Atrial Fibrillation - Treatment Options And Management Plan

What drug therapy would you prescribe for stroke prevention in atrial fibrillation? Why?
What are the parameters for monitoring success of the anticoagulant therapy?
Discuss specific patient education based on the prescribed therapy.
List one or two adverse reactions for the selected agent that would cause you to change therapy.
What would be the choice for the second-line therapy?
What OTC or alternative medications would be appropriate for D.G.?
What lifestyle changes would you recommend to D.G.?
Describe one or two drug–drug or drug–food interactions for the selected agent.

Goals of Treatment for Atrial Fibrillation

D.G. has a heart rate of 120 bpm. She is suffering from tachycardia. She is also suffering from tachypnea as her respiratory rate is 30 bpm. Tachypnea is common in people with atrial fibrillation as well as having high blood pressure. D.G. also has high blood pressure. The ideal goals of treatment for D.G. suffering from atrial fibrillation are restoration of the heart rhythms to normal levels that is carrying out rhythm control, reducing the high heart rate called heart rate control. Other goals of treatment include preventing the formation of blood clots also called thromboembolism prevention, preventing the occurrence of strokes. Moreover, it is also necessary to manage the risk factors associated with stroke. These include high blood pressure, diabetes, heart disease, smoking, obesity, high cholesterol levels, unhealthy diet, among others. D.G.’s medical history reveals the presence of diabetes mellitus, hypertension or high blood pressure, heart failure, among others. Moreover, she also does not follow a healthy diet and her weight has also increased. Thus, the control and management of all these factors will be a part of her treatment plan. Additionally, it is also necessary to prevent heart failure and other heart rhythm problems (Amin et al., 2016).

Atrial fibrillation is most commonly associated with cardiac arrhythmia and can increase the risk of strokes by approximately 5 fold. Anticoaglation therapy for atrial fibrillation involves the use of warfarin, which is a vitamin K antagonist and has been shown to reduce the risk of stroke. It is the most commonly used therapy for preventing strokes or the recurrence of strokes in patients diagnosed with atrial fibrillation. Warfarin stops the clotting of blood. Patients suffering from atrial fibrillation and having a high to moderate risk of suffering from strokes are usually subjected to warfarin therapy (Dlott et al., 2014).

The International Normalized Ratio or INR is the most important and reliable tool or parameter for monitoring the success of anti-coagulation therapy in patients with atrial fibrillation. The INR is a mathematical calculation of the measured prothrombin time (PT). The INR is a ratio of the patient prothrombin time and the mean normal prothrombin time. The patient prothrombin time is the measured prothrombin time and the mean normal prothrombin time is the geometric mean of the prothrombin time reference range. Monitoring the success of Warfarin treatment involves measurement of INR and interpreting the results with the aim to regulate the warfarin dosage. An appropriate INR target range for warfarin treatment is 2-3 and is appropriate for treatment and risk prevention of systemic embolism in patients diagnosed with atrial fibrillation. INR monitoring in atrial fibrillation is essential in order to maintain the INR within the therapeutic range for 2 consecutive days. If INR levels are high than the reference range then it increases the risks of bleeding and if its low then formation of blot clots will not be prevented (Levine, Shao & Klein, 2012).

Anti-coagulation Therapy - Warfarin

Warfarin is an anticoagulant and also enhances the risks of bleeding in patients subjected to the Warfarin therapy (Uygngl et al., 2014). Patient education with respect to Warfarin includes undergoing regular blood tests in order to monitor the success of the Warfarin therapy and determine the INR. Moreover, according to the INR measurements obtained the doctors can change the dose of Warfarin to the patients. Moreover, it is necessary for the patients to check if any other medication, which they are taking interact with Warfarin. Additionally, while on Warfarin therapy, patients are advised not to consume too much alcohol and avoid any form of binge drinking. Moreover, patients should also be advised not to consume cranberry or grapefruit juice as these are known to interact with Warfarin (Nhs.uk, 2018).

One of the most important adverse reaction that is associated with Warfarin is the risk of bleeding (Seek et al., 2013). Moreover, the risk of bleeding increases in the case of medical conditions like hypertension, history of strokes, alcoholism, among others. The patient in this case study has a history of hypertension as well as stroke or heart failure. Another Warfarin side effect is red or brown colored urine, which is due to the presence of blood in the urine. Occurrence of such adverse reaction requires immediate medical attention (Healthywa.wa.gov.au, 2018).

Antiarrhythmic drug therapy can be used as the second line therapy for the management and treatment of atrial fibrillation. This therapy helps to reduce the frequency as well as the duration of arrhythmic episodes in patients with atrial fibrillation. Some of the commonly used antiarrhythmic drugs are Quinidine, Disopyramide, Propafenone, Flecainide, Amiodarone, Vernakalant, among others (Zimetbaum, 2012).

Alternative medications can be the use of other coagulants like Rivaroxaban, Apixaban, Dabigatran and Edoxaban. According to the National Institute for Health and Care Excellence or NICE, these alternative anticoagulants can be used to treat atrial fibrillation in place of Warfarin. These anticoagulants have not been found to interact with other medications as compared to Warfarin and regular blood tests are not necessary when using these anticoagulants. Moreover, they have been found to be more effective when compared with Warfarin in the prevention of strokes or even death. Some of them are also associated with lower rates of bleeding as compared to Warfarin. Moreover, Edoxaban is specifically prescribed for patients having risk factors like hypertension, diabetes or a previous history of heart failure. So, in the case study the patient having the described risk factors can be prescribed Edoxaban as an alternative for Warfarin in the treatment of Atrial Fibrillation (Harris & Mant, 2013). Complementary therapies can include the consumption of omega 3 fatty acids, vitamins C and E, antioxidants, herbal medicines like Berberis, cinchona, shensongyangxin, hawthorn, motherwort, among others (Kanmanthareddy et al., 2015).

INR Monitoring for Warfarin

Lifestyle changes can include consumption of a diet that is low in fat and sodium and increasing consumption of fruits and vegetables. Moreover, the diet should also comprise of lean meats and fish. Consumption of foods that contain high levels of vitamin K is essential (Violi et al., 2016). These include green leafy vegetables as well as broccoli and fish. Regular exercise is also important and can also carry out yoga, which has been found to be beneficial for the prevention of heart diseases (Kanmanthareddy et al., 2015).

Warfarin can interact with a variety of drugs or antibiotics and thereby result in reduced efficiency or increase the risk of bleeding. Warfarin has been found to interact with aspirin, ibuprofen, acetaminophen, medications that are given for treatment of abnormal heart rhythms (Teklay et al., 2014). Moreover, certain foods can also interact with Warfarin. These include cranberry juice, soyabeans or any food that is rich in vitamin K, alcohol, among others (Nhs.uk, 2018).

Reference List

Amin, A., Houmsse, A., Ishola, A., Tyler, J., & Houmsse, M. (2016). The current approach of atrial fibrillation management. Avicenna journal of medicine, 6(1), 8.

Dlott, J. S., George, R. A., Huang, X., Odeh, M., Kaufman, H. W., Ansell, J., & Hylek, E. M. (2014). A national assessment of warfarin anticoagulation therapy for stroke prevention in atrial fibrillation. Circulation, CirculationAha-113.

Harris, K., & Mant, J. (2013). Potential impact of new oral anticoagulants on the management of atrial fibrillation?related stroke in primary care. International journal of clinical practice, 67(7), 647-655.

Healthywa.wa.gov.au. (2018). Warfarin and risk of bleeding. Healthywa.wa.gov.au. Retrieved 1 February 2018, from https://healthywa.wa.gov.au/Articles/U_Z/Warfarin-and-risk-of-bleeding

Kanmanthareddy, A., Reddy, M., Ponnaganti, G., Sanjani, H. P., Koripalli, S., Adabala, N., ... & Vallakati, A. (2015). Alternative medicine in atrial fibrillation treatment—Yoga, acupuncture, biofeedback and more. Journal of thoracic disease, 7(2), 185.

Levine, M. A., Shao, W., & Klein, D. (2012). Monitoring of international normalized ratios: comparison of community nurses with family physicians. Canadian Family Physician, 58(8), e465-e471.

Nhs.uk. (2018). Treatment. nhs.uk. Retrieved 1 February 2018, from https://www.nhs.uk/conditions/atrial-fibrillation/treatment/

Seet, R. C., Rabinstein, A. A., Christianson, T. J., Petty, G. W., & Brown, R. D. (2013). Bleeding complications associated with warfarin treatment in ischemic stroke patients with atrial fibrillation: a population-based cohort study. Journal of Stroke and Cerebrovascular Diseases, 22(4), 561-569.

Teklay, G., Shiferaw, N., Legesse, B., & Bekele, M. L. (2014). Drug-drug interactions and risk of bleeding among inpatients on warfarin therapy: a prospective observational study. Thrombosis journal, 12(1), 20.

Uygungül, E., Ayrik, C., Narci, H., Erdo?an, S., Toker, ?., Demir, F., & Karaaslan, U. (2014). Determining risk factors of bleeding in patients on warfarin treatment. Advances in hematology, 2014.

Violi, F., Lip, G. Y., Pignatelli, P., & Pastori, D. (2016). Interaction between dietary vitamin K intake and anticoagulation by vitamin K antagonists: is it really true?: a systematic review. Medicine, 95(10).

Zimetbaum, P. (2012). Antiarrhythmic drug therapy for atrial fibrillation. Circulation, 125(2), 381-389.