Nursing pharmacology made incredibly easy. pharmacology made incredibly easy. Ambler, PA: Lippincott, Williams, Ambler, PA: Lippincott, Williams, and Wilkins.and Wilkins.

Hodgson, B. B., & Kizior, R. J. (2007). Hodgson, B. B., & Kizior, R. J. (2007). Saunders nursing drug handbook.Saunders nursing drug handbook. St. Louis, MS: Saunders Elsevier.St. Louis, MS: Saunders Elsevier.

Khan, M. G. (2007). Khan, M. G. (2007). Cardiac drug therapy, Cardiac drug therapy, (7(7thth ed.). Totowa, NJ: Humana ed.). Totowa, NJ: Humana Press.Press.

Lilley, L. L., Harrington, S., & Snyder, J. S. (2007). Lilley, L. L., Harrington, S., & Snyder, J. S. (2007). Pharmacology and the Pharmacology and the nursing process, nursing process, (5(5thth ed.). St. Louis, MO: Mosby Elsevier. ed.). St. Louis, MO: Mosby Elsevier.

ReferencesReferencesPrudente, L. A. (2008). Quelling atrial chaos: Current approaches to Prudente, L. A. (2008). Quelling atrial chaos: Current approaches to

managing atrial fibrillation. managing atrial fibrillation. American Nurse Today, 3American Nurse Today, 3(8), 21-26.(8), 21-26.

Skidmore-Roth, L. et al. (2007). Skidmore-Roth, L. et al. (2007). Mosby’s nursing drug reference, Mosby’s nursing drug reference, (20(20thth ed.). ed.). St. Louis, MS: Mosby Elsevier.St. Louis, MS: Mosby Elsevier.

Smeltzer et al. (2008). Smeltzer et al. (2008). Brunner and suddarth’s textbook of medical-Brunner and suddarth’s textbook of medical-surgical nursing, surgical nursing, (11(11thth ed.). Philadelphia, PA: Lippincott Williams and ed.). Philadelphia, PA: Lippincott Williams and Wilkins.Wilkins.

Zak, J. (2010). Ablation to treat atrial fibrillation: Beyond rhythm control. Zak, J. (2010). Ablation to treat atrial fibrillation: Beyond rhythm control. Critical Care Nurse, 30Critical Care Nurse, 30(6),(6), 68-78.68-78.

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