Complex A-Fib Patients Bring Nuance and Hard Choices

Care for a patient diagnosed with atrial fibrillation might appear straightforward: Control the rate and rhythm of the heartbeat. But if a patient is suffering from other health complications, many treatment options for A-fib can carry risks that outweigh the potential benefits.

To illustrate the many factors emergency nurses must consider when treating a patient with A-fib, University of Chicago flight nurse Teri Campbell delivered the case study session “Tell No Fibs: The Truth About Difficult A-fib Management.”

Since there are multiple variations of A-fib, and effective care depends upon disparate health factors specific to the patient, Campbell started the session by clarifying that she had based her lecture on an experience she had with a patient who did not have a structurally normal heart and had not induced A-fib with alcohol. In this case, Campbell was dealing with a critically unstable A-fib patient.

It was a challenge with no easy solution.

“I want you to lower your expectations, because my partner and I did not take stellar care of this patient,” Campbell acknowledged. “There were so many lessons that we learned after the case, so I want you guys to be better clinicians than I was.”

From the outset, the clinical team sought to get the patient healthy enough for a transplant operation. In addition to A-fib, the patient had pulmonary hypertension, left ventricular dysfunction, acute renal failure and cirrhosis. The patient also had a history of strokes, a septic Swan-Ganz catheter, an intra-aortic balloon pump and Noonan’s disease.

The care team had a “chicken and the egg” quandary to determine whether the A-fib had exacerbated these pre-existing conditions or if the health conditions had helped bring on the A-fib, Campbell explained.

“Is that valuable information? It is. Because it helps you to direct their care,” Campbell said. “What am I going to throw mud at first? I’m going to throw mud at what’s causing the problem first.”

After establishing the root cause of the health complications, Campbell took the audience through more than 10 different medications and treatment strategies their team considered for the patient. With each option, there were accompanying risks that were equivalent to or outweighed the anticipated benefits. For example, phenylephrine would have potentially increased left ventricle and diastolic pressures and led to dramatically increased systolic vascular resistance.

Campbell described the potential outcome as pushing a sick heart against a closed door.

Unfortunately, this patient was ultimately not healthy enough to be a candidate for a transplant. Once at the care facility, the patient was placed on amiodarone for four days before dying.

“I used to think A-fib was no big deal because I’d taken care of so many A-fib patients,” Campbell said. “What I realized is that I didn’t know anything.”

This live-streamed session will be available for on-demand viewing through Jan. 31.