REVIEW OF LITERATURE Atrial fibrillation is the most common cardiac arrhythmia

REVIEW OF LITERATURE

Atrial fibrillation is the most common cardiac arrhythmia. It impairs cardiac function and increases the risk of stroke. The incidence of atrial fibrillation increases with age. It affects about 1 percent of patients younger than 60 years and about 8 percent of patients older than 80 years. Atrial fibrillation is an independent risk factor for mortality; it can also lead to or worsen heart failure and increase mortality rates in patients who have had myocardial infarction (Rosamond, 2010).

The QRS complex remains narrow unless other conduction abnormalities exist (e.g., bundle branch block, accessory pathways). The ventricular response is often rapid, between 90 and 170 beats per minute. Atrial fibrillation is a source of significant morbidity and mortality because it impairs cardiac function and increases the risk of stroke. The cost of caring for patients with atrial fibrillation is about five times greater than caring for patients without it (Connolly, Eikelboom, Joyner, Diener, Hart et al., (2011;…).

Atrial fibrillation is the most common sustained cardiac rhythm disturbance, increasing in prevalence with Age. AF is often associated with structural heart disease although a substantial proportion of patients with AF have no detectable heart disease. Hemodynamic impairment and thromboembolic events. Related to AF result in significant morbidity, mortality, and cost. Accordingly, despite good progress in the management of patients with atrial AF, this arrhythmia remains one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity in the world. Furthermore, the number of patients with AF is predicted to rise steeply in the coming years (American Heart Association, 2011).
Anatomy and Physiology of the Heart:
The human heart is the most essential organ of the human body as it supplies blood to all parts of the body. Blood acts as a medium for transporting substances such as oxygen, nutrients, enzymes, antibodies, as well as collecting end result of multiple metabolic process as toxic byproducts for disposal. The heart is situated in the chest cavity posterior to the sternum and costal cartilages and rests on the superior surface of the diaphragm (Vaizurs, Raja, Sarath, Chandra,& Prasad, 2018).

The heart has four chambers: two upper chambers (atria) and two lower chambers (ventricles). A muscular septum divides the heart internally into left half and right half. The two upper chambers left atrium (LA) and right atrium (RA) function as collecting chambers. The lower two chambers left ventricle (LV) and right ventricle (RV) pump blood (Jan & Sherri, 2012).

In general, de-oxygenated blood in the right atrium collected from all veins of the body (except from the veins of the lungs) is pumped into the right ventricle. Contraction of the right ventricle pumps the blood to the lungs through the pulmonary arteries. In the lungs oxygen is supplied to the blood making it oxygenated blood. (Andrade, Khairy, Dobrev,&Nattel, 2014).

Both the left and right pulmonary veins carry the oxygenated blood from lungs to LA. Further, the blood in the LA is pumped into the left ventricle. Upon the contraction of the left ventricle, the blood through the aortic artery and its branches is supplied to all tissues in the body. Oxygen is used by the cells to produce energy and carbon dioxide is generated as a product (Smeltzer& Bare, 2010).

Oxygen poor, carbon dioxide rich blood collected by the superior and inferior vena cava empties into the right atrium. The direction of the blood flow is controlled by atrioventricular valves between the atria and the ventricles, and the pulmonary and aortic valves between the ventricles and the arteries (Baczkó, Liknes, Yang, Hamming, Searle et al., (2014;…).

During one heart beat or cardiac cycle, a sequence of electrical and mechanical events takes place. Under normal conditions, heart contractions are very rhythmic and synchronized. The contraction of the heart muscle is due to the electrical impulse generated spontaneously by Sino-atrial node (SAN). Hence, SAN is called the “pacemaker” of the heart. The electrical stimulus from SAN spreads through both atria and reaches the atrioventricular node (AVN) (Frank &Yanowitz, 2011).

Figure (1) Electrical activity of a normal heart (left) and a heart with atrial fibrillation (right). Dowenloded from (https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm).

The impulse from AVN will reach ventricles via left and right bundles of HIS. In general, bundle of HIS extends into the septum where it forms two branches, giving rise to Purkinje network. The impulse now spreads rapidly in both ventricular chambers as Purkinje fibers conduct impulses faster than ordinary cardiac muscles. Hence both the ventricles contract almost simultaneously. The basic heart conduction system explained above is shown in Figure 3 (Smeltzer& Bare, 2010).

Epidemiology and Prognosis of Atrial Fibrillation:
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in 1–2% of the general population. A recent Swedish study even suggesting 3%. Over 6 million Europeans suffer from this arrhythmia, and its prevalence is estimated to at least double in the next 50 years as the population ages (Friberg, Engdahl, Frykman, Svennberg, Levin et al., (2013;…). The incidence of AF appears to be increasing already (13% during the past two decades). The prevalence of AF increases with age, from 0.5% at 40–50 years to 5–15% at 80 years. The lifetime risk of developing AF is 25% in those who have reached the age of 40 (Camm, Kirchhof, Lip, Schotten, Savelievaet al., (2010;…).

The incidence and prevalence of atrial fibrillation (AF) are progressively rising with resultant increases in health-care burden globally much of the health-care burden of AF is related to an exponential rise in hospitalizations that have surpassed heart failure admissions. Importantly, this ‘rising tide’ of AF is accompanied by an almost increase in AF related mortality over the last two decades (Wong, Bai, Li, Ye, Zhang et al., (2014;…).

Contemporary studies show that 20–30% of patients with an ischemic stroke have AF diagnosed before, during, or after the initial event. White matter lesions in the brain, cognitive impairment, decreased quality of life, and depressed mood are common in AF patients, and between 10–40% of AF patients are hospitalized each year (von, Hutt, Baumert, Breithardt, Goette et al., (2015;…).

The direct costs of AF approximately 1% of total health care spending in the UK, and between 6.0–26.0 billion US dollars in the US for 2008, driven by AF-related complications (e.g. stroke) and treatment costs (e.g. hospitalizations). These costs will increase dramatically unless AF is prevented and treated in a timely and effective manner (Kirchhof et al., (2016;…).

Despite these advances, substantial morbidity remains. Oral anticoagulation (OAC) with vitamin K antagonists (VKAs) or non VKA oral anticoagulants (NOACs) markedly reduces stroke and mortality in AF patients. Other interventions such as rhythm control and rate control improve AF-related symptoms and may preserve cardiac function, but have not demonstrated a reduction in long-term morbidity or mortality (Ruff, Giugliano, Braunwald, Hoffman, Deenadayalu et al., (2014;…).

In contemporary, well-controlled, randomized clinical trials in AF, the average annual stroke rate is about 1.5% and the annualized death rate is around 3% in anticoagulated AF patients. In real life, the annual mortality can be different (both higher and lower) (Senoo, Lip, Lane, Buller, & Kotecha, 2015).

A minority of these deaths are related to stroke, while sudden cardiac death and death from progressive heart failure are more frequent, emphasizing the need for interventions beyond anticoagulation. Furthermore, AF is also associated with high rates of hospitalization, commonly for AF management, but often also for heart failure, myocardial infarction, and treatment associated complications (Soliman, Safford, Muntner, Khodneva, Dawood et al., (2014;…).
Women with diagnosed AF can be more symptomatic than men and are typically older with more comorbidities. Bleeding risk on anticoagulation is similar in both sexes, but women appear less likely to receive specialist care and rhythm control therapy, while the outcomes of catheter ablation or AF surgery are comparable to those in men. These observations high light the need to offer effective diagnostic tools and therapeutic management equally to women and men (Ko, Rahman, Schnabel, Yin, Benjamin et al., (2016;…).

Definition of Atrial Fibrillation:
Atrial fibrillation is defined as a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of mechanical atrial function. Electrocardiographic findings include the replacement of the normal consistent P waves (which represent synchronous atrial activation) with oscillatory or fibrillary waves of different sizes, amplitudes, and timing (Van, Groenveld, &Crijns, 2010).

Atrial ?brillation is a rapid, disorganized, and uncoordinated twitching of atrial musculature. It is the most common dysrhythmia that causes patients to seek medical attention. It may start and stop suddenly. Atrial ?brillation may occur for a very short time (paroxysmal), or it may be chronic (Smeltzer& Bare, 2010).

Atrial ?brillation is usually associated with advanced age, valvular heart disease, coronary artery disease, hypertension, cardiomyopathy, hyperthyroidism, pulmonary disease, acute moderate to heavy ingestion of alcohol (“holiday heart” syndrome), or the aftermath of open heart surgery. Sometimes it occurs in people without any underlying pathophysiology (termed lone atrial ?brillation) (Patricia & Dorrie, 2013).

Atrial fibrillation is characterized by the following (1) the surface Electro-cardio gram (ECG) shows “absolutely” irregular RR intervals (AF is therefore sometimes known as arrhythmia absolute), i.e. RR intervals that do not follow a repetitive pattern. (2) There are no distinct P waves on the surface ECG. Some apparently regular atrial electrical activity may be seen in some ECG leads, most often in lead V1. (3) The atrial cycle length (when visible), i.e. the interval between two atrial activations, is usually variable and 65 years of age, reported that light to moderate physical activities such as leisure-time activity and walking were associated to significantly lower risk of AF (Andersen, Farahmand, Ahlbom, Held, Ljunghall et al., (2013;…).

Alcohol consumption is positively associated with risk of AF. Even moderate consumption of alcohol, which lowers the risk of other cardiovascular diseases seems to slightly increase the risk of AF (Larsson, Drca, & Wolk, 2014).

Diabetes mellitus requiring medical treatment is found in 20% of AF patients, and may contribute to atrial damage. Chronic obstructive pulmonary disease (COPD) is found in 10–15% of AF patients, and is possibly more a marker for cardiovascular risk in general than a specific predisposing factor for AF (Camm et al., (2010;…).

Sleep apnea, especially in association with hypertension, diabetes mellitus, and structural heart disease, may be a pathophysiological factor for AF because of apnea-induced increases in atrial pressure and size, or autonomic changes. Chronic renal disease is present in 10–15% of AF patients. Renal failure may increase the risk of AF-related cardiovascular complications, although controlled data are sparse (Camm et al., (2010;…).

Mechanism of Atrial fibrillation
A normal heart rate at rest varies from 60 to 80 beats per minute. A normal heart beat is rhythmic as the impulse generated by SAN is very periodic as shown in left figure of Figure 5. In AF, the impulse is generated from the sinus node and multiple random signals „fire off? from different abnormal tissues in the atria as shown in the right figure of Figure 5 (Schotten et al., (2010;…).

Due to the presence of multiple disorganized electrical impulses in the heart, the atria begin to quiver or fibrillate, so they no longer effectively pump blood into the ventricles. Such ineffective contraction induces stagnation of the blood in low flow areas of the atria potentially leading to blood clotting. Small pieces of the clot can break off causing occlusion of small arteries and hence stroke or peripheral artery occlusion (peripheral in front) (Camm et al., (2010;…).

Hence, during AF, ventricles stimulated by fibrillating atria beat irregularly with varying frequencies. Ventricular function becomes impaired causing heart failure. It is therefore not surprising that AF is associated with an increased risk of death (Smeltzer& Bare, 2010).

Figure (3): Sinus Rhythm and AF in Heart. (Raja, 2011) downloaded from http://scholarcommons.usf.edu/etd/3386
Atrial factors any kind of structural heart disease may cause a progressive process of structural remodeling in both ventricles and atria, which may result in electrical dissociation and may facilitate the initiation and continuation of AF. After the onset of AF, changes of atrial properties occur, resulting in shortening of the atrial refractory time and deterioration of atrial contractile functions (Camm et al., (2010;…).

Electrophysiological mechanisms Focal activity from the pulmonary veins (PVs) may initiate and perpetuate atrial tachy-arrhythmias. These focuses are targets for ablation therapy. According to the multiple wavelet theory, AF is continued by uninterrupted conduction of several independent wavelets spreading through the atrial musculature in a seemingly chaotic manor. Interaction of these wavelets sustains the arrhythmia (Christophersen, Olesen, Liang, Andersen, Larsen et al., (2013;…).

Genetic factors AF has a familial component, especially early-onset AF. Numerous inherited cardiac syndromes, such as short and long QT syndrome and Brugada syndrome, have been associated with AF. A 2014 Swedish study showed that an AF-genetic risk score of twelve single nucleotide polymorphisms can identify 20% of individuals who are at two-fold increased risk for incident AF and at 23% increased risk of ischemic stroke (Tada, Shiffman, Smith, Sjogren, Lubitz et al., (2014;…).

Atrioventricular conduction, in patients with AF and a normal conduction system (in the absence of accessory pathway or His purkinje dysfunction), the atrioventricular node functions as a frequency filter preventing excessive ventricular rates. Electrical impulse reaching the atrioventricular node may not be conducted to the ventricles (Christophersen et al., (2013;…).

Hemodynamic changes, acute loss of coordinated atrial mechanism function after the onset of AF reduces cardiac output by 5-15%. High ventricular rates limit ventricular filling due to the short diastolic interval. In addition, irregularity of ventricular rate can reduce cardiac output. Because of force- interval relationships, fluctuations of the RR intervals cause a large variability in the strengths of subsequent heart beats, often resulting in pulse deficit (Camm et al., (2010;…).

Thrombo-embolism, risk of stroke and systemic embolism in patients with AF is linked to a number of underlining pathophysiological mechanism. Flow abnormalities in AF are evidenced by stasis within the left atrium, with reduced left atrial appendage (LAA) flow velocities dominant source of embolism (90%) in non-valvuler AF. Endocardial abnormalities and abnormalities of blood constitutes are also well described in AF as shown in Figure 6 (Watson, Shantsila, & Lip, 2009).

Figure (4): Mechanism of atrial fibrillation. Downloaded From: http://content.onlinejacc.org/ by (Sheila Tynes) on 02/05/2015

Clinical Manifestation of Atrial Fibrillation:
Atrial fibrillation has a wide spectrum of clinical presentations. Some patients may be asymptomatic. Others may present with stroke, overt heart failure, or cardiovascular collapse. Patients most commonly report palpitations, dyspnea, fatigue, lightheadedness, and chest pain. Because symptoms are nonspecific, they cannot be used to diagnose and determine the onset of atrial fibrillation. If electrocardiography does not demonstrate atrial fibrillation and a strong suspicion persists, a Holter or cardiac event monitor may be needed to document the arrhythmia (Christophersen et al., (2013;…).

Diagnosis of Atrial Fibrillation
The diagnosis of AF is based on history, clinical examination and confirmed by ECG recording. Clinical history and physical examination: The initial evaluation of a patients with suspected or proved AF involves characterizing the pattern of arrhythmia as paroxysmal or persistent, determining its cause, and defining associated cardiac and extra cardiac factors pertinent to the etiology, tolerability, and history of prior managements. Delay occurs when the rhythm has not been specifically documented and additional monitoring is necessary (Chung, Manganiello, & Dyck, 2012).

Typically AF occurs in patients with underlying heart disease. Pulmonary pathology, pre-excitation syndrome, and thyroid disease. Because of reports of genetic transmission of AF, the family history is important as well. Also various environmental triggers can initiate episodes of AF, commonly mentioned triggers include alcohol, sleep deprivation, and emotional stress, but vagally mediated AF may occur during sleep or after a large meal and is more likely to arise during a period of rest succeeded by a period of stress. Stimulants such as caffeine or exercise may also precipitate AF (Connolly et al., (2011;…).

The physical examination may suggest AF on the basis of irregular pulse, irregular jugular venous pulsation and variation in the intensity of the first heart sound or absence of a fourth sound heard previously during sinus rhythm. Examination may also disclose associated valvular heart disease, myocardial abnormalities or HF (Smeltzer& Bare, 2010)

Manual pulse palpation should be performed to assess for the presence of an irregular pulse in people presenting with any of the following: breathlessness/dyspnea, palpitation, syncope/dizziness, chest discomfort, stroke/TIA (Cowan, Campbell, Cheong, Chung, Fay et al., (2014;…).

ECG (Electro Cardio Graph): recording is necessary to diagnose AF any arrhythmia that has the ECG characteristic of AF and lasts sufficiently long for a 12 –lead ECG to be recorded, or at lasts 30 second on a rhythm strip, should be considered as AF (Kirchhof et al., (2016;…).
ECG characteristics of AF:
a) The surface ECG show irregular RR intervals.
b) There are no distinct P waves on the surface ECG.
c) The atrial cycle length (when visible).i.e. the interval between two atrial activations, is usually variable and ?200 ms (>300 bpm) (Camm et al., (2010;…).

Figure (5): ECG characteristics of AF. (Edward, 2017). Available at:
https://i2.wp.com/lifeinthefastlane.com/wpcontent/uploads/2011/08/af2.jpg?ssl=1
The diagnosis of AF requires rhythm documentation using an electrocardiogram (ECG) showing the typical pattern of AF: Absolutely irregular RR intervals and no discernible, distinct P waves. ECG documented AF was the entry criterion in trials forming the evidence for these guidelines. By accepted convention, an episode lasting at least 30 s is diagnostic (Kishore, Vail, Majid, Dawson, Lees et al., (2014;…).

Individuals with AF may be symptomatic or asymptomatic (‘silent AF’). Many AF patients have both symptomatic and asymptomatic episodes of AF. Silent, undetected AF is common, with severe consequences such as stroke and death. Prompt recording of an ECG is an effective and cost-effective method to document chronic forms of AF (Sanna, Diener, Passman, Di Lazzaro, Bernstein et al., (2014;…).

The technology to detect paroxysmal, self-terminating AF episodes is rapidly evolving. There is good evidence that prolonged ECG monitoring enhances the detection of undiagnosed AF, e.g. monitoring for 72 h after a stroke or even longer periods. Daily short-term ECG recordings increase AF detection in populations over 75 years of age (Grond, Jauss, Hamann, Stark, Veltkamp et al., (2013;…).

Ongoing studies will determine whether such early detection alters management (e.g. initiation of anticoagulation) and improves outcomes. Once the ECG diagnosis of AF has been established, further ECG monitoring can inform management in the context of: (1) a change in symptoms or new symptoms; (2) suspected progression of AF; (3) monitoring of drug effects on ventricular rate; and (4) monitoring of antiarrhythmic drug effects or catheter ablation for rhythm control. (Xiong, Proietti, Senoo & Lip, 2015).

Undiagnosed AF is common, especially in older populations and in patients with heart failure. Opportunistic screening for silent AF seems cost-effective in elderly populations (e.g. 65years), and similar effects have been reported using single-lead ECG screening in other at-risk populations (Aronsson, Svennberg, Rosenqvist, Engdahl, Al-Khalili et al., (2015,…).

Screening of older populations (mean age 64 years) yielded a prevalence of 2.3% for chronic forms of AF in 122,571 participants using either short-term ECG or pulse palpation (followed by ECG in those with an irregular pulse). Previously undiagnosed AF was found in 1.4% of those aged 65 years, suggesting a number needed to screen of 70. These ?ndings encourage the further evaluation of systematic AF screening programs in at-risk populations (Levin, Husberg, Sobocinski, Kull, Friberg et al., (2015;…).

Paroxysmal AF is often missed. Repeated daily ECG recordings increased the detection of silent, asymptomatic paroxysmal AF in an unselected Swedish population aged 75 years. Several patient-operated devices and extended continuous ECG monitoring using skin patch recorders have been validated for the detection of paroxysmal AF (Tieleman, Plantinga, Rinkes, Bartels, Posma et al., (2014;…).

The detection of asymptomatic AF by new technologies, such as smart phone cases with ECG electrodes, smart watches, and blood pressure machines with AF detection algorithms, has not yet been formally evaluated against an established arrhythmia detection method (Quinn &Gladstone, 2014).

Implanted pacemakers or de?brillators with an atrial lead allow continuous monitoring of atrial rhythm. Using this technology, patients with atrial high rate episodes (AHRE) can be identi?ed. Depending on the risk pro?le of the population studied, such AHRE are detected in 10–15% of pacemaker patients. AHRE are associated with an increased risk of overt AF hazard ratio (HR) 5.56; 95% con?dence interval (CI) 3.78–8.17; P, 0.001 and ischemic stroke or systemic embolism (HR 2.49; 95% CI 1.28–4.85; P¼0.007) (Brambatti et al., (2014;…).

The stroke risk in AHRE patients seems lower than the stroke risk in patients with diagnosed AF, and not all AHRE represent AF. Strokes often occur without AHRE detected within 30 days before the event (Healey et al., (2012;…).

Consequently, it is unclear whether AHRE imply the same therapeutic requirements as overt AF and the bene?t of OAC in patients with AHRE is tested in ongoing clinical trials e.g. Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation (ARTESiA) and Non vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH – AFNET (Boriani, Glotzer, Santini, West, De Melis et al., (2014;…).

At present, pacemakers and implanted devices should be interrogated on a regular basis for AHRE, and patients with AHRE should undergo further assessment of stroke risk factors and for overt AF, including ECG monitoring (Lamas, 2012).

Sequential strati?ed ECG monitoring detected AF in 24% of stroke survivors and in 11.5% in another meta-analysis, with large variations depending on the timing, duration, and method of monitoring (Kishore et al., (2014;…).

AF detection is not uncommon in unselected stroke patients, but is more likely in patients with cryptogenic stroke implanted with loop recorders or who have had ECG monitors for several weeks. Cryptogenic stroke is de?ned as a stroke in which the cause could not be identi?ed after extensive investigations. A broader de?nition is embolic stroke of undetermined source (Sanna et al., (2014;…).

Several studies have also found AF in patients in whom another competing cause for stroke has been identi?ed clinically (e.g. hypertension or carotid artery stenosis). Hence, prolonged ECG monitoring seems reasonable in all survivors of an ischaemic stroke without an established diagnosis of AF (Thijs, Brachmann, Morillo, Passman, Sanna et al., (2016;…).

Additional investigation of selected patients with atrial fibrillation:
Blood test: Blood test are routine but can be abbreviated. It’s important that CBC, thyroid, renal, hepatic function, serum electrolytes and the hemogram be measured at least once in the course of evaluating a patients with AF. Both B-type natriuretic peptide (BNP), which is produced mainly in the ventricles, and atrial natriuretic peptide (ANP), which is produced primarily in the atria are associated with AF. Plasma level of both peptides are elevated in patients with paroxysmal and persistent AF and decrease rapidly after restoration of sinus rhythm (Kirchhof et al., (2016;…).

Exercise testing: Should be performed if MI suspected and prior to initiating type IC antiarrhythmic drug therapy. Another reason for exercise testing is to study the adequacy of rate control across a full spectrum of activity, not only at rest, in patients with persistent or permanent AF (Corradi, Callegari, Maestri, Ferrara, Mangieri et al., (2012;…).

Transesophageal echocardiography (TEE): Transesophageal echocardiography is not part of the standard initial investigation of patients with AF. By placing a high-frequency ultrasound transducer close to the heart, however, TEE provides high quality images of cardiac structure and function. It’s the most sensitive and specific technique to detect sources and potential mechanisms for cardiogenic embolism. The technology has been used to stratify stroke risk in patients with AF and to guide cardioversion (Dobrev, Carlsson & Nattel, 2010)
Electrophysiological study (EP): In short, EP testing is indicated when ablative therapy of arrhythmias that trigger AF or ablation of AF is planned. In patients with AF who are candidates for ablation, an EP study is critical to define the targeted site or sites of ablation in the LA and /or right sided structures (Fuster, Rydén, Cannom &Crijns, 2011).

Chest radiograph: To evaluate lung parenchyma and pulmonary vasculature, when clinical findings suggest an abnormality (Fuster et al., (2011;…).

Management Strategies of Atrial Fibrillation:
Two main strategies have been compared in the treatment of atrial fibrillation: rhythm control and rate control. Data show that patients assigned to rhythm control have more hospitalizations from adverse cardiovascular events, more serious adverse effects from medications, and the same rate of thromboembolic events compared with patients assigned to rate control (Fuster et al., (2011;…).

Therefore, rate control is recommended in most patients. Rhythm control remains an option when rate control is unsuccessful or when symptoms persist despite rate control. Both strategies require anticoagulation therapy to prevent stroke (Dobrev et al., (2012;…).

Rhythm?Control:
Cardioversion to restore normal sinus rhythm can be achieved electrically or pharmacologically. Anticoagulation therapy, before and after cardioversion, is recommended with either strategy to prevent thromboembolism (Fuster et al., (2011;…).

Guidelines recommend initiating anticoagulation therapy three weeks before and four weeks after cardioversion, because thrombi may form as soon as 48 hours after the onset of atrial fibrillation, and atrial function does not return to normal immediately after cardioversion to normal sinus rhythm. The atria are often “stunned,” and the risk of stroke is high for several weeks if warfarin (Coumadin) is not used (Dolinsky, Meyer, Hesselbrock, Hof- mann &Tennen, 2011).

Pharmacologic cardioversion and maintenance of normal sinus rhythm are difficult to achieve because of the limited long-term effectiveness of medications, the risk of triggering ventricular arrhythmias, and the risk of long-term adverse effects from medication use (Fuster et al., (2011;…).

Older agents such as quinidine, procainamide, and disopyramide (Norpace) are rarely used because of adverse effects. Dronedarone (Multaq), which is a non-iodinated derivative of amiodarone, has been shown to reduce atrial fibrillation without the long-term serious adverse effects of amiodarone, but there are concerns about safety in patients with severe heart failure (Piccini, Hellkamp, Lokhnygina, Patel, Harrell et al., (2014;…).

The choice of medication depends on the patient’s cardiac history, For example, flecainide and propafenone are preferred in patients with minimal or no heart disease and preserved left ventricular systolic function, whereas amiodarone and dofetilide are preferred in patients with heart failure (Fuster et al., (2011;…).

Patients with paroxysmal atrial fibrillation may use the “pill-in-the-pocket” approach with flecainide or propafenone, which involves taking a pill when an episode begins. This method is often effective in converting the rhythm to normal, and obviates the need to take antiarrhythmic medications long term (Van et al., (2010;…).
Rate?Control:
Decreasing the ventricular response rate, known as rate control, improves diastolic filling and coronary perfusion, decreases myocardial energy demand, and prevents tachycardia-mediated cardiomyopathy. The aiming for a ventricular response of less than 80 beats per minute at rest and less than 110 beats per minute during exercise (Fuster et al., (2011;…).

However, a recent randomized controlled trial showed that lenient rate control, defined as a ventricular rate of less than 110 beats per minute at rest, was not inferior to strict rate control in preventing cardiac death, heart failure, stroke, and life-threatening arrhythmias (Van et al., (2010;…). Beta blockers (e.g., metoprolol, esmolol Brevibloc, propranolol Inderal) and non-dihydropyridine calcium channel blockers (e.g., diltiazem, verapamil) are often used for rate control. Beta blockers are generally first line agents (Fuster et al., (2011;…).

Digoxin is no longer considered a first-line agent for atrial fibrillation, because studies have shown that it has little effect during exercise. However, it may be used in conjunction with beta blockers or calcium channel blockers. Digoxin slows the ventricular rate mostly via enhancing vagal tone (Connolly et al., (2010;…).

Anticoagulation:
In patients with atrial fibrillation, the estimated risk of stroke without anticoagulation therapy is 5 percent per year. Paroxysmal and chronic atrial fibrillation, treated by rate or rhythm control, require long-term anticoagulation therapy unless the risks of anticoagulation use exceed the benefits (Fenger-Grøn, Morten, Christensen, Bo, Glummer et al., (2017;…).

Warfarin, aspirin, and clopidogrel (Plavix) are the most commonly used oral agents for anticoagulation. Several trials and a Cochrane review have demonstrated that warfarin is more effective than aspirin but confers a higher risk of bleeding; that warfarin is superior to aspirin plus clopidogrel, with the same risk of bleeding and that adding full-dose aspirin to warfarin should be avoided because of an increased risk of bleeding (Fuster et al., (2011;…).

Pooled data from five randomized controlled trials demonstrated that warfarin use reduces the risk of stroke by about 68 percent, whereas data from three randomized controlled trials showed that aspirin reduces the risk of stroke by about 21 percent (Connolly et al., (2010;…).

Warfarin poses significant challenges because of its narrow therapeutic range, the need for frequent monitoring, multiple drug and food interactions, and the risk of bleeding. The warfarin dosage should be adjusted to achieve a target International Normalized Ratio (INR) of 2 to 3 (Fuster et al., (2011;…). An INR less than 1.8 doubles the risk of stroke, whereas an INR greater than 3.5 does not further benefit patients and increases the risk of bleeding. Contraindications to warfarin therapy include hypersensitivity to warfarin, severe liver disease, recent trauma or surgery, and active bleeding (Ford, Milnes, Wettwer, Christ, Rogers et al., (2016;…).

As patients age, the risk of experiencing a thromboembolic event increases, as does the risk of experiencing adverse effects from anticoagulation therapy. Balancing these risks is key to optimizing outcomes. The stroke risk prediction tool known by the acronym CHADS2 has been validated in several trials (Haemers, Claus ; Willems, 2017).

CHADS2 uses the following risk factors: congestive heart failure; hypertension, age 75 years or older, diabetes mellitus, and stroke or transient ischemic attack. Each risk factor counts as one point, except for the stroke and transient ischemic attack risk factor, which counts as two points (Haemers et al., (2017;…). Risk is stratified into high (score of 4 or greater), moderate (score of 2 or 3), and low (score of 0 or 1). The CHADS2 tool has limitations; it does not include coronary artery disease and sex as risk factors, although women are at a higher risk of thromboembolic events than men (Fuster et al., (2011;…).

The American College of Physicians, the American Academy of Family Physicians, and the American College of Cardiology/American Heart Association/European Society of Cardiology recommend that patients with non valvular atrial fibrillation who are at low risk of stroke be treated with 81 to 325 mg of aspirin per day, whereas patients at higher risk should be treated with warfarin (at a dosage necessary to achieve a target INR of 2 to 3). There is general agreement that warfarin should be recommended in patients with atrial fibrillation and a CHADS2 score of 2 or greater (Heijman et al., (2016;…).

Decisions about the use of warfarin versus aspirin can be challenging in older patients and in those at risk of bleeding. The Outpatient Bleeding Risk Index is a validated tool used to predict the risk of bleeding in patients taking warfarin (January, 2014).

The Outpatient Bleeding Risk Index includes four risk factors, each counting as one point: (1) age older than 65 years; (2) history of stroke; (3) history of gastrointestinal bleeding; and (4) one or more of the following: recent myocardial infarction, severe anemia (hematocrit level less than 30 percent), diabetes, or renal impairment (serum creatinine level greater than 1.5 mg per dL 132.6 µmol per L) (Fuster et al., (2011;…).

A score of 0 is considered low risk, a score of 1 or 2 is intermediate risk, and a score of 3 or 4 is high risk. One study evaluating the Outpatient Bleeding Risk Index found that the risk of major bleeding after one year in low-, intermediate-, and high-risk patients was 3, 12, and 48 percent, respectively. Point of-care guides from the American Academy of Family Physicians are useful tools to assess the risk of stroke and bleeding using CHADS2, the American College of Chest Physicians risk assessment, and the Outpatient Bleeding Risk Index (Connolly et al., (2010;…).

The anticoagulation agent dabigatran (Pradaxa), a direct thrombin inhibitor, was recently approved by the U.S. Food and Drug Administration for the prevention of stroke and systemic embolism with atrial fibrillation. In a randomized trial, 150 mg of dabigatran twice per day was shown to be superior to warfarin in decreasing the incidence of ischemic and hemorrhagic strokes. Patients assigned to dabigatran had a higher incidence of myocardial infarction than those assigned to warfarin, but the difference was not statistically significant (Hassantash, Kalantarian, ; Bikdeli, 2009).

Surgical?Therapies:
There are two surgical therapies for atrial fibrillation: disruption of abnormal conduction pathways in the atria, and obliteration of the left atrial appendage. The maze procedure disrupts the initiation and conduction of electrical activity of the arrhythmogenic foci (Kaess, Parzer, Brunner, Koenig, Durkee et al., (2016;…).

Incisions are made in both atria to isolate and interrupt the multiple reentry circuits while maintaining the physiologic activation of the atria. The rationale for left atrial appendage obliteration is that more than 90 percent of thrombi form in the left atrial appendage (Terasawa, Balk, ; Chung, 2009).

If successful, obliteration decreases the patient’s risk of stroke and potentially avoids the need for long-term anticoagulation therapy. Preliminary data on percutaneous left atrial appendage obliteration show promise, but little long-term follow-up data are available. Direct left atrial appendage obliteration is an option in patients who will undergo valvular surgery, particularly involving the mitral valve (Wilber, Pappone & Neuzil, 2010).

Catheter?Ablation:
The discovery of specific foci that trigger atrial fibrillation (e.g., at or near the pulmonary veins, at the cristae terminalis, at the coronary sinus ostium) has stimulated research and development of ablation approaches. In 2009, a systematic review of six trials showed that catheter ablation is effective for up to 12 months as second line therapy in patients with minimal cardiac disease (mean age of 55 years) (Terasawa et al., (2009;…).

A later study found that ablation was significantly more effective than medical treatment for preventing recurrences in patients with intermittent atrial fibrillation. Currently, ablation therapy is a good option in patients with paroxysmal atrial fibrillation and normal left atrial size (Wilber et al., (2010;…).

Heath Needs about Atrial Fibrillation:
It is well-know that empowering patients by involving them in the decision-making and goal-setting processes can improve outcomes. Despite this, many patients have a poor understanding of AF, its managements and the associated risk. There is a clear needs to support patients through better educations and to close the current gabs between patients and physicians understandings (Aliot, Breithard, Brugada, Camm, Lip et al., (2010;…).

Definition of Health Needs:
Objectively determined deficiencies in health that require health care, from promotion to palliation. Perceived health needs: the need for health services as experienced by the individual and which he/she is prepared to acknowledge; perceived need May or may not coincide with professionally defined or scientifically confirmed need (Expert Patients programme community interest Company, 2012).

Professionally defined health needs: the need for health services as recognized by health professionals from the point of view of the benefit obtainable from advice, preventive measures, management or specific therapy; Professionally defined need may or may not coincide with perceived or scientifically confirmed need. Scientifically confirmed health needs: the need confirmed by objective measures of biological, anthropometric or psychological factors, expert opinion or the passage of time; it is generally considered to correspond to those conditions that can be classified in accordance with the International Classification of Diseases (Expert Patients ProgrammeCommunity Interest Company, 2012).

Recommendations for educational and counselling content include categories related to pathophysiology, natures of AF (its cause, consequences and trajectory), treatment, action plan, symptom managements and managing the psychosocial challenges of living with AF (McCabe, Schumacher, & Barnason, 2011).

Disease Process Information:
Patients reported that knowing what AF is and how it relates to their symptoms is helpful as a background but emphasized that meaningful patient education must also address questions such as «What caused this? » (Cause) «How will this affect my life? » (Consequences) and «What can be done about it? » (Controllability) (McCabe, 2009; McCabe et al., (2011;…).

Cause Information:
Patient’s beliefs about the cause of an illness and their psychological response to the illness. Being able to identify a cause of the illness provides patients with a direction for actions plan to control the illness (Hirani; Newman, 2005). Patient who have AF want providers to discuss factors that cause AF, promote its progressions, and offer recommendations for modifying factors that might trigger and foster persistence of AF. In some cases, such as old age, the cause is non modifiable, or, in AF without comorbidities, the cause is unknown. In ability to identify a modifiable cause for the AF can be emotionally distressing to patients (McCabe et al., (2011;…).

Despite making adjustment to diet and activities, the patient may still be unsuccessful in avoiding recurrent episodes of AF. If the patient has been adherent to treatment recommendations, it is important for providers to reassure patients that it is not something they have or have not done to cause the AF recur (Barnason ; Houfek, 2011).

If patients who have modifiable conditions that may promote progression of AF believe their AF is simply due to age, heredity, or chance, it is important for provider to modify those beliefs by educating them about lifestyle behaviors or comorbid conditions that require modification and management. Patients need to know how unmanaged conditions such as hypertension, diabetes, hyperlipidemia, obstructive sleep apnea, and obesity contribute to the development of AF and its progression (Chmberlain, Agarwal, Ambrose, Folsom et al., (2010;…).

Consequences and Trajectory of AF:
Patient’s beliefs about the consequences and trajectory of their illness influences their functional and psychological response to their illness correction of misperceptions related to the cause of the symptoms and perceived consequences, as well as providing reassurance about the ability to control the symptoms, is an important educational intervention in the early phase of the AF trajectory (McCabe, 2009).

Study participants reported that it was important for the provider to convey the serious nature of AF, its consequences and the importance of seeking treatment. Some patients failed to pursue treatment when AF episode were recurrent because they perceived little concern from their provider and therefore concluded that if the provider was not concerned, they should not be concerned. Although patients want clinicians to offer encouragement that AF can be managed, they also emphasize that providers need to convey the serious consequences of untreated AF: risk of stroke, heart failure, or progression of AF (McCabe et al., (2011;…).

Providing the patients with a realistic expectation about the trajectory of AF –that, for most patients, AF is a recurrent and chronic illness- is an important factor in supporting patients’ adjustment to AF. If patients leave the care encounter with the belief that AF will not recur, they may be distressed when they experience a recurrent episode of AF. This anticipatory guidance give the patients the knowledge they need to cope more effectively if and when another episode of AF occurs (McCabe et al., (2009;…).

Control and Treatment Information:
Study participants reported that a full discussion of treatment options, with rationale for each, was important. When they understood that AF may recur, they wanted to know that there was “something else that can be done.” Some patients were distressed by hearing different opinions among providers who did not provide rationales for their recommendations (McCabe et al., (2009;…).

Patients who discuss AF with one another may not realize the importance of individualized treatment provided according to type of AF and with consideration of each patient’s clinical condition. Thus, it is important to provide information about why a particular treatment is being recommended for the patient at this particular phase in their trajectory of AF and why another treatment option is not recommended (McCabe et al., (2011;…).

Providing information about the treatment, its benefits, risks, and side effects in a manner that is encouraging, yet clear about its limitations, will help the patient to develop realistic expectations that support positive adjustment. Without such information, patients come to their own conclusions, may not understand the difference between a rate-control versus a rhythm-control strategy and may have unrealistic expectations for the outcome of the plan of care (McCabe, Schad, Hampton, & Holland, 2008).

Koponen reported that 3 months after treatment in the emergency room 67% of participants believed that AF would not recur if they were taking medication to inhibit it. Patients who do not understand the limitations of drug or ablation therapy may become very distressed if they have AF episodes even though they are being treated with medications and/or ablation (Koponen, Rekola, Ruotsalainen, Lehto, Leino-Kilpi et al., (2007;…).

Patients who are at moderate to high risk for stroke will likely require warfarin or other anticoagulant therapy for stroke prevention. Education and counseling to support patients with moderate to high risk for stroke to gain the knowledge and skills for self-management for safe anticoagulant therapy will need to be added to the discussion regarding strategies for AF rate or rhythm control. A discussion of the recommended content for patient education regarding warfarin use is beyond the scope of this paper but is available elsewhere (Zeolla, Brodeur, Dominelli, Haines, & Allie, 2006).

Action plans:
Patients want direction regarding actions to take in response to symptoms and possible adverse responses or lack of response to treatment. A mutual understanding between the patient and provider regarding the treatment goal must be achieved before developing the action plan because symptoms alone are not adequate for determining effectiveness of therapy, pulse taking is an important strategy for monitoring response to treatment whether the goal is rate control or maintenance of sinus rhythm. Patients should be taught how to palpate their pulse, count its rate, and monitor the pattern for irregularity (Mehall, Kohut, Shcneeberger, Merrill, &Wolf, 2007).

Palpating the pulse is favored over electronic readings because electronic methods do not provide information about the regularity of the pulse and may provide inaccurate rates if the patient is in AF. If the patient is unable to palpate the pulse, patients who are willing to learn to auscultate their heart for rhythm and rate can be taught to do so with a stethoscope that can be purchased for US$10–15 at home medical supply or drug stores (Fredericks, Beanlands, Spalding & DaSilva, 2010).

If the treatment goal is to maintain sinus rhythm, the patient should be counseled about the actions to take if the pulse becomes irregular, which may indicate return of AF. If rate control is the goal, patients should be informed about the target range for their pulse rate and what actions should be taken if symptoms are not controlled or heart rate is outside of the target goal range (American Heart Association, 2011).

Patients need guidance regarding the type of provider, setting they should contact for evaluation, treatment assistance for specific symptoms; for example, which symptoms require a call to 911 for emergency services versus those that could be monitored and managed with a visit or telephone call to their provider (McCabe et al., (2008;…).

When AF is diagnosed, patients should be educated about signs and symptoms of stroke and the importance of seeking emergency services promptly if stroke signs or symptoms occur. Because this critical information may not be retained after initial communication, reinforcement of this information should occur on subsequent clinical encounters (McCabe et al., (2008;…).

Symptom Management:
Despite the best attempts to treat AF with medications and or ablation procedures, some patients continue to experience intermittent or persistent symptoms they attribute to AF. Furthermore, some patients attribute symptoms to AF even when objective reports show AF is not present. Thus, education and counseling regarding symptom-management strategies is an important intervention to promote quality of life for patients with AF (McCabe et al., (2009;…).

Decreased energy level and endurance and shortness of breath, known to clinicians as fatigue and dyspnea, respectively, are symptoms frequently attributed to AF and reported as having a high symptom burden among patients with recurrent symptomatic AF (Mehall et al., (2007;…).

Management of fatigue and dyspnea in the context of AF is critically understudied and evidence-based interventions directed specifically toward patients with AF are not established. However, reports of patients who participated in a qualitative descriptive study and recommendations offered for patients with other chronic illnesses who experience fatigue or dyspnea provide some guidance that may be useful until knowledge specific to patients with AF can be generated (Piper, Fatigue, Carrieri-Kohlman, Lindsey,& West, 2003).

Patients who experience persistent fatigue in the context of optimal treatment should be evaluated for conditions other than AF that may be contributing to fatigue. Obstructive sleep apnea is one of the common contributors to fatigue in patients with AF. Screening for obstructive sleep apnea can be accomplished using the Berlin Questionnaire and, if positive, patients should be referred for polysomnography. If an assessment reveals that fatigue is simply related to poor sleep quality resulting from the patient’s behaviors and habits, sleep hygiene counseling may provide the patient with self-management strategies to improve sleep (Gami, Hodge, Herges, Olson, Nykodym et al., (2008;…).

Because depression may be a contributor to fatigue, patients should be assessed for depression and treated. Patients who reported more symptoms of anxiety and emotional distress related to AF also reported more symptoms of fatigue and less vigor. Although the benefit of cognitive behavioral therapy (CBT) for managing fatigue in patients with AF has not been studied, research in other patient populations where CBT was used to treat fatigue suggest that CBT could be beneficial for fatigue management in patients with AF (McCabe et al., (2011;…).

Other fatigue management strategies reported by patients included: acceptance of a different level of activity tolerance; prioritizing activities – giving up activities that they did not value; restructuring expectations about the amount of time devoted to accomplishing the project/task; taking more rest breaks between activities requiring physical and mental exertion; delegating work to others; and increasing hours of sleep (McCabe et al., (2009;…).

Providers should discuss with their AF patients the benefit of regular exercise for managing fatigue. Although evidence is limited, small studies reported that AF patients participating in aerobic exercise and muscle strengthening reported greater vitality and physical functioning, improved emotional health, and less symptom severity. Some patients with AF become reluctant to engage in exercise for fear of triggering an AF episode or because they perceive themselves as too exhausted to exercise (Hegbom, Stavem, Sire, Heldal, Oming et al., (2007;…).

Patients should be informed that exercise is safe, beneficial, and may actually promote an electro physiologic environment that reduces the potential for triggered electrical activity which can induce AF. Patients who are very deconditioned or afraid of beginning an exercise program may benefit by a referral to a cardiac rehabilitation program for exercise training instruction and a short-term program of supervised exercise (Gami et al., (2008;…).

Referral to a cardiac rehabilitation program should not be withheld simply because of third-party payer concerns. Some patients who have private insurance may have coverage for payment or some patients may be willing to pay out of pocket costs for a Phase III program that provides supervised exercise at lower costs than the Phase II programs provided for patients who require more monitoring and supervision during exercise (McCabe et al., (2009;…).

Patients with symptomatic recurrent AF who reported more symptoms of fatigue also reported more dyspnea; thus, interventions for the management of fatigue already discussed may be useful for reducing dyspnea as well. Patients with symptomatic AF who reported greater symptom burden related to shortness of breath reported more symptoms of anxiety. Because anxiety can enhance the sensation of dyspnea, use of self-management anxiety reduction strategies such as distraction and relaxation may promote an increased sense of control over the dyspnea (Nacarelli et al., (2009;…).

Patients reported that learning to live with activity limitations and energy conservation strategies such as pacing activities and stopping to rest frequently were helpful for managing their shortness of breath. Patients who have a chronic pulmonary illness in addition to their AF may benefit from participation in a pulmonary rehabilitation program (McCabe et al., (2011;…).

Managing Psychosocial Challenges of Living with AF:
Some patients experience symptoms of depression and anxiety that they associate with the challenges of living with the symptoms and unpredictable nature of recurrent AF. Research participants expressed discouragement and demoralization when function-limiting symptoms and uncertainty associated with AF recurrence caused them to curtail valued activities and give up important goals (Chamberlain et al., (2010;…).

The true prevalence of depression and anxiety in patients with AF is unknown, but in study participants recruited from referral settings, up to 38% of participants’ scores on instruments to measure psychological distress were in the clinically significant range or mean scores were greater than those of the control sample means. Thus, providers should assess AF patients for psychological distress and provide treatment and referrals based on those assessments (Hegbom et al., (2007;…).

Most patients’ emotional needs can be addressed by providers who clearly explain the situation and options, actively listen to concerns, acknowledge the challenges of living with AF and treatment limitations, and show a caring attitude and willingness to refer if needed. Patients who have clinical depression or anxiety disorder should be treated and/ or referred to a psychiatrist if the provider believes specialty care is needed. Patients who are having difficulty coping may benefit from a referral to a therapist for CBT (McCabe et al., (2011;…).

The effect of living with AF on the patient’s family/social dynamics has not been well studied, but patients do report that AF has consequences for those close to them. Some research participants reported that the functional limitations and emotions they experienced strained family and social relationships. Perceived lack of support and understanding from family members and coworkers in regard to how symptoms affected their ability to carry out usual home, social, and work activities were described. Even after being diagnosed with AF, participants worried that others would think they were shirking responsibilities and feared being labeled as “lazy” or “hypochondriacs” because family and coworkers did not perceive AF as a serious health problem (Munschauer, Sohocki, Smith Carrow, & Priore, 2004).

If the patient allows family members to be present during clinical visits, providers should include family in discussions about AF, its symptoms and consequences, and realistic treatment goals. This information may help family members provide effective support for patients. As noted above, CBT may help patients learn strategies to promote healthy social relationships and to set realistic goals for meeting the demands of their family, social, and work roles (McCabe et al., (2011;…).

Some patients seek Internet resources for education and support, especially if they perceive information provided face-to-face by their provider is incomplete or not in line with their goals. If patients and family members wish to access Internet resources, they should be counseled to seek information from accurate and current sources that are supported and maintained by credible institutions or organizations. There are an abundance of websites dedicated to AF, but not all contain accurate and helpful information (Shea et al., (2008;…).

The clinician may want to inquire if the patient has used Internet resources and, if so, what perceptions patients have developed from information they retrieved. If the Internet visits have led to inaccurate perceptions, the clinician can address the inaccuracies. This author does not endorse specific websites, but patient information about AF can be found on the American Heart Association, Heart Rhythm Society, and many major medical center websites. A website known as StopAfib.org, created specifically for patients and families, is maintained by an individual but is well-known by experts in electrophysiology, some of whom are listed on the board of directors of the site (American Heart Association, 2011).

Self-care of Patients with Atrial Fibrillation
In response to the growing incidence of chronic illness, one set of approaches seek to involve patients directly in their own care by improving their capacity to self-manage. These approaches assume that this involvement will be positive in terms of quality of care and health outcome. (Lawn & Schoo, 2010).

Current evidence suggests that patients with effective self-management skills make better use of health care professionals’ time and have enhanced self-care skills and improved quality of life. Systemic review of the effectiveness of many self-managements programs indicate clear clinical benefits for patients with conditions such as a diabetes, hypertension, and systemic lupus erythematous (Jordan ; Osborne, 2007).

The institute for clinical system improvement (ICSI) guideline for care of the patient with AF emphasizes the important relationship between patient education and effective self-management. Educational programs are regarded as an essential part of providing patients with information required for successful self-management activities is frequently associated with exacerbation of the illness and is associated with readmission to the hospital (McCabe et al., (2011;…).

Definition of self-care:
Self-care is about encouraging and empowering people to take care of their own health. Self-care has a role in the health decision people make for themselves and their families to get and stay fit, both physically and mentally. Self-care can be further divided into two areas: preventions and active management. Prevention via healthy eating weight management and exercise. Active intervention via risk factor reduction (weight control, smoking cession and alcohol reduction), management of minor ailments and long term conditions (DelotteCenter for Health Solutions, 2012).
At one end of the spectrum the individual is wholly responsible for their health and wellbeing, at the other end responsibility lies solely with the health care professionals, in the vast majority of cases, outside of major trauma and surgery, self-care has a role throughout this conditions (Pillay, 2010).

Self-care can play a critical role in helping to long term conditions. The average AF six hours per year face to face with health care professional. It is the decision they make in the remaining 8.754 hours that will impact on the quality and duration of their life. By helping them make good choices and providing support in making these decisions, nurses can positively affect health outcome in this patient population, as well as other with long term conditions (QResaerch and National Health Service information center, 2008).

Motivating self-care:
The principals of behavior change make it clear that telling people to implement self-care or telling them they at risk of developing disease is really effective. Patient will only change if they reach the conclusion that change is of value. Multiple interventions are often required to prompt the patient to consider change and reach their own decision (Pillay, 2010).

As healthcare professionals, we are encouraged to implement motivational interviewing around disease states, such as stopping smoking and weight control. I believe we should go wider and focus on self-care as the starting point for behavior change and building up patients confidence in their ability to take small health steps can be the gateway to greater health gains (Banks, 2010).

Optimal therapeutic management require patients to monitor for sign and symptom of AF, adhere to a medication regimen, monitor for medication side effect, attend to follow-up appointments, and if warfarin is prescribed, manage dietary-drug interaction. Failure to carry out recommended self-management behavior puts the patient at risk for complication such as stroke, bleeding, uncontrolled heart rate that may contribute to cardiomyopathy, or toxic drug level that could induce lethal proarrhythmia(StopA?b.org, 2011).

Adherence to Treatment:
Patient adherence to medications used in the AF treatment plan can have a major impact on outcome. Outcome impacted by anticoagulant, medication for rate control, and medication for rhythm control could all be negatively affected by poor patient adherence. Among patients taking warfarin it is estimated that patients may be outside of their target INR range approximately 50%-60% of the time. Nearly 20% of patients with a low INR were identified as being poorly adherent to their warfarin regimen (Van et al., 2010; Rose, Ozonoff, Grant, Henault, ; Hylek, 2009).

Because poor adherence is a strong contributor to a patient’s time spent out of the target INR range, it is clear that there is a strong link between warfarin adherence and potential stroke risk. The risk of stroke increase three fold when INR decreased below two (Nemerovski, Lekura, & Kalus, 2011).

Even when patient is maintained within the target INR range, stroke can still occur. However, it is notable that when stroke occur in the setting of a therapeutic INR, outcome of stroke may be less severe and less likely to be fatal. Therefore, patient adherence to an anticoagulant regimen is important for many reasons (Hylek, Go, Chang, Jensvold, Henault et al., (2003;…).
The most likely reason for a patient with AF to seek medical care and utilize health care resources is the development of symptom of AF (shortness of breath and palpitations). Control of heart rate is one of the most effective ways to control symptoms. Therefore, poor adherence to medications used to control heart rate could lead to increase AF symptoms and potentially increased risk of hospitalization. Some heart rate controlling medications can have bothersome adverse effects, such as exercise intolerance (ie, beta blockers) or constipation (ie, verapamil), which could negatively impact patient adherence. Poor adherence to antiarrhythmic medication regimens may also be common (Nemerovski et al., (2011;…).

Lifestyle Adjustments:
Treatment for AF must be individualized. There are a number of lifestyle considerations that can be helpful that include (diet, medications, managing anticoagulant, exercise and stress managements.

Diet: diet is an important consideration in the management of AF, particularly if one is taking warfarin. The liver uses vitamin K to make clotting factors that prevent excessive bleeding. Erratic consumptions of food with vitamin K can cause the INR level to fluctuate. This does not mean that these foods need to be avoided altogether, but care should be taken to maintain a balanced intake (Desmarais, Golden, & Beynon, 2003)
Alcohol and caffeine: are both known triggers of AF and therefore should be avoided in susceptible individuals. Inverse relation of coffee to risk of hospitalization for arrhythmia, especially supraventricular arrhythmias for heavier coffee drinkers (?4 cups/day) was observed (Klatsky, Hasan, Armstrong, Udaltsova, & Morton, 2011).

Blood pressure and cholesterol: should be monitored. Poor blood pressure control among patients with AF is associated with a 50-percent increase risk of stroke (Rao, 2014). DASH-sodium study has suggested that reducing the intake of salt is effective for lowering the blood pressure. Epidemiological studies suggest that the composition of dietary fatty acid has important consequences for cardiovascular health and cardiac arrhythmo-genesis (Erkkila, de Mello, Riserus, & Laaksonen, 2008).

Nicotine: is a cardiac stimulant and can aggravate AF. Both current and former smoking are associated with the risk of AF so stopping smoking is recommended (Heering, van, Hofman, Kors, van Herpen et al., (2008;…).

Medication: specific over-the-counter (OTC) medications, such as nasal sprays and cold remedies and some herbal remedies, contain substances that can aggravate AF and can interfere with the metabolism of anticoagulant agent resulting in an INR that is either too high or too low, therefore should be used cautiously and only under the advice of physician. Patients should always consult their prescribing practitioner, pharmacist, or anticoagulation clinic before starting, changing or stopping any medications (Shea & Sear, 2008).

Most antibiotic will interfere with anticoagulation agent metabolism; therefore, the anticoagulant dosage should be adjusted along with careful monitoring of INR. Multivitamins can also interfere with anticoagulant and may require an adjustment of the dosage of anticoagulant. The multivitamins should be taken on a consistent basis to avoid variations in the INR level (Rice, Perry, Afzal, & Stockley, 2003).

Exercise and physical activity: Regular physical activity is important. Before starting any exercise routine, patient should consult physician or nurse to establish what would be a safe and reasonable level of activity. Patients should be informed that exercise is safe, beneficial, and may actually promote an electro-physiologic environment that reduce the potential for triggered electrical activity which can induce AF (Hegbom et al., (2007;…).

Patient who are very deconditioned or afraid of beginning an exercise program may benefit by a referral to a cardiac rehabilitation program for exercise training instruction and a short term program of supervised exercise. Patients who need medication to slow their heart rate may find that their heart rate does not increase as much as they expect with exercise (Shea & Sears, 2008).

Stress management: the trigger of AF are still being investigated, but stress is likely to play a role for some people. Contemporary research suggested that approximately 54% of patients with intermittent AF cite psychological stress as the most common trigger. Because many different types of stress are common aspects of life, patients with AF benefit from being aware of stress and taking specific strategies to deal with it (Hansson, Dhamey, Sigström, Sixt, Stokland, et al., (2004;…).

Nursing Interventions:
The chronic care model, originally developed by Wager and subsequently adapted by the world health organization. Show the critical elements in improving critical care. In particular, the chronic care model recognizes the importance of patients centered care and self-management as part of a multidimensional approach to improving the management of chronic care. Also nurses play a critical role in delivering effective chronic care (Davies, 2010).

Recurrences are common in patients with AF and consequently it is consider as a chronic condition. Chronic condition can be managed through education, health promotion, medication therapy and self-management and resources to inform their choices regarding health-seeking behaviors. Atrial fibrillation patients in particular are most appropriate for activation for their self-management role. Nurses play a pivotal role in providing advice, guidance, education and support to people with long term conditions (Hendriks, Crijns, Tieleman, &Vrijhoef, 2013).

Many patients leave hospital with a misconception that they are «cure». Cardiac nurses are only too aware that heart disease is a chronic conditions and our challenge is to engage our patients and their families as partners in chronic disease management strategies. Nurses are well placed to promote self-management and educate patients on the quality of life benefits of self-management (Kucia & Quinn, 2010).

Assessment and identifications of patient needs: Helping patient to learn what they need to know (knowledge and skill) and to feel component and confident enough to use their knowledge to cope with and manage their disease. Individuals with AF need to learn many concepts and procedure to successfully live with and self- manage their disease. They must be able to take the knowledge and skills regarding what to do and how to do it and then feel both capable and confident in integrating their knowledge into their daily lives.

The role of health care provider team members is to assess what patient already know (declarative knowledge) or know how to do (procedural knowledge). At diagnosis, team member should first address the patients’ fears and concerns about the diagnosis by asking what most is concerning for them. Continuous assessment for the educational needs of patient-learners requires taking advantage of every interaction between team members and patients (Beebe ; Schmitt, 2011).

Monitoring and managing the dysrhythmia: the nurse regularly evaluates blood pressure, pulse rate and rhythm, rate and rhythm of respiration, and breathe sounds to determine the dysrhythmia’s hemodynamic effect. The nurse also asks the patients about episodes of lightheadedness, dizziness, or fainting as part of the ongoing assessment. If a patient with a dysrhythmia is hospitalized, the nurse may obtain a 12-lead ECG, continuously monitor the patient, and analyze rhythm strips to track the dysrhythmia.

Control of the incidence or the effect of the dysrhythmia, or both, is often achieved by the use of antiarrhythmic medications. The nurse assess and observes for the beneficial and adverse effects of each of the medications. The nurse also manages medication administration carefully so that a constant serum blood level of the medication is maintained at all times. In addition to medication, the nurse assess for factors that contribute to the dysrhythmia (e.g. caffeine, stress, nonadherence to the medication regimen) and assists the patient in developing a plan to make lifestyle changes that eliminate or reduce these factors (Smeltzer& Bare, 2010).

Minimizing anxiety: When the patient experiences episodes of dysrhythmia, the nurse maintains a clam and reassuring attitude. The demeanor fosters a trusting relationship with the patient and assists in reducing anxiety (reducing the sympathetic response). Successes are emphasized with the patient to promote a sense of confidence in living with a dysrhythmia. The nursing goal is to maximize the patient’s control and make the unknown less threatening (Smeltzer;Bare, 2010).

Teaching Patients Self-care:
When teaching patients about dysrhythmia, the nurse presents the information in terms that are understandable and in a manner that is not frightening or threatening. The nurse explain the importance of maintaining therapeutic serum level of antiarrhythmic medications so that the patient understands why medication should be taken regularly each day. In addition, the relationship between a dysrhythmia and cardiac output is explained so that the patient understands the rationale for the medical regimen. If the patient has a potentially lethal dysrhythmia, it is also important to establish with the patient and family a plan of action to take of case an emergency. This allow the patient and family to feel in control and prepared for possible events (Smeltzer ; Bare, 2010).

Promoting Self-care:
Nurses in particular, are at the fore of a national shift towards management promotion. Although for many decades health professionals, particularly nurses, have sought to involve patient in their own health, recent developments have extended this concept beyond purely providing information to engaging in active partnership and empowering the individual to participate in their care plans (Marks, Allegrante, ; Lorig, 2005).

Interactions between health care professional and the expert patient are critical for the exchange of information and decision making. For guided self-management to be successful. A positive patient professional relationship has been shown to be a key factor (Coulter ;Ellins, 2006).

The role of cardiac nurse is to facilitate the development of knowledge and skills so that the patient may engage in self-management practices the use of a traditional education- delivery approach, which involves didactic teaching method with little follow up to assess how well the patient has understood the information, are often ineffective as they fail to engage the patient in a meaningful relationship and employ principles of adult learning (Davies et al., (2010;…).

Home based Services:
The evidence supporting home based nursing care provided by HF nurse specialists is indisputable. Home based programmers demonstrated a decrease in readmission to hospital improved psychological well-being, anxiety level, self-confidence, self-esteem, knowledge of disease return to work, resumption of driving and improved quality of life. Home based critical room has also been reported to promote physical activity and facilitate convalescence. Home based programmes have been associated with low costs (Dracup, Evangelista, Hamilton, Erickson, ; Hage, 2007).