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Latest Developments in the Management of Atrial Fibrillation

INTRODUCTION

Atrial fibrillation (AF) is the most common type of heart arrhythmia, characterized by irregular beating of the upper chambers of the heart (i.e., the atria). It occurs when a diffuse and chaotic pattern of electrical activity in the atria suppresses or replaces the normal sinus mechanism. During periods of AF, blood is not pumped through the heart efficiently, which can lead to complications such as the formation of clots (i.e., thrombi) and heart failure. The disease increases with age and is associated with substantial morbidity and mortality.¹

The American Heart Association estimates the prevalence of AF to range from 2.7 million to 6.1 million people in the United States, and this figure is expected to rise to 12.1 million by 2030.² Stroke is a common complication in patients with AF, with the disease associated with a 5-fold increased risk for stroke and responsible for an estimated 15% of all strokes.³ More than 750,000 hospitalizations occur each year because of AF, and the condition contributes to an estimated 130,000 deaths annually.¹ Sudden cardiac death and progressive heart failure are frequent causes of death in patients with AF.²

Costs associated with AF are also high, with the estimated incremental cost of AF being approximately $26 billion for the U.S. population.² Of this amount, $6 billion can be directly attributed to AF, $9.9 billion to other cardiovascular expenses, and $10.1 billion to noncardiovascular expenses.

RISK FACTORS

The majority of patients with AF have structural heart disease (e.g., coronary artery disease, heart failure, valvular heart disease) that contributes to the pathophysiology of the disease.³ However, the disease can also occur in the absence of known structural or electrophysiological abnormalities.

Both modifiable and nonmodifiable risk factors that can contribute to the development of AF.^4,5 Examples of nonmodifiable risk factors include genetics, age, and race; modifiable risk factors include a sedentary lifestyle, smoking, increased body mass index (e.g., obesity), diabetes, obstructive sleep apnea, and increased blood pressure (i.e., hypertension). Selected risk factors for AF are listed in Table 1.⁵

Age is the most prominent nonmodifiable risk factor for AF, with the incidence of the disease increasing with advancing age.⁴ In addition, data have shown that patients of European ancestry have an enhanced susceptibility to AF, while patients of African ancestry have a protective effect.

Modifiable risk factors such as physical inactivity can result from increased systemic inflammation, which may induce atrial remodeling that has been associated with AF. Conditions such as obstructive sleep apnea, which is common in obese patients, may also result in structural and electrical remodeling of the atrium. Smoking may also predispose patients to atrial ischemia, which may contribute to the development of AF. Triggers for AF include excess consumption of alcohol or caffeine, use of stimulants or illegal drugs (e.g., cocaine), and extreme stress.⁴

TYPES OF AF

There are four main types of AF—paroxysmal, persistent, long-standing persistent, and permanent AF. The type of AF is determined by how long the patient has had the AF; the classification is useful because it may help predict responses to treatment. In paroxysmal AF, episodes terminate without intervention in fewer than 7 days, often within 24 hours. In persistent AF, the episode lasts longer than 7 days and often requires an intervention to restore normal sinus rhythm. Long-standing persistent AF is defined as lasting longer than 12 months, and patients with permanent AF have an arrhythmia that is continuous and interventions to restore the patient back to normal sinus rhythm have failed. Over time, patients with AF may become resistant to therapy because of the development of atrial fibrosis, along with other pathophysiologic processes. A patient can fluctuate between paroxysmal and persistent episodes of AF.⁵

Two other classification terms that are used include nonvalvular AF and lone AF.^5,6 Nonvalvular AF is defined as patients who have AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.⁵ Lone AF is more of a historical term that has been used for younger patients to describe those who have AF without clinical evidence of cardiopulmonary disease, hypertension, or diabetes.⁶

CLINICAL PRESENTATION AND DIAGNOSIS

Some patients with AF may be asymptomatic; however, the majority of patients present with symptoms such as fatigue, palpitations, shortness of breath, low blood pressure (i.e., hypotension), dizziness, fainting (i.e., syncope), exercise intolerance, and/or chest pain. The most common symptom is fatigue. Symptoms tend to be greatest when patients initially present, and they tend to diminish over time when arrhythmias become persistent.³

During the physical exam, the clinician may find a faster-than-expected heart rate and an irregularly irregular time between heart sounds. A typical electrocardiogram (ECG) in patients with AF is identifiable by its absence of discreet and identifiable P waves and varying R-R intervals. The ECG findings are needed to confirm the diagnosis of AF. Clinicians should also look for identifiable causes contributing to the AF such as underlying heart conditions or thyroid disorders. This can be done via a transesophageal echocardiogram (TEE) to assess for structural heart disease and by ordering laboratory tests to look for any abnormalities.³

GOALS OF TREATMENT

There are three primary goals for the management of AF: prevention of thromboembolism, control of the heart rate, and rhythm control for select patients. In addition, risk factor management is also essential in patients with AF. Ultimately, risk reduction, symptom reduction, and an improvement in the quality of life of these patients are the desired outcomes.

The American College of Cardiology (ACC), American Heart Association (AHA) and the Heart Rhythm Society (HRS), in collaboration with the Society of Thoracic Surgery, released guidelines for the management of patients with AF in 2014.⁵ Since that time, no new updates for the management of AF have been released from these organizations; however, in August 2018, the American College of Chest Physicians (i.e., CHEST) updated their antithrombotic therapy guidelines for patients with AF.⁷ Anticoagulation recommendations in this program are based on the 2018 CHEST guidelines; the rate and rhythm control recommendations are based on the 2014 recommendations from ACC/AHA/HRS.

2018 CHEST GUIDELINE: ANTICOAGULATION IN PATIENTS WITH AF

Patients with undertreated or untreated AF are at high risk for thromboembolism. Therefore, strategies must be in place to lower this risk with appropriate treatments, but clinicians must also take into account potential bleeding risks with prescribed medications.⁷ The first step is to assess the stroke risk in patients with AF by using a risk-factor-based approach. The CHA₂DS₂VASc is the tool that is recommended to identify a patients’ stroke risk.⁸ The components of this risk scoring tool are summarized in Table 2, along with the points associated with each variable.

Patients with a score of 0 in males and 1 in females are considered to be at “low risk” for stroke, and the CHEST guidelines recommend that these patients should not be offered antithrombotic therapy to prevent stroke and reduce mortality.^7,8 The organization noted that low-risk patients are generally those of either gender who are younger than 65 years and have “lone AF.” Once scores reach 1 or more in males and 2 or more in females on the CHA₂DS₂VASc tool, anticoagulant therapy should be offered to patients with AF, including those with paroxysmal AF.⁷

The most significant difference between older guidelines and the 2018 version is the omission of aspirin as a recommendation for low-risk patients. CHEST noted that low-risk patients have event rates of about 1% per year or even less, so no antiplatelet therapy is needed in patients with AF who have a score of 0 (males) or 1 (females). Low-risk patients with AF who are taking aspirin should be educated on the new guidelines and counseled to discontinue therapy if there is no other reason to be on the aspirin (e.g., secondary prevention of CV events).

In addition to the stroke risk, a patients’ bleeding risk must be assessed prior to initiating anticoagulant therapy. Some factors that increase the risk of bleeding include poor blood pressure control, inappropriate use of concomitant antiplatelet drugs such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), and excessive alcohol intake. Nonessential medications such as concurrent use of antiplatelet drugs (if not used after stent implantation) or NSAIDs should be avoided in patients receiving anticoagulation. Lifestyle factors, fall risks, and cognitive impairment should also be assessed to determine if these factors may increase the risk of bleeding. For example, patients receiving anticoagulation should avoid activities that have the potential to result in serious trauma such as contact sports or rock-climbing. Fall risk should also be assessed in older patients to ensure the risk is minimized; for patients with cognitive impairment or dementia, caregivers need to be actively involved to ensure appropriate medication use.⁷

The CHEST guideline summarizes six bleeding risk scores; however, the HAS-BLED is recommended for assessment of patients with AF.^7,9 The organization noted that the HAS-BLED has been shown to be similar to or outperform older bleeding scores,^10,11 and it is the only score considered predictive of intracranial bleeding.¹² A summary of the components of the HAS-BLED is presented in Table 3. Patients with a HAS-BLED score of 0–1 are classified as low risk, those with a score of 2 are intermediate, and those with a score of 3 or higher are at high risk for bleeding.^7,9

The CHEST guideline recommends that all patients with AF should undergo a bleeding risk assessment, and clinicians should focus on managing potentially modifiable bleeding risk factors. They recommended the use of the HAS-BLED score and noted that patients at high risk for bleeding (i.e., score of ≥3) need more frequent follow-up. They advised that a HAS-BLED score of 3 or higher is rarely a reason to avoid anticoagulation, but individual modifiable components of the score can serve to reduce the risk.⁷

Antithrombotic Therapy for Patients With AF

Numerous antithrombotic therapies are on the market in the United States, including aspirin, other antiplatelet agents (e.g., clopidogrel), vitamin K antagonists (VKA, i.e., warfarin), and non-VKAs (also known as the direct oral anticoagulant drugs, DOACs). These DOACs include dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa).^13-16 The appeal of these DOACs has been the convenience associated with their use compared with warfarin, because of the lack of required routine monitoring (i.e., international normalized ratio [INR] assessments needed for warfarin), their rapid onset, their lack of food interactions, and fewer drug-drug interactions. The DOACs can be given as fixed dosing, thereby simplifying treatment.

All of the DOACs have been compared with warfarin in patients with AF.^17-20 In phase 3 trials of these agents, they were at least as safe as and effective as warfarin for preventing stroke and systemic embolism in patients with AF. Based on the assessment of the current literature of antithrombotic use in patients with AF, the CHEST guidelines made the following recommendations for patients with AF⁷:

• The use of antiplatelet therapy alone or aspirin in combination with clopidogrel is not recommended for patients for stroke prevention, regardless of the stroke risk.
  • This was a strong recommendation based on moderate quality evidence after CHEST assessed the literature and noted that warfarin was superior to antiplatelet therapy with respect to the risk of stroke and CV outcomes with similar rates of major bleeding,²¹ and a study comparing apixaban to aspirin found that this DOAC was associated with a 55% reduction in the risk of stroke or systemic embolism, with no difference in the risk of major bleeding for the two treatment arms.²²
• DOACs are recommended over VKAs (i.e., warfarin).
• For patients receiving VKAs with consistently low time in the therapeutic INR range, interventions to improve the time in therapeutic INR should be implemented or patients should be switched to a DOAC.
• In patients with prior unprovoked bleeding, warfarin-associated bleeding, or at high risk of bleeding, the use of apixaban, edoxaban, or dabigatran at a dose of 110 mg is recommended as all of these agents have been shown to have significantly less bleeding compared with warfarin.

The dosing for dabigatran for nonvalvular AF is 150 mg orally twice daily for patients with a creatinine clearance (CrCl) of greater than 30 mL/min, and 75 mg orally twice daily for those with a CrCl between 15 and 30 mL/min.¹³ Dosing recommendations are not provided for patients with a CrCL of less than 15 mL/min or for those on dialysis. In addition, the 110 mg dosage form of dabigatran is used in other countries for the management of AF, but this dosage form is only approved only in the United States for the prophylaxis of deep vein thrombosis and pulmonary embolism following hip replacement surgery.

The dosing for rivaroxaban for nonvalvular AF is 20 mg orally once daily with the evening meal for patients with CrCl of greater than 50 mL/min, and 15 mg orally once daily with the evening meal for those with a CrCl of 50 mL/min or less.¹⁴

The dosing for apixaban for nonvalvular AF is 5 mg orally twice daily.¹⁵ However, for patients with at least 2 of the following characteristics: age greater than or equal to 80 years, body weight less than or equal to 60 kg, or serum creatinine greater than or equal to 1.5 mg/dL, the recommended dose is 2.5 mg orally twice daily.

The recommended dose of edoxaban is 60 mg once daily in patients with a CrCl of greater than 50 to less than or equal to 95 mL/min. The drug must not be used in patients with a CrCL of greater than 95 mL/min because reduced efficacy was observed with this agent when the CrCl was above 95 mL/min. Also, the dose should be reduced to 30 mg once daily in patients with creatinine clearance 15 to 50 mL/min. Edoxaban is not recommended in patients with CrCl of less than 15 mL/min.¹⁶

Actual body weight should be used to calculate CrCl for patients taking DOACs. Product labeling for of the DOACs has a boxed warning stating that premature discontinuation of these drugs can increase the risk of thromboembolic events, and that spinal/epidural hematomas can occur.^13-16 In addition, all of the labels discuss the potential for these agents to can cause serious and even fatal bleeding, and bleeding is listed as one of the most common adverse events for all 4 DOACs.

For patients receiving warfarin, the optimal target INR range is 2.0 to 3.0, with a goal of aiming for a value of 2.5.⁷ When the INR value falls below 2.0, patients are at a higher risk of thromboembolism/stroke; when the value is above 3.0, the risk of bleeding increases.^23-26 The risk of intracranial hemorrhage increases when the INR is above 3.5.²⁶ The time within the therapeutic INR range (i.e., time within 2.0 to 3.0), calculated as a percentage of time the patient is taking warfarin, is an extremely important measure. Specifically, the risk of thromboembolism, major bleeding, and death is lower when the proportion of time within the therapeutic INR range is higher, and at least 65% or more.^27-29 The CHEST guidelines recommend that the time within therapeutic INR range should ideally be achieved at least 70% of the time in patients receiving warfarin, and action is required in patients with suboptimal warfarin use (i.e., <65–70%).⁷

The SAMe-TT₂R₂ scoring system has been developed to help predict which patients may be able to gain good anticoagulation control with warfarin.³⁰ A summary of the components of the SAMe-TT₂R₂ is presented in Table 4. Patients with a score of 0–2 are likely to achieve a good time within the therapeutic range; those with a score of greater than 2 are less likely to achieve good control and would require more routine INR checks, education/counseling, and frequent follow-up. For these patients, the use of DOACs may be a better option.

Practical Management of Patients With AF

The CHEST guideline describes a three-step process to selecting the best antithrombotic treatment option for patients. These steps include assessing the stroke risk, assessing the bleeding risk, and deciding which anticoagulant to use. Because the DOACs have not been compared with each other in prospective clinical trials in patients with AF, none of the agents is recommended over the others. One of the largest retrospective observational studies, known as ARISTOPHANES (Anticoagulants for Reduction in Stroke: Observational Pooled Analysis on Health Outcomes and Experience of Patients) used multiple data sources to compare the risk of stroke/systemic embolism and major bleeding among a large number of nonvalvular AF patients on DOACs or warfarin.³¹ The results showed that all of the DOACs were associated with a lower risk of stroke/systemic embolism compared with warfarin (apixaban [HR, 0.61; 95% CI, 0.54–0.69], dabigatran [0.80; 0.68–0.94], and rivaroxaban [0.75; 0.69–0.82], and both apixaban [0.58; 0.54–0.62] and dabigatran [0.73; 0.66–0.81]) were associated with lower rates of major bleeding compared with warfarin.

The guideline noted that factors such as local availability, cost, and patient comorbidities need to be considered when selecting the best treatment. The organization actually created a simplified schema to assist clinicians in selecting the appropriate anticoagulant. A summary of this schema is presented in Table 5.⁷

Reversal of Anticoagulants

If minor bleeding occurs with anticoagulants, then temporary discontinuation of the agent may be sufficient to manage the side effect.⁷ However, if major or serious bleeding occurs, patients may require supportive measures (e.g., transfusions, volume resuscitation) and/or a reversal agent. For warfarin, administration of vitamin K is recommended. Two agents for the DOACs are currently approved by the Food and Drug Administration: idarucizumab (Praxbind—Boehringer Ingelheim) and andexanet alfa (Andexxa —Portola Pharmaceuticals) for reversal of apixaban and rivaroxaban.^32,33 Both of these reversal agents have a rapid onset on action.

Idarucizumab is indicated for patients treated with dabigatran when reversal of the anticoagulant effects of dabigatran is needed for emergency surgery/urgent procedures, or in life-threatening or uncontrolled bleeding situations. The recommended dose is 5 g (2 vials each containing 2.5 g), given as two consecutive infusions or as a bolus injection by injecting both vials consecutively one after another via a syringe. Warnings and precautions for this agent include increased thromboembolic risk, hypersensitivity reactions, and potential serious adverse reactions because of the sorbitol excipient in select patients. ³²

Andexanet alfa is a recombinant modified human Factor Xa (FXa) protein that exerts its procoagulant effect by binding and sequestering the FXa inhibitors. It is indicated when reversal of anticoagulation from rivaroxaban or apixaban is needed due to life-threatening or uncontrolled bleeding. Two studies have been published showing the efficacy of this reversal agent.^34,35 Andexanet alfa is also anticipated to work for reversal of edoxaban. The dose of andexanet alfa should be based on the specific FXa inhibitor, dose of the FXa inhibitor, and time since the patient’s last dose. There is both a low dose (I.V. bolus of 400 mg at a target rate of 30 mg/min, then a follow-on infusion of 4 mg/min up to 120 min) and high dose (I.V. bolus of 800 mg at a target rate of 30 mg/min, then a follow-on infusion of 8 mg/min up to 120 min) listed in the label. The product has a boxed warning for thromboembolic risks, ischemic risks, cardiac arrest, and sudden deaths.³³

Special Situations and Populations

The CHEST guideline also goes into great detail with respect to appropriate antithrombotic therapy for patients undergoing cardioversion, catheter or surgical ablation, and use in special populations (e.g., patients with underlying cardiac diseases, renal impairment, pregnancy); however, these recommendations are beyond the scope of this continuing education module.⁷ Clinicians are encouraged to access the full CHEST guidelines via www.CHESTnet.org.

2014 ACC/AHA/HRS GUIDELINE: RATE AND RHYTHM CONTROL IN PATIENTS WITH AF

In addition to appropriate antithrombotic therapy discussed above, rate and rhythm control are two additional treatment modalities that are pivotal to the management of patients with AF. The 2014 ACC/AHA/HRS guideline recommendations are reviewed in this section.⁵

Rate Control

Control of the ventricular rate is important in patients with AF, as it reduces morbidity and improves symptoms. Many medications are used for rate control including beta-blockers, nondihydropyridine calcium channel blockers (CCBs), digoxin, and amiodarone. A summary of these medications is presented in Table 6.

The 2014 ACC/AHA/HRS guideline recommended a goal of less than 80 bpm for the resting heart rate, particularly for patients who have symptoms. However, the 2016 European Society of Cardiology guidelines for the management of AF recommended a goal resting heart rate of less than 110 bpm, and a lower rate in symptomatic patients (e.g., palpitations, heart failure symptoms).³⁶ This recommendation was based on data from the RACE (Rate Control Efficacy in Permanent Atrial Fibrillation) II study, which randomized 614 patients with permanent AF to either a target heart rate of less than 80 bpm at rest and 110 bpm during moderate exercise or to a lenient heart rate target of less than 110 bpm and showed no difference in a composite of clinical events, New York Heart Association Class, or hospitalizations.³⁷

The heart rate should be assessed during activity in patients with symptoms to ensure treatment reduces the ventricular rate within the normal range. If patients are hemodynamically unstable, then electrical cardioversion is indicated; however, a review of this procedure is beyond the scope of this program. ⁵

The ACC/AHA/HRS makes the following recommendations for rate control in patients with AF:⁵

• For patients with paroxysmal, persistent, or permanent AF, use a beta-blocker or nondihydropyridine CCB.
• For patients with pre-excitation in the acute setting, use an intravenous beta-blocker or nondihydropyridine CCB.
• For critically ill patients without pre-excitation, IV amiodarone can be a useful medication to control the heart rate.
• Oral amiodarone may be a useful agent for patients in whom other treatment modalities have failed or are contraindicated.
• Nondihydropyridine CCBs should not be used in patients with decompensated heart failure, as this may lead to hemodynamic compromise.
• Digoxin, nondihydropyridine CCBs, or amiodarone should not be used in patients with pre-excitation AF.
• Dronedarone should not be used to control the ventricular rate in patients with permanent AF.

When using beta-blockers, clinicians need to be aware of the potential for these agents to slow the heart rate too much (i.e., bradycardia), and they should be used cautiously in patients who have asthma. For the nondihydropyridine CCBs, they should not be used in patients with decompensated heart failure because they may worsen this condition.

Digoxin is not recommended as a first-line agent for ventricular rate control, and it is usually combined with a beta-blocker or nondihydropyridine CCB to improve the ventricular rate during exercise. Digoxin may also be a useful agent in patients with heart failure. Drug levels of digoxin need to be periodically assessed and dose adjustments are recommended for patients with renal impairment and when used with certain interacting drugs.

Amiodarone’s use in this setting is also limited, because this agent is associated with a variety of toxicities (e.g., liver, lung, thyroid issues) and drug interactions that make its long-term use for ventricular rate control undesirable.⁵

Rhythm Control

In some patients, restoring sinus rhythm is ideal, especially in patients who have persistent bothersome symptoms associated with their AF. Being in sinus rhythm also helps prevent structural remodeling that can occur with long-standing AF. Rhythm control may be a good option for those who have difficulty achieving an adequate heart rate with rate control, younger patients, and those who prefer this approach. Restoring the patient to sinus rhythm can be done via electrical or pharmacologic cardioversion. Patients who have had AF for 48 hours or longer must be appropriately anticoagulated prior to the cardioversion (at least 3 weeks) and for 4 weeks after the cardioversion to prevent thromboembolic events.⁵ AF catheter ablation is also an option as a rhythm-control strategy. Patients must be receiving appropriate anticoagulation therapy before, during, and for a period of time after the procedure.

The medications recommended for acute cardioversion are flecainide, dofetilide, propafenone, and IV ibutilide. Amiodarone may also be a reasonable option for acute cardioversion. Once patients are back in sinus rhythm, the ACC/AHA/HRS guideline also has a list of agents it recommends for maintenance of sinus rhythm. These agents are summarized in Table 7. The guidelines also mention the use of disopyramide, quinidine, and dronedarone for maintenance of sinus rhythm.⁵

Underlying heart disease and other comorbidities must be considered when selecting the most appropriate agent. For example, dofetilide and amiodarone have been studied post-myocardial infarction and in patients with heart failure. Other therapy considerations include avoiding flecainide/propafenone in patients with structurally abnormal hearts such as those with a low ejection fraction or coronary artery disease and initiating the use of dofetilide and sotalol in the hospital. Dofetilide and sotalol are contraindicated in patients with prolonged QTc of greater than 440 or 450 msec, respectively.⁵

Anticoagulation needs to be maintained in patients taking antiarrhythmic drugs because the majority of these agents have low efficacy (e.g., 70% for amiodarone), placing them at risk for stroke if they revert back to AF.

General Tips for Patients

The ACC has a patient-friendly website known as “CardioSmart” (www.cardiosmart.org) that lists 10 tips to help patients live and manage their AF. Many of these tips focus on positive lifestyle modifications, but some are general tips about speaking with healthcare providers, managing medications, and getting support when needed. It is important for patients to understand their disease, their risk of stroke, and the importance of being adherent to prescribed treatment regimens. These tips include the following³⁸:

1. Discussing with a healthcare provider how the disease is affecting their life
2. Understanding their stroke risk, signs and symptoms of a stroke, and how their risk is calculated
3. Taking medications exactly as prescribed and talking to healthcare providers about any side effects they may be experiencing
4. Taking steps to manage their other conditions such as their high blood pressure, elevated lipids, diabetes, thyroid disorders, and heart failure
5. Eating a heart-healthy diet and understanding potential triggers of AF (e.g., excessive alcohol intake)
6. Losing excess weight
7. Finding a long-term exercise plan that will fit into their daily routine
8. Finding ways to lower stress
9. Staying connected socially to help cope with the disease and keep a positive attitude
10. Getting support when needed from family and friends

Pharmacists and pharmacy technicians are well suited to review these tips with patients and help to implement them. Lifestyle modifications that encourage patients to eat a heart-healthy diet (e.g., fruit, vegetables, fiber-rich foods, lean meats and fish, and unsaturated fats such as olive oil) and participate in routine physical activity (at least 30 minutes per day) can be discussed with patients who have AF in the community. In addition, patients who smoke should be educated on the importance of quitting and given information on nonprescription and prescription treatment options available for smoking cessation. Patients should also be told to reduce potential triggers for AF, such as reducing their consumption of caffeine and alcohol, avoiding the use of any stimulants, and limiting their stress.

Since AF places patients at an increased risk for stroke, patients should also be educated on the classic symptoms of stroke.³⁹ Educate them that some potential warning signs of a stroke may include the following:

• Numbness or weakness in the face, arms, or leg, especially on one side of the body
• Trouble walking or loss of balance or coordination
• Trouble seeing out of one or both eyes
• Confusion or trouble speaking or understanding
• Severe headache

If any of these symptoms occur, patients should be instructed to contact emergency personnel immediately, as time is of the essence when treating an acute stroke.

In addition, pharmacists and pharmacy technicians can also assess patients to see if they are having a stroke by following the FAST test.⁴⁰ This includes:

• F—Face: Ask the person to smile. Does one side of the face droop?
• A—Arms: Ask the person to raise both arms. Does one arm drift downward?
• S—Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange?
• T—Time: If you observe any of these signs, call 9-1-1 immediately. Every minute matters.

Patients should also be educated on appropriate administration of their medications and any potential side effects. Patients receiving anticoagulation should understand that they are at an increased risk of bleeding and should be aware of signs of bleeding such as bleeding gums, blood in the stool, black and tarry stools, blood in the urine, and/or excessive nosebleeds. If patients experience excess bleeding, they should be instructed to contact their health care provider immediately.

PATIENT-FRIENDLY RESOURCES

In addition to the CardioSmart website (www.cardiosmart.org) mentioned above, many other patient-friendly resources can be useful to patients with AF. Some are specific to AF and others are general websites that include information on a variety of medical topics.

Examples include the following:

• My Afib Experience at myafibexperience.org
• StopAfib at stopafib.org
• The American Heart Association at heart.org
• The National Heart, Lung and Blood Institute at nhlbi.nih.gov
• The Centers for Disease Control and Prevention at cdc.gov
• The U.S. National Library of Medicine at gov

CONCLUSION

AF is a common condition, resulting in substantial morbidity and mortality if not appropriately treated. Pharmacists and pharmacy technicians should be familiar with the risk factors for AF, typical symptoms, and appropriate management strategies. The goal is to reduce the risk of stroke in these patients and improve their symptom burden via either rate or rhythm control. Since many of the risk factors for AF are modifiable, pharmacists and pharmacy technicians are well positioned to educate patients on lifestyle modification focused on a healthy diet, increased physical activity, and smoking cessation.

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