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European Society of Cardiology (ESC) and European Heart Rhythm Association (EHRA), in collaboration with the European Association of Cardio-Thoracic Surgeons (EACTS), published new evidence-based guidelines for the management of atrial fibrillation (AF) in 2016.
Doctor Jeroen Hendriks (University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia and Linköping University, Linköping, Sweden), an author of the guidelines, provides insights into how nurses and allied professionals can play a key role in implementing the recommendations.
“For the first time, a nurse was involved in developing ESC AF guidelines, which is just one indication of the shift to a new integrated approach. The involvement of nurses and allied professionals in the writing group reflects their importance in the development and the use of evidence-based guidelines. They are key players in guideline implementation and the ‘Be Guidelines Smart Toolkit’, developed by ACNAP, was devised to help in this role.2
Looking at the 2016 ESC AF guidelines, nurses and allied professionals can play a particularly important part in the implementation of several recommendations. With EHRA’s President, Professor Hein Heidbüchel, an article was published on this recently in the European Journal of Cardiovascular Nursing.3 A major point highlighted is that the 2016 ESC guidelines state an integrated care approach for AF management should be considered (class IIa; level of evidence B). This is a new concept in the delivery of care and managing AF—it is also an approach that has been recently adopted by the Cardiac Society of Australia and New Zealand4 based on the ESC guidelines, demonstrating global awareness and importance.
One of the four major components of the integrated approach is patient involvement.1,3 It is crucial to actively involve patients in their care in line with shared decision making.”
“We need to engage patients to identify their values and preferences and see how we can work with them to follow guideline recommendations.”
“The second component is working within multidisciplinary teams, i.e. having nurses and allied professionals working with physicians in a collaborative effort. As an example collaboration within this framework, the cardiologist can focus on the medical treatment while the nurse can coordinate care plus also provide education to empower patients to undertake self-management interventions. This can be supported by technology tools, and that’s the third component. Using smart technology, we can provide information to patients and also guide them, from a distance, to manage their condition in the home situation. Health professionals can benefit from technology too, with checklists and communication tools to ensure complete diagnostic and therapeutic management according to guidelines. And finally, a comprehensive care approach should be adopted that focuses not only on managing the arrhythmia itself, but also on identifying and managing underlying comorbidities, for example, hypertension, diabetes, sleep apnoea and obesity. Nurses and allied professionals can also focus on risk factor management, helping to reduce the burden of AF, improve quality of life and decrease healthcare utilisation.
The ESC guidelines also state that individuals older than 65 years with an increased risk of AF and cardiovascular complications but without an AF diagnosis should be checked for AF when presenting for a healthcare appointment for another reason. As well as GPs, there’s a role for nurses in opportunistic screening, which sits well with the integrated care approach. In fact, this is the first step in the integrated approach and thus very important.
Another important aspect for nurses and allied professionals is reducing the devastating impact of stroke in patients with AF. In all patients with AF, the CHA2DS2- VASc score should be systematically assessed to identify the risk of stroke and to determine whether oral anticoagulation is appropriate. Also, a structured follow-up is needed for those starting anticoagulation as advocated in EHRA’s practical guide on the use of non-vitamin K antagonist oral anticoagulants.5 Nurses can play a role in actively following-up patients to assess adherence, thromboembolic complications and symptoms of bleeding, particularly in the crucial early stages after anticoagulant initiation. During the follow-up visit or call, the nurse can also discuss other care aspects to further involve and engage the patient. Nurses and allied professionals are at the forefront of managing patients with AF and we can help to deliver care that is based on the best available evidence and meets the needs of individual patients.”
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