Uncontrolled Afib

Cardiac-RN · Dec 7, 2007

Hey everyone...quick question...
I had a 52 y/o male patient today who was found unconscious in his apartment. Has been hospitalized x1 week. It was found he had a large CVA, uncontrolled Afib (up to 160's) and CHF. He was started on a Cardizem drip the night he came in. Now, a week later (and still on the drip) he is still uncontrolled afib in the 140's. The man has no family to speak of. The stroke has left him aphasic, complete right side paralysis.
Anywho....tonight was my first night having him. I noticied he was only on 81mg ASA RECT and nothing else for anticoag. I called doc and he gave me a really hard time and kinda made me feel dumb for asking. I just thought he already had a CVA, Im sure the Afib wasnt much help. Not to mention...his risk factor for another CVA was high. I got a Lovenox order and an order to call consultation for ablation.
so..with uncontrolled afib do they normally jump right to ablation??? I thought they would try cardioversion first?
What am i missing??
:) thanks everyone!!
steph:idea:

This sounds unusual- they have not tried any other meds besides cardizem to help slow the rate and attempt to convert- no dig or amio?

It sounds to me as if the CVA was likely throbolytic as opposed to a bleed, in which case I would except someone to be on more than a rectal baby ASA daily. What did the head CTs show? Was this doc a cardiologist?

Cardiac-RN, BSN, PCCN

Editorial Team / Admin · Dec 8, 2007

Sometimes the previous notes (when one has time to read them, that is! There will be a lot of notes to read through, if he's been hospitalized X1 wk!) will shed light on the MD thought processes and what problem(s) is (are) being addressed.

My question echoes Cardiac's: was it a Cardiologist you talked with (I hope there is one following him)?

I found the following link enlightening re: tx of atrial fib:

http://www.healthsystem.virginia.edu/Internet/afibcenter/treatment.cfm

How sad that he's aphasic. I'm sure he has lots of questions about what's happening.

Tele_Nurse4u · Dec 8, 2007

This sounds unusual- they have not tried any other meds besides cardizem to help slow the rate and attempt to convert- no dig or amio?
It sounds to me as if the CVA was likely throbolytic as opposed to a bleed, in which case I would except someone to be on more than a rectal baby ASA daily. What did the head CTs show? Was this doc a cardiologist?
Cardiac-RN, BSN, PCCN

This doc was a cardiologist. My thoughts were exactly like yours. He had a thrombolytic CVA. CT and MRI showed a large left sided cerebral infarct. He is on Dig 0.125mg daily..NOTHING ELSE though. I was happy to get the Lovenox order! I asked the cardiologist why an ablation and all he could offer was "uncontrolled afib." :trout: Duh, I know that!!! So anyways, I was just curious! Thanks for the quick response :)

-Steph

Tele_Nurse4u · Dec 8, 2007

Sometimes the previous notes (when one has time to read them, that is! There will be a lot of notes to read through, if he's been hospitalized X1 wk!) will shed light on the MD thought processes and what problem(s) is (are) being addressed.
My question echoes Cardiac's: was it a Cardiologist you talked with (I hope there is one following him)?
I found the following link enlightening re: tx of atrial fib:
http://www.healthsystem.virginia.edu/Internet/afibcenter/treatment.cfm
How sad that he's aphasic. I'm sure he has lots of questions about what's happening.

Thanks for the link. I am constatnly asking questions. His primary is a cardio doc, thats who i spoke with. I didnt have time to go back and look through the progress notes, but i wiill definetly try to do that.

It is sooo sad he is aphasic. Hes a rather young guy. Really really sad.

Thanks so much!!

-Steph

Virgo_RN, BSN, RN · Dec 8, 2007

AV nodal blocking agents are contraindicated in patients with heart failure, no?

Cardioversion can damage myocardial tissue, not so good for someone with CHF, and it can also knock loose any blood clots he might have floating around in his atria.

Why the doc would let him go on for a week this way is beyond me, though. I'd be scouring those progress notes for some clues. Maybe he's waiting for the patient to "declare himself", so to speak?

Tele_Nurse4u · Dec 9, 2007

AV nodal blocking agents are contraindicated in patients with heart failure, no?
Cardioversion can damage myocardial tissue, not so good for someone with CHF, and it can also knock loose any blood clots he might have floating around in his atria.
Why the doc would let him go on for a week this way is beyond me, though. I'd be scouring those progress notes for some clues. Maybe he's waiting for the patient to "declare himself", so to speak?

I was thinking the same thing. Lets throw him back into NSR and throw a clot...errr...im going in tonight and I plan to investigate!!

Virgo_RN, BSN, RN · Dec 9, 2007

Let us know what you find out!

mrod, LPN, LVN · Dec 14, 2007

Well in general when stroke occurs in association with atrial fibrillation, patients have a greater mortality and morbidity, longer hospital stays, and greater disability than those without atrial fibrillation. Maybe one of the reasons he put him on Aspirin and not Coumadin or something because Aspirin is much safer than Coumadin because it is less likely to cause abnormal bleeding, including even strokes from bleeding due to the Coumadin itself. So since he is already at risk (previous stroke/TIA and age greater than 75) and probably because he received the stroke because of his a-fib....Actually in studies have shown that the use of coumadin vs aspirin with a-fib, coumadin was assessed with a significant lower incidence of CVA and cardiovascular events, but significant higher incidence of major bleeding, about twice as much as aspirin. I have heard that the majority of people with a-fib should be on coumadin with a goal INR of 3.0 but people who had a stroke and not on antiplatelet meds shouold be intiated on ASA 50-325 mg. I also heard that patients with lone atrial fib and no thromboembolic risk factors, the annual rate of stroke is 1%, and these patients seem to have little to gain from anticoagulation, therefore these patients may be prescribed aspirin if no contraindications exist.

What is his PMH? Is this his first stroke? Has he had TIA's before? Was he on anticoagulation when he came in for his a-fib? What about his SBP? Hypertension and of course CHF is a risk factor for a cardioembolic stroke.

Also sometimes restoring sinus rythm is not the best because the rate of stroke and death are not better with rhythm control than with rate control and anticoagulation. There is also a huge risk for toxicity with anti-arrhythiics as well.

Just some thoughts, look into more information and I hope this helps.

nursej22, MSN, RN · Dec 16, 2007

Hmmm, maybe the docs in my area a more aggressive, but if this patient was on my unit he would be on heparin and coumadin. I am thinking that the Lovenox is going to be most helpful to prevent DVT and pulmonary embolism.He would have also had a TEE to look for atrial clot and then possibly cardioverted and/ or more aggressive rate control. And our electrophysiologists would be doing a heart cath to rule out ischemic heart disease as a cause for the afb and CHF, before doing any electrophysiology studies or ablation.

PS I think the term is "embolic CVA" vs thrombolytic. An embolism is a clot that has moved from its point of origin, thrombolytic means to break up a clot. Of course, if you have an embolic CVA, you can receive a thrombolytic drug up 3 hours after onset of symtptoms.

XueZQ · Apr 14, 2012

I know this is an old post but correct me if I am way outta line, the cardiologist may have consulted with the neurologist and since the guy didn't seem like he had other commorbities, and he was relatively young he could withstand surgery for ablation and hopefully take care of the afib altogether, therefore anticoags would not be started before the procedure anyway.

allnurses Guide · Apr 21, 2012

If someone's been in sustained afib for that long, the chances of synchronized cardioversion converting him are slim. The risks are that you're going to make him throw off another clot when you do cardiovert. In someone with recent embolic CVA, not a good idea. You'd need to fully anticoagulate, but again with recent embolic stroke, you're going to be worried about hemorrhagic conversion and further bleeding in the brain so that's not an attractive option. If he was hemodynamically stable despite the rapid AF, maybe taking care of his neurologic status took precedence. If you can go directly to definitive therapy such as ablation, that sounds like a reasonable option. I don't understand why you'd wait a week though, unless you were waiting to see what the neuro/functional status was going to end up like.