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AF Management
Best Practices for Screening for and Managing Atrial Fibrillation

Released: February 14, 2024

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Key Takeaways
  • Assessing risk factors and screening at-risk patients are key to identifying and treating atrial fibrillation early and effectively.
  • Use of anticoagulation agents is a necessary treatment approach to prevent stroke in patients with atrial fibrillation.
  • Leveraging the multidisciplinary care team to coordinate patient care and access to treatments can improve follow-up and outcomes.

Atrial fibrillation (AF) is the most common arrhythmia that healthcare professionals (HCPs) encounter in clinical practice. Of all AF risk factors, aging is an important one to remember. Even a healthy older adult is at risk of AF and, therefore, at increased risk of stroke.

Screening for AF
Patients often present as asymptomatic, so it is important to understand the risk factors associated with AF. Of note, HCPs should screen at-risk patients even in the absence of symptoms. Like elevated blood pressure, AF can go undiagnosed until it is monitored.

Unfortunately, patients’ first presentation of AF can be a stroke or transient ischemic attack. In these cases, patients will present to an emergency department with stroke-like symptoms. After evaluation by an HCP, lo and behold, they are found to have AF. It is not something I want patients to lose sleep over, but I want everyone to be aware of their AF and stroke risk. Whether HCPs suggest that patients use a wearable health device or ensure that regular follow-up visits are occurring, they should know their risks, regardless of their overall health status.

Can We Restore Normal Sinus Rhythm?
A common question that comes up when patients are diagnosed with AF is: Can one’s heart rhythm be restored to normal function? And the answer—in some cases—is yes. When evaluating patients with AF, the healthcare team should include cardiology so certain cardiac testing can be performed. One of the key tests is an echocardiogram to look at the size of the heart chambers. This can give cardiologists an idea of which interventions may help revert the heart back to its normal sinus rhythm (NSR). HCPs also may prescribe treatments (generally in the hospital setting) to revert the heart rhythm from AF to NSR—and if NSR can be achieved, that is critical. In the absence of AF, patients may not need an anticoagulant agent, as the pumping power of the heart will be better.

Unfortunately, in many cases, restoration of NSR is not possible. This is why diagnosing and managing AF should be done in partnership with primary care and cardiology to ensure that there are no other explanations. For example, hyperthyroidism could stimulate the body in such a way that one develops AF. Once other causes have been thoroughly explored and ruled out or treated, if AF persists, cardiologists and primary care providers should work together with patients on next steps in their AF management (eg, starting an anticoagulant).

Preventing Stoke Is Key
Once AF is diagnosed, it is critical for patients to understand that their arrhythmia puts them at risk of cardioembolic stroke. I often describe this process to patients by having them visualize water flowing down a stream. Normally, the water flows easily, but when there is a collection of rocks in the way, the water pools behind them. Similarly, in AF the abnormal rhythm causes blood to pool in part of the heart; the pooled blood then clots, and when the clot is expelled from the heart, it travels to the brain and can cause a stroke. Patients should understand that although they will not physically feel it, the process of the blood clotting is taking place. I then ensure that they know an oral anticoagulant will prevent the blood from clotting.

I have had newly diagnosed patients ask, “If I take an aspirin every day, that will protect me from having a stroke, right?” Although aspirin is generally safe and commonly used for certain cardiovascular conditions, it is not an effective option for stroke prevention for a patient with AF. Sometimes patients may not want to start a medication that they think is risky (such as anticoagulants) and may believe aspirin is safer. In AF management, however, anticoagulants are recommended, and there is no role for aspirin therapy. Of importance, anticoagulants do not reverse AF; they do not slow the heart rate or change the heart’s rhythm. Patients with AF and certain risk factors for stroke—who are not at risk of bleeding—should be prescribed an anticoagulant.

Warfarin is an older anticoagulant approved by the FDA for stroke prevention in AF. It is a challenging agent to use because patients receiving it must be frequently monitored using the international normalized ratio (INR). A high INR poses increased bleeding risk, whereas a low INR poses increased blood clotting and stroke risk. In addition, certain foods, alcohol, medications, and patient-specific factors interact with warfarin, affecting its efficacy and safety. Even if patients are consistently taking warfarin, their INR still often fluctuates, and this can be discouraging and disheartening. Therefore, one of the real advantages of newer oral anticoagulants is that their level of anticoagulation is consistent, with external factors such as food having little influence on their efficacy. In turn, this negates the need for ongoing laboratory monitoring. Although these newer anticoagulants are more expensive than warfarin, they can be cost saving in the long term by removing the need for frequent laboratory monitoring and preventing the downstream effects of stroke.

Social Determinants of Health: Best Practices
Social determinants of health (SDOH) are factors that influence patients’ health, such as one’s access to healthcare, health literacy level, education level, environment, and socioeconomic status. HCPs treating AF need to consider SDOH to optimize patients’ care and outcomes.

Although health literacy is important for every patient, it is particularly critical to address if English is not their preferred spoken language. I often will assess patients’ health literacy during our conversations. If I get a sense that patients are not attuned to the issues being discussed, I will then ask their permission to involve a family member or caregiver in the conversation. This can help reinforce what is being discussed and ensure that patients accomplish any planned follow-up. Furthermore, it is important to assess patients’ understanding of their follow-up plan—the importance of scheduling and attending appointments with cardiology—regardless of their health literacy level.

Other SDOH to consider include the community in which patients live, which can help in determining if patients have access to a cardiologist before referring them. Additional factors that may affect patients’ AF care include their ability to take time off work, arrange childcare, and/or access transportation. Caring for a patient with AF is so much more than diagnosing it, writing prescriptions, and inviting them back for follow-up. It truly involves answering the question, “Am I doing everything I can to give my patient the best opportunity for success?”

One approach to this is involving and empowering other members of the healthcare team, such as a nurse or medical assistant, to help in coordinating care. Taking a multidisciplinary care approach can make follow-up easier, too. They can call patients to check in with them, as well as assist in accessing financial assistance programs to ensure that patients can afford and adhere to their prescribed treatment. In my practice, many patients need assistance with navigating the healthcare system, so we support them any way we can with this. I admit that it can be frustrating and time-consuming at times to ensure that patients receive the best care possible, but it critical that HCPs do so.

At-home Devices for AF Monitoring
One innovation from the past 10-20 years that has affected this field is the ability to monitor arrhythmias using wearable and other at-home health devices, such as smartwatches. In addition to monitoring sleep and step counts, these devices can monitor one’s heart rhythm in real time. This functionality is especially helpful if used by someone with a known AF diagnosis to monitor their heart rhythm between follow-up visits. It also can be used to identify asymptomatic AF, whether the person is awake or sleeping. If the device’s data can be shared with HCPs in real time, they can ensure that person is remaining in NSR and flag the treating cardiologist if necessary.

In addition to smartwatches, there are personal, single-lead ECG devices that people can use at home. These devices are roughly the size of a business card and can monitor one’s heart rhythm in real time. I think using devices like this is a step up from checking one’s own pulse. These devices require little training for accurate use and can provide real-time data, even when a patient may be asymptomatic. I liken it to a person with hypertension using an at-home machine to monitor their blood pressure between visits. This type of in-between visit data and monitoring can be lifesaving.

At-home and personal technologies are becoming more commonplace and accessible—but I also caution that these devices do not replace the need for the patient‒HCP relationship. Furthermore, these devices should not be used to diagnose AF. If there is concern that a person monitoring their heart rate with a device might have AF, I recommend that they be fully evaluated by their HCP right away.

Your Thoughts?
What is your opinion on the role of wearable or at-home health devices in monitoring patients with AF? Join the discussion by posting a comment and answering the polling question.

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