Patients are the heart of what we do · Tapping into Nursing Research Carolyn Miller Reilly, RN,...

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Patients are the heart of what we do

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the CONNECTION • Winter 2012

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Features

Thromboembolism: Prevention in the Presence

of Atrial Fibrillation . . . . . . . . . . . . . . . . 10

Ventricular Arrythymias: Focus on Device Therapy . . . . . . . . . . . . 14

Departments

Leadership Notes . . . . . . . . . . . . . . . . . . . . . . . 5

Editor’s Note . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Guest Editor Message . . . . . . . . . . . . . . . . . . . 7

Certification Corner . . . . . . . . . . . . . . . . . . . . 8

Research Corner . . . . . . . . . . . . . . . . . . . . . . . 9

Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Research Committee . . . . . . . . . . . . . . . . . . .16

Membership Committee . . . . . . . . . . . . . . . .16

Education Committee . . . . . . . . . . . . . . . . . .17

Nominating Committee . . . . . . . . . . . . . . . . .17

Clinical Pearl . . . . . . . . . . . . . . . . . . . . . . . . .18

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EDITORIAL STAFFEditor

Carolyn Reilly, RN, PhD, CHFN

Guest EditorMargaret Bowers, FNP-BC, CHFN, AACC

Contributing AuthorsNancy Albert, PhD, CCNS, CCRN, NE-BC, FAHA, CHFN

Sana M . Al-Khatib, MD, MHSRebecca Castro, MSN, CNS, FNP-BC, CHFN

Beth Davidson, DNP, ACNP, CHFNTracey Dewald, MHS, PharmD

Karol Harshaw-Ellis, MSN, DNP, GNP, ANP/ACNP-BCMary Louise Osevala, MSN, CCNS, ANP-BC

Marilyn Prasun, PhD, CCNS, FAHAKismet Rasmusson, FNP-BC, FAHA, CHFN

THE CONNECTIONThe official newsletter of the American Association

of Heart Failure Nurses (AAHFN)

AAHFN Offices15000 Commerce Parkway, Suite C

Mt . Laurel, NJ 08054

Phone: 888 .45 .AAHFN Fax: 856 .439 .0525

www .aahfn .org

The material published in The Connection does not necessarily express the views of AAHFN . Every attempt has been made to ensure the accuracy of the content of The Connection . AAHFN, however, will not be responsible for the accuracy of information published, nor will AAHFN be liable in any way for injury or other expenses resulting from the use of information appearing in The Connection . Publication of products, techniques, or companies does not constitute an endorsement by AAHFN .

The Connection is published quarterly by the AAHFN and is distributed to approxi-mately 1,500 AAHFN members . These members come from the full spectrum of nurses and other health professionals interested in heart failure . AAHFN serves as the interface for sharing ideas, translating research findings into practice and setting priorities for the future . AAHFN welcomes and values all professionals involved in heart failure care . AAHFN focuses on patients across all environments of care from the hospital, to the clinic, to home .

Board and Staff

Executive DirectorPete Pomilio, MBA

Assistant Executive DirectorJillian Cinardo

Director of Membership and Client ServicesGail Haas

Publication ManagerErik Caplan

Meeting and Exhibits ManagerClare MacNab, CEM, CMP

Membership and Certification ManagerPam Brown

AAHFN STAFF

2011COMMITTEE CHAIRS

Annual Meeting CommitteeRobin Trupp, PhD, RN, APRN, CHFN

Education CommitteeRebecca Castro, MSN, CNS, FNP-BC, CHFN

Membership CommitteeBeth Towery Davidson, DNP, RN, ACNP, CCRN, CHFN

Nominations CommitteeSue Wingate, RN, PhD, CRNP, CHFN

Publication CommitteeMaureen Flattery, RN, MS, ANP-BC

Research CommitteeMarilyn Prasun, PhD, CCNS-BC, FAHA

Certification CommitteeNancy Albert, PhD, CCNS, CCRN, CHFN

Mechanical Circulatory Support Community of Practice

Cynthia J . Bither, RN, MSN, ANP-C, ACNP-C, CHFN

Support and Palliative Care Community of Practice

Beth Fahlberg, PhD, MN, BS, RN

2011BOARD OF DIRECTORS

PresidentMarie Galvao, MSN, ANP-BC, CHFN

President ElectLinda Baas, PhD, RN, ACNP, CHFN

TreasurerAshley Moore, MSN, ANP/GNP-BC, CHFN

SecretaryKismet Rasmusson, FNP-BC, FAHA, CHFN

DirectorsPeggy Kirkwood, RN, MSN, APRN-BC, CHFNConnie Lewis, MSN, ACNP-BC, NP-C, CHFN

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Leadership Notes

Staying ConnectedKismet Rasmusson, FNP-BC, FAHA, CHFNAAHFN, Board of Directors, Secretary

Through this and other editions of The Connection, I hope our members and extended readers see the

value of staying “connected .” This publication is one of the leading benefits for AAHFN members, which is why the leaders of AAHFN and the Publications Committee work hard to maintain its quality . Our goal for The Connection is to provide valuable organizational updates and timely education about varying topics in heart failure .

AAHFN has further hopes to facilitate a way for you to stay connected to your patients . As heart failure nurses, we have the inherent desire to help our patients understand this chronic condition . We guide them through self-monitoring and assist them with medication titrations—not only to improve symptoms, but to improve mortality and reduce hospitalizations . Educating patients in a meaningful

manner is difficult . Because of this, AAHFN has been able to create an educational curriculum for patients that includes valuable information on our website, and, for an audio experience, patients may use their cell phones to hear clips about heart failure . For the web-based curriculum, go to www .aahfnpatienteducation .com/index .php, and, to access the AAHFN Patient Education Heartline, call (856) 539-9006 . Marketing tools about this information will be available soon .

I join the leaders of AAHFN in hoping you will use and share our patient education information . Please let us know if you have suggestions and recommendations to AAHFN about ways to improve our product . As we continue to grow, we don’t want to lose sight of what is important to you, the members . Our goal at AAHFN is leadership staying connected to members and our patients .

As heart failure nurses, we have the inherent desire to help our patients understand this chronic condition.”

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As we wrap up a year full of growth and change at AAHFN, we are introducing a new column

to The Connection . The Research Corner will serve to highlight current or recently completed nursing research related to the theme of the edition .

Research is the foundation for evidence-based practice, and while it has been a cornerstone since the days of Florence Nightingale, often the names and faces of who is studying the care we provide on a daily basis are unknown until we read an article or hear a presentation at a conference . Inherent in the research process is the need for deliberate methodology . And research takes money . The process for developing an idea, obtaining necessary funding, recruiting patients, collecting data, analyzing and interpreting results and disseminating findings is arduous and lengthy . Despite our best attempts, this process can take five or more years from the conception of an idea until bedside clinicians have outcomes that can guide practice .

Thus, with this and each subsequent edition, we hope to provide you not only with what we know today, but information of who is doing research

now on the topic at hand . As nursing colleagues, these nurse scientists may be studying something you are struggling with in your clinical practice . As funded scientists, they have undergone rigorous peer review to establish themselves as experts in their subjects, and they have a solid understanding of the research done to date . As colleagues, they may be able to answer a quick question from you or appreciate hearing your insights .AAHFN is blessed to have leading HF nurse scientists as members and leaders in the organization to assure our practices are meaningful and evidence-based .

Finally, as we move forward, one of the resources we are developing is an expanded research page on the AAHFN website to include a database with topics and contact information of AAHFN members performing nursing research . Please contact Marilyn Prasun, the Research Committee Chair at mprasun@mail .millikin .edu with suggestions, comments or your research information as that committee begins expanding our website and developing this database . And feel free to contact me at Carolyn .reilly@emory .edu with any suggestions or comments to make this newsletter more meaningful to you . Happy 2012!

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Tapping into Nursing ResearchCarolyn Miller Reilly, RN, PhD, CHFN

AAHFN is blessed to have leading HF nurse scientists as members and leaders in the organization to assure our practices are meaningful and evidence-based. ”

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Editor’s Note

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Managing Arrhythmias in Patients with Heart FailureMargaret Bowers, FNP-BC, CHFN, AAC Duke University Health System

The focus of this issue is the evaluation and management of atrial and ventricular arrhythmias in patients with

heart failure . I have invited several of my colleagues from Duke University Health System to share their expertise . It has been several years since the MADIT II trial recommended the use of implantable cardioverter defibrillators (ICDs) in selected patients with reduced ejection fraction who are being treated with optimal medical therapy .1 Sana Al-Khatib, MD, MHS, electrophysiologist, discusses mortality benefits of ICDs and the impact on quality of life and reduction in hospitalizations associated

with cardiac resynchronization (CRT) therapy .

Since heart failure may induce atrial fibrillation, or atrial fibrillation may exacerbate heart failure symptoms, we must recognize the challenge of managing this patient population . We straddle a fine line between rate and volume control as we partner with patients to enhance their understanding of these diagnoses . Perhaps one of most interesting treatment options now available is the advent of new anticoagulation therapies, which do not require ongoing monitoring . Tracey

Dewald, PharmD, MHS, highlights options for anticoagulation including traditional warfarin compared with newer medications like dabigatran and includes the process of bridging patients with low molecular weight heparin . Karol Harshaw-Ellis, MSN, DNP, GNP, ANP/ACNP-BC, shares her insight on atrial arrhythmias through a complex patient case presentation .

References1 . Moss, A ., Wojciech, Z ., Areba, Hall, W . Klein, H, Wilber, D ., Cannom, D ., Daubert, J ., Higgins, S ., Brown, M . and Andrews, M . (2002) . Prophylactic Implantation of Defibrillator in Patients with Myocardial Infarction and Reduced Ejection Fraction . N Engl J Med, 346 (12): 877-883 .

Guest Editor Message

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Certification Corner

Defining Clinical HoursNancy M. Albert, RN, PhD, CHFN, Chair

The Heart Failure Nursing Certification Board is interested in hearing from you! Please let us know

if you have any questions about the certification application or process . One frequently asked question is related to how we define “Clinical Hours .” Nurses have provided examples of their work in heart failure but are not sure if they meet criteria . Clinical hours are defined to be broad in scope . A nurse can work directly with patients (assessment, care planning, interventions and evaluation of care) as a patient caregiver, advance practice nurse, case manager, preceptor, discharge educator, etc . Care delivery can be in any care setting (home, hospital, physician office or clinic, long-term facility), by any means (telephone, in-person, digitally/remotely) and it can be continuous or intermittent as long as there are 1200 hours of time caring for patients with heart failure in a two-year period .

Further, nurses may meet the requirement for clinical hours by working directly or indirectly with heart failure “populations .” For example, a clinical nurse specialist may not have a patient assignment, but they can meet the clinical hour requirement by:

• Educating nurses about heart failure care delivery in a clinical or academic setting (hospital, clinic/office, skilled nursing facility, classroom, etc .)

• Developing, implementing or evalu-ating new initiatives to improve heart failure performance measures, quality indicators or other outcomes .

• Developing, implementing, trans-lating or disseminating a clinical research project that involves patients with heart failure .

• Working in the fields of telemonitoring, health maintenance organizations, insurance companies or for a funded research project sponsored by a company or organization .

• Working as a population-based case manager, care coordinator, transition coach, manager or preceptor if the work responsibilities relate to clinical heart failure at a population level .

Academic nurses who only teach theoretical or non-clinical courses at a college/university setting or administrators/managers may not meet the clinical hours requirement unless they have enough hours in adjunct responsibilities related to clinical heart failure . Examples include mentoring a student in thesis, capstone or dissertation work, public speaking at clinical symposiums on heart failure, volunteer or consultant work with national organizations/hospitals/universities on care of patients with heart failure (performance measures committee, guideline writing group, hospital certification committee, etc .) . I hope the examples above assist you in determining if you meet criteria to take the 2012 exam . We look forward to seeing you in Chicago!

Next CHFN exam offeredSunday, July 01, 2012; AM (time TBD)

Sheraton Chicago Hotel and Towers301 East North Water Street

Chicago, Illinois 60611

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Atrial and Ventricular Arrythmias in Heart FailureMargaret Bowers, FNP-BC, CHFN, AACC

It is well known that patients diagnosed with heart failure are at higher risk for the development of both ventricular and atrial

arrhythmias . The prevalence of ventricular arrhythmias increases with worsening heart failure, from 15-20% in patients with NYHA Class I and II symptoms up to 50-70% in patients with Class III and IV symptoms .1 Atrial arrhythmias are common across all classes of heart failure and up to 42% of these arrhythmias present as atrial fibrillation .2 Since atrial fibrillation is so commonplace, it often provokes episodes of decompensation .2 Identifying the hemodynamic and symptomatic effects of atrial and ventricular dysrhythmias in a patient with heart failure guides the pharmacologic and therapeutic treatment options .

As members of a nursing organization dedicated to the care of heart failure patients and their families, we have an opportunity to focus our clinical inquiry in targeted efforts to improve care through nursing research . The prevalence of heart failure and the incidence of arrhythmias in these patients require us to have an increased awareness of ongoing clinical research and newer treatment options as they become available . Beyond just looking at morbidity and mortality, nursing research related to arrhythmias has studied patient outcomes related to quality of life, symptoms, physical and psychological function as well as family responses .3

Across the nation there are several nursing researchers investigating arrhythmias from different vantage points . Dr . Kathleen Hickey, C-FNP, C-ANP, from Columbia Presbyterian Medical Center is researching sudden cardiac death from a cardiogenetics perspective exploring the use of remote technology to improve cardiac outcomes . Dr . Cynthia Dougherty, ARNP, from the University of Washington Biobehavioral Nursing and Health Systems, is currently funded by the NIH on two clinical trials to improve physical functioning and psychological adjustment after an ICD and to improve patient and family outcomes after an ICD . Dr . Kathy Wood, CCRN, from Duke University School of Nursing, is researching, “Women’s Perspectives of Symptoms in Atrial Fibrillation .” Each of these nursing researchers should inspire us to look at our clinical environments and seek opportunities to advance our practice through nursing research .

References1 . Eckardt, L ., Haverkamp, W . Johna, R . Breithardt, G and Borggrefe, M . (2000) . Arrhythmias in heart failure: Current concepts of mechanisms and therapy . Journal of Cardiovascular Electrophysiology, 11 (1): 106-117 . 2 . Nieuwlaat, R ., Eurlings, L ., Cleland, J ., Cobbe, S ., Vardas, P ., Capucci, A ., Lopez-Sendon, J ., Meeder, J ., Pinto, Y . and Crijns, H . (2009) . Atrial fibrillation and heart failure in cardiology practice: Reciprocal impact and combined management from the perspective of atrial fibrillation . J Am Coll Cardiol, 53 (18): 1690-1698 .3 . Dunbar, S ., Funk, M ., Wood, K . and Valderrama, A . (2004) . Ventricular dysrhythmias: Nursing approaches to health outcomes . Journal of Cardiovascular Nursing, 19 (5): 316-328 .

Research Corner

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Preventing Thromboembolism in the Presence of Atrial FibrillationTracey Dewald, MHS, PharmD

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Atrial fibrillation and heart failure are commonly associated conditions . The incidence and

prevalence of both atrial fibrillation and heart failure increase with age, and both conditions are associated with substantial economic cost, morbidity and mortality . Prevention of thromboembolic events represents an important treatment goal in this population . Multiple clinical trials have demonstrated the benefit of oral anticoagulation for reduction of stroke in patients with non-valvular atrial fibrillation (NVAF) with incorporation of these findings into the AHA/ACC guidelines for both atrial fibrillation and heart failure .¹, ²

Dabigatran etexilate mesylate (Pradaxa®), an oral direct thrombin inhibitor, represents a new therapeutic alternative for the reduction of stroke and systemic embolism associated with NVAF . The beneficial effects of dabigatran in this patient population were studied in the Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial .³ This study compared dabigatran 110 mg and 150 mg twice daily with open-label, dose-adjusted warfarin in patients with NVAF . The mean CHADS2 score was two . In this study, both doses of dabigatran

were non-inferior to warfarin for the primary outcome of stroke or systemic embolism . The 150 mg twice-daily dose was superior to either warfarin or dabigatran 110 mg twice-daily for the primary outcome . Dabigatran, 150 mg twice daily, was associated with similar rates of major hemorrhage compared with warfarin, but with lower incidences of intracranial hemorrhage .

Unlike warfarin therapy, dabigatran may be prescribed at standard doses and does not require routine monitoring for confirmation of therapeutic anticoagulation . Dabigatran is renally cleared . Patients with an estimated creatinine clearance of <30 ml/min were excluded from clinical trials, and current recommendations for dosing in patients with reduced creatinine clearance are based on a single center pharmacokinetic/pharmacodynamic study . No dosing recommendations can be made for patients with a creatinine clearance < 15 ml/min . Dabigatran should generally not be used in this population . Renal function should be evaluated at baseline and routinely thereafter . Patient resources should be carefully considered before selecting this agent for anticoagulation . The cost of dabigatran (one-month supply, AWP) is approximately $250 .00, and, for patients without medication insurance coverage or alternative prescription coverage, the monthly

cost may exceed this amount . The FDA approved two dosage strengths of dabigatran: 150 mg and 75 mg . A reduced dose of 75 mg twice daily is currently recommended when creatinine clearance is 15-30 ml/min . Importantly, dabigatran 75 mg has not been studied in any prospective clinical trials for efficacy or safety in patients with atrial fibrillation .

Reversal of dabigatran anticoagulation in the presence of life-threatening bleeding remains unclear . No effective antidotes have been identified . When clinically possible, hemodialysis can remove about 60% of the drug in three hours . Alternative considerations include transfusion of fresh frozen plasma or red blood cells . Prothrombin complex concentrate has not been found to be beneficial in reversing the anticoagulant action of dabigatran .5

Warfarin remains an effective therapeutic option for many patients . For patients who have demonstrated the ability to maintain therapeutic range, comply with INR monitoring and manage food and drug interactions associated with warfarin therapy, warfarin is an inexpensive and effective therapy to prevent systemic embolism and stroke in patients with atrial fibrillation .

Bridging with low molecular weight heparin such as enoxaparin should be considered when there is an interruption in oral anticoagulation

Preventing Thromboembolism in the Presence of Atrial Fibrillation

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Agent Mechanism/Dosing Pertinent PK Characteristics Routine Monitoring Significant

Interactions Clinical Considerations Cost

Warfarin

(generic and brand available)

Vitamin K antagonist.Dosing must be individualized and variable based on patient characteristics, current medications and dietary intake of Vit K.

Hepatic clearance; genetic variations in metabolism present.

INR Many food and medication interactions.

Remains an effective treatment option for patients who have been stabilized and routinely remain in targeted therapeutic range.

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Dabigatran

(Pradaxa® brand only)

Direct thrombin inhibitor.

150 mg twice-daily.

75 mg twice daily for CrCl 15-30 ml/min.

Avoid use when CrCl < 15 ml/min.

Renal clearance, modify dose when CrCl ≤ 30 ml/min.

Renal function, Ecarin clotting time most sensitive for dabigatran effect. Can cause modest elevations aPTT and INR, however these do not accurately reflect therapeutic activity.

Rifampin should be avoided.

Only FDA-approved indication is for reduction in risk of stroke and systemic embolism in nonvalvular atrial fibrillation.

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Enoxaparin

(generic and brand)

Inhibition of factors Xa and IIa.

1 mg/kg SQ q 12 hours or 1.5 mg/kg SQ daily.

1 mg/kg SQ daily for CrCl < 30 ml/min.

Renal clearance; modify dose when CrCl ≤ 30 ml/min.

Chromogenic Xa monitoring for select populations: obese patients and impaired renal function.

Anticoagulants, compounds containing anticoagulant activity (including herbal products), antiplatelet agents, NSAIDs, and thrombolytic agents may provide additive risk for bleeding when co- administered with enoxaparin.

Generally utilized for short-term anticoagulation while awaiting therapeutic anticoagulation with warfarin.

Not FDA- approved for prevention of arterial thromboembolism prophylaxis in patients with atrial fibrillation.

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Table of Anticoagulant PropertiesAdditional reference: Dabigatran (Pradaxa®) prescribing information, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT., 2010.

such as an invasive procedure or surgical intervention . Similar to dabigatran, enoxaparin is renally cleared, so therefore, dose adjustments are required when CrCl is <30ml/min . An assessment of financial resources is important to consider since cost is also a consideration when initiating therapy with low molecular weight heparin . Clinicians should always balance the financial cost, stroke and bleeding risk in determining the best anticoagulation treatment plan .

References1 . European Heart Rhythm, A ., et al ., ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) .[Erratum appears in J Am Coll Cardiol . 2007 Aug 7;50(6):562 .] . Journal of the American College of Cardiology, 2006 . 48(4): p . 854-906 .2 . Jessup, M ., et al ., 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines:

developed in collaboration with the International Society for Heart and Lung Transplantation . Circulation, 2009 . 119(14): p . 1977-2016 .3 . Connolly, S .J ., et al ., Dabigatran versus warfarin in patients with atrial fibrillation .[Erratum appears in N Engl J Med . 2010 Nov 4;363(19):1877] . New England Journal of Medicine, 2009 . 361(12): p . 1139-51 .4 . Stangier, J ., et al ., Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate: an open-label, parallel-group, single-centre study . Clinical Pharmacokinetics, 2010 . 49(4): p . 259-68 .5 . Eerenberg, E .S ., et al ., Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects . Circulation, 2011 . 124(14): p . 1573-9 .

Preventing Thromboembolism

(Continued)

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Case PresentationL .J . is a 68-year-old African American female, with NYHA Class IV symptoms who presented with a one-month history of progressive HF symptoms: post nocturnal dyspnea, orthopnea, fatigue, early satiety and a 60-pound weight gain . Several diuretic regimens had been attempted without significant improvement in her symptoms, and evidence-based HF medications were only tolerated at low doses due to symptomatic hypotension . Warfarin had been started for new onset atrial fibrillation (AF) .

Past medical history: Severe mitral regurgitation, hypertension, obesity, hyperlipidemia, breast cancer (status post mastectomy and chemotherapy) and chronic kidney disease .

Physical Exam: Vital Signs: Wt . 243 lbs, BP 105/75, pulse 117 and irregular and saturation 97% on 2L/min NC . Neck veins were elevated up to the angle of the jaw and hepatojugular reflux visualized at the ear lobe . Heart sounds were distant with an S3 gallop and II/VI systolic murmur loudest at the apex . Lung sounds were diminished . Abdomen had a positive fluid wave and the liver tip palpable four fingerbreadths below the costal margin . Extremities were cool with 4+ edema to the inguinal creases .

Objective data: • Echocardiogram: EF 20%; global

hypocontractility; mild left ventricular

hypertrophy; global decrease in right ventricular function; severe mitral and tricuspid regurgitation .

• Electrocardiogram: AF with a rapid ventricular response (RVR) of 127 beats per minute . QRS duration was 141 ms .

• Cardiac MRI: grade IV diastolic dysfunction, severely reduced systolic function, and suggestive of idiopathic dilated cardiomyopathy, tachycardia associated or cardiomyopathy .

• Laboratory data: pro-BNP 17,991, hemoglobin 10 .5, hematocrit 33, potassium 4 .2, BUN 108, creatinine 2 .6, AST 24, ALT 28, glucose 127, magnesium 2 .3, LDL 80, triglycerides 112, HDL 48, total cholesterol 150, Hgb A1C 7 .2, and serial cardiac biomarkers unremarkable .

DiscussionAF is the most common cardiac arrhythmia,¹ and, while thromboembolism prevention is significant, rate control and rhythm control are important aspects in the overall treatment plan . The significance of rate versus rhythm control is controversial, but research suggests no significant advantage of rhythm control over rate control and anticoagulation .² Therefore, a primary strategy in individuals with AF and HF should be rate control .³

AV nodal medications recommended to control ventricular response in HF include beta blockers, digoxin and calcium channel antagonist (non-

dihyropyridine) . Beta blockers are the most effective, and digoxin is the least effective, given its limited effect on rate during exertional activities .5 All of these agents can be used in combination, but calcium antagonist should be avoided in reduced systolic function .5

Antiarrhythmics are indicated in the management of rhythm control, but adverse effects impact their use in HF and must be closely monitored . Amiodarone is the most effective anti-arrhythmic in AF and is recommended for pharmacological cardioversion, facilitation of electric cardioversion and maintenance of sinus rhythm (SR) in NYHA Class III-IV HF or recent (< four weeks) unstable NYHA Class II HF .6 Dronedarone is less toxic and is a reasonable alternative to reduce the risk of hospitalization .7 Dronedarone maintains SR in paroxysmal AF or after conversion of persistent AF, but it is contraindicated in NYHA Class IV or a recent exacerbation requiring hospitalization .7 Dofetilide is a Class III agent, safe to use in HF and recommended to convert and maintain SR .8 It is initiated in highly symptomatic, hospitalized individuals and before prescribing, providers must complete an educational program .

In addition to pharmacological cardioversion, nonpharmacological interventions may be used for AF in

Case Study in the Management of Atrial FibrillationKarol Harshaw-Ellis, MSN, DNP, GNP, ANP/ACNP-BC • Duke Heart Failure Program

Case Study

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Nearly five million Americans have heart failure, and an additional 550,000 are diagnosed with this condition each year . With the aging of the American population, the prevalence of heart failure will continue to increase . Thus, healthcare providers should learn about all the complications of heart failure and the best therapies to address them, including one of the most serious complications, ventricular arrhythmias . Given their potential to result in cardiac arrest or syncope, every attempt should be made to prevent occurrence by controlling hypertension, diabetes, hyperlipidemia and cardiac ischemia (when present), and by optimizing cardiac medications, patient fluid status and electrolytes . If with this optimization, the patient’s left ventricular ejection fraction (LVEF) does not improve to > 35%, an implantable cardioverter defibrillator (ICD) is indicated .¹ While the ICD does not prevent ventricular arrhythmias, it remains the most effective therapy currently available to treat ventricular arrhythmias .¹

Several studies have examined the role of the ICD in improving the survival of patients who experienced cardiac arrest or hemodynamically unstable ventricular tachycardia .1,2 In those studies, heart failure was present in an appreciable number of patients .³ 4Survival of patients with an LVEF

of 20-34% has been demonstrated to significantly improve with ICD therapy as compared with antiarrhythmic medications .³ Unfortunately, few patients with an LVEF of < 20% were enrolled in those trials prohibiting conclusions regarding the role of the ICD in this population .³ Outcomes from the Canadian Implantable Defibrillator Study demonstrated that older aged patients with LVEF of 35% or less and NYHA class III or IV symptoms derived a significant improvement in survival with an ICD compared with amiodarone .4

In persons with systolic heart failure who have not had prior ventricular arrhythmias, research has

demonstrated the efficacy of ICD therapy in improving the survival .1,2 Based on these results, ACC/AHA guidelines call for an ICD in patients with NYHA class II or III heart failure symptoms, ischemic or non-ischemic cardiomyopathy (LVEF ≤ 35%) who are on optimal medical therapy . An ICD is also indicated in patients with NYHA class I symptoms in the presence of ischemic cardiomyopathy .1,2 Should patients with an ICD start receiving appropriate shocks (i .e ., for ventricular arrhythmias), active ischemia, heart failure decompensation and electrolyte abnormalities must be ruled out . In the absence of these conditions, health care providers have to consider starting an antiarrhythmic medication or referring the patient for catheter ablation if deemed an appropriate candidate . Preventing ICD shocks is important because these shocks, whether appropriate or inappropriate, have been associated with increased mortality and reduced quality of life .

Finally, cardiac resynchronization therapy (CRT) is another intervention proven to reduce heart failure hospital-izations and improve the survival and quality of life for patients with heart failure .¹ While current recommenda-tions call for this therapy in patients with an LVEF ≤ 35% due to ischemic or non-ischemic cardiomyopathy, a QRS width ≥ 120 ms, and NYHA class

Ventricular Arrhythmias: Focus on Device TherapySana M. Al-Khatib, MD, MHSAssociate Professor of Medicine, Division of Cardiology, Duke University

ACC/AHA guidelines call for an ICD in patients with NYHA class II or III heart failure symptoms, ischemic or non-ischemic cardiomyopathy (LVEF ≤ 35%) who are on optimal medical therapy.”

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III or IV heart failure symptoms despite optimal medical therapy,¹ concerns remain that CRT may be pro-arrhythmic . Data regard-ing the effect of CRT on the risk of ventricular arrhythmias have been limited and conflicting, but a recent analysis of the MADIT-CRT trial demonstrated reverse remodeling was associat-ed with a significant reduction in the risk of subsequent life-threat-ening ventricular arrhythmias .5

Ongoing clinical trials will help clarify the effect of CRT on ventricular arrhythmias .

References1 . ACC/AHA Task Force on Practice Guidelines . ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities . Circulation . 2008; 117: e350–e408 .2 . ACC/AHA Task Force . ACC/AHA/ESC 2006 Guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death . Circulation . 2006; 114:e385–e484 .3 . Domanski MJ, Sakseena S, Epstein AE, et al . for the AVID Investigators . Relative effectiveness of the implantable cardioverter-defibrillator and antiarrhythmic drugs in patients with varying degrees of left ventricular dysfunction who have survived malignant ventricular arrhythmias . AVID Investigators . Antiarrhythmics versus Implantable Defibrillators . J Am Coll Cardiol 1999; 34: 1090-1095 .4 . Sheldon R, Connolly S, Krahn A, Roberts R, Gent M, Gardner M . Identification of patients most likely to benefit from implantable cardioverter-defibrillator therapy: the Canadian Implantable Defibrillator Study . Circulation 2000; 101:1660-1664 .5 . Barsheshet A, Wang PJ, Moss AJ, Solomon SD, Al-Ahmad A, McNitt S, Foster E, Huang DT, Klein HU, Zareba W, Eldar M, Goldenberg I . Reverse remodeling and the risk of ventricular tachyarrhythmias in the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy) . J Am Coll Cardiol 2011; 57: 2416-23 .

specific clinical situations . In highly symptomatic or hemodynamically unstable individuals, electrical cardioversion may be performed . When pharmacological or electrical cardioversion is warranted, individuals must be therapeutic on anticoagulation at the time of cardioversion . Catheter ablation and permanent pacemaker for AF may be recommended based on cardiac structural criteria in those who have significant symptoms despite a trial of one or more antiarrhythmics .7

Case ResolutionL .J . was admitted and randomized to ultrafiltration as part of a clinical trial . It was felt that her continued AF with RVR was contributing to her HF symptoms . A transesophageal echocardiogram was negative, and she was treated with an amiodarone load . She converted to SR, but reverted back to AF within 36 hours, so amiodarone was stopped . Deciding that rate control would be the best course of treatment, her beta blocker was reinitiated and titrated . Her HF symptoms significantly improved and her weight decreased from 109 .4 kilograms to 79 .1 kilograms at discharge . Discharge medications included warfarin, lisinopril, simvastatin, aldactone, metoprolol, torsemide, hydralazine, metolazone (as needed), digoxin and aspirin .

Several months later, she continued to have AF with RVR associated with NYHA Class III-IV symptoms . An electrophysiology referral led to an AF ablation and placement of a biventricular pacemaker with cardiac resynchronization . After intense management in

the HF Disease Management Program for eight months, her quality of life had significantly improved with EF >55% .

AF and HF are complex conditions that require complex management . The overall treatment for AF is guided by clinical practice guidelines, but the plan of care must be individualized based on the clinical and social history, symptoms, quality of life and type of AF .

References1 . Lloyd-Jones D, Adams R, Carnethon M, et al . Heart disease and stroke statistics—2009 update: a report from the American Association statistics committee and stroke statistics . Circulation . 2009; 119: 480-486 .2 . Wyse DG, Waldo AL, DiMarco JP, et al . Atrial fibrillation follow-up investigation of rhythm management (AFFIRM) investigators . A comparison of rate control and rhythm control in patients with atrial fibrillation . N Engl J Med . 2002; 347: 1825-1833 . 3 . Denis Roy, MD, Mario Talajic, MD, Stanley Nattel, MD, et al . Rhythm control versus rate control in atrial fibrillation and heart failure . N Engl J Med 2008; 358: 2667-2677 .4 . DiMarco, JP . Atrial fibrillation and acute decompensated heart failure . Cir Heart Fail 2009; 2:72-73 .5 . Fuster, V, Rydén, LE, Cannom, DS, et al . ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College and the European Society of Cardiology Committee for Practice Guidelines . Circulation, 2006; 114(7): e257-354 .6 . Camm, JA, Kirchhof, P . Lip, GY, et al . Guidelines for the Management of Atrial Fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC) . European Heart Journal 2010; 31, 2369–2429 . 7 . Wann LS, Curtis AB, January CT, et al . 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guidelines): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines . Circulation . Jan 4, 2011; 123(1): 104-123 .8 . Alexander, E . & Sulsa, G . Update the clinical impact and issues surrounding dofetilide (tikosyn) therapy . AACN . Advanced Clinical Care 2006; 17(2): 102-110 .

Case Study (Continued)

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Committee Reports

The Research Committee has established and focused on three initiatives this year . These include revising all

research and clinical innovation evalu-ation forms, advancing the research collaborative network and further expanding and increasing awareness of the mentor program . In addition, the committee would like to increase and facilitate abstract submission and participation of members during the annual research presentations .

The Research Committee is currently reviewing all evaluation forms . Once the forms have been revised, we plan to share the evaluation criteria on the

abstract submission website . This will facilitate participant awareness of the criteria used to judge their research or clinical innovation abstract .

The Research Committee continues to work on identifying opportunities for networking and development of special interest groups related to heart failure research . The focus group sessions held at the last annual meeting were well received . We are tentatively planning future focus sessions, and we anticipate findings from the sessions will be shared at the annual meeting . Opportunities are also being explored to facilitate and support novice nurse researchers through the mentor program .

The abstract site opens Dcember 1 . By now members should have received an announcement regarding the call for research and clinical innovation abstracts . The Research Committee anticipates receiving a record number of submissions this year . We would like to encourage all members to consider submitting and sharing their research findings and clinical innovation strategies at the annual meeting .

Finally, as the Research Committee moves forward on its initiatives, research within the AAHFN and the research support for the membership will continue to develop and evolve .

Research CommitteeMarilyn A. Prasun, PhD, CCNS-BC, FAHA • Chair

Season’s Greetings from the Membership Committee! Hope everyone is ready for the holiday season .

What a busy and productive year at AAHFN—expanding annual conference, MCS Community of Practice, “Guide by Cell” patient education program, certification and much, much more!

The membership committee has been hard at work as well . We hope you have seen the revised message board

and resource page . Our first heart failure clinic directory is currently under development . We are pleased to announce a new award the “Distinguished Mem-ber .” Stay tuned for additional details .

As the year comes to a close, it is time for our dues renewal process . Remember, you can easily continue all your AAHFN benefits by renewing your membership online at www .aahfn .org .

In an effort to bring you all the best in membership benefits, please complete the needs survey coming in early 2012 . AAHFN strives to be the most recognized heart failure organization .

Happy New Years!

Membership CommitteeBeth Davidson, DNP, ACNP, CHFN • Chair

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Attention AAHFN Leaders of the Future! Our annual call for nominations for the 2012-2014 Board

of Directors and officer positions is officially underway . You will soon see the web flyers and begin receiving e-mail blasts detailing open leadership positions . AAHFN is seeking strong, passionate, visionary leaders . We welcome applicants who have been active AAHFN members and served at least one year in a volunteer or committee role . Online applications for nominations will open January 3, 2012 . The Nominating Committee will conduct phone interviews with potential candidates, and a slate of officers for the ballot will be presented to the Board of Directors for approval . General online membership voting will take place in the spring . New officers and directors will be inducted at our Annual Meeting in Chicago, June 2012 .

I am pleased to announce members of the 2011-2012 Nominating Committee:Sue WingateJessica Shank CovielloTraci StewartConnie White –WilliamsLinda WickAshley Moore, Board LiaisonPete Pomilio, Staff Liaison

Nominating CommitteeSue Wingate, RN, PhD, CRNP, CHFN, ChairT

he education committee has been busy this fall with two live Webinars offering continuing education

(CE) credit to AAHFN members . In September, Nancy Albert presented the first Webinar of the results from the IMPROVE-HF study . IMPROVE-HF was the largest and most comprehensive quality improvement study for patients in the outpatient setting . The study demonstrated that a process improvement program can improve the use of evidence-based guidelines and recommended therapies in the treatment of patients with HF . Nancy’s presentation was well organized and very informative, resulting in very positive feedback from those who attended . In October, Cindy Wetzel presented a Webinar on Hemodynamic monitoring that included case studies . If you missed either one of these live Webinars, you can still view them on the Website and receive CE credit after completing the post test and evaluation .

Coming up in 2012, members of the education committee will be presenting a continuing education

program on health literacy, health disparities and patient education . This should be a very enlightening presentation . Also in 2012, the Palliative Care Community of Practice will be presenting continuing education programs .

The education committee also plans to post case studies with corresponding questions on the website beginning in January 2012 . This should be a good learning experience and a great way to prepare for the next HF certification exam . Finally, we are using your feedback from the 2011 review course to help guide planning of the 2012 review course before the next HF certification exam at the annual meeting in Chicago .

If there are topics you would like to learn more about or suggestions for continuing education venues, please contact Becky Castro: jbcastro@embarqmail .com .

Education CommitteeRebecca Castro, MSN, CNS, FNP-BC, CHFN • Chair

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Beta Blocker Conversion (The following conversions are approximations)

Metoprolol Tartrate Beta 1

Metoprolol SuccinateBeta 1

CarvediololBeta 1 &2

Atenolol*Beta 1

BispropolBeta 1

50 – 100 mg twice daily 100 -200 mg daily 25 mg twice daily 100mg daily 5-10 mg daily

Clinical Pearl

Converting beta blockers to evidence-based beta blockers for heart failure requires the provider to be cognizant of

basic medication properties . Sometimes, patients referred for heart failure disease management are on non-evidence based beta blockers or would benefit from a different beta blocker . A typical example is the need to change to a beta 1 selective agent for improved heart rate control or pulmonary concerns of broncospasms .

Always consider the drug properties when converting a patient’s beta blocker:1 . Is the medication you want to convert

a low, moderate or high dose?2 . Is it beta 1 selective or not? ( beta 2

may cause bronchospasms)3 . What is the lipid solubility? (For

example, propranolol is a highly lipid soluble agent, so it may cause nightmares, but it also could treat tremors .)

4 . How is it eliminated - via the liver or kidney? (Atenolol may be better in patients with hepatic insufficiency, while metoprolol may be better in those with renal insufficiency .)

5 . What are the vital signs? Does the patient require more control? (Usually it is best to start low and titrate up based on patient response .)

Conversion of Common Heart Failure MedicationsMary Lou Osevala, MSN, CCNS, ANP-BC

• Metoprolol is employed either as metoprolol succinate or metoprolol tartrate . The tartrate is an immediate-release and the succinate is an extended-release formulation .

• Atenolol is recommended for hepatic insufficiency .• Metoprolol is recommended in patients with renal insufficiency . • Additional conversions in the heart failure population: • Acebutolol (Beta 1 and ISA**) 400 mg (low dose) = atenolol 25 mg- 50 mg daily . • Acebutolol 800 mg (high dose) = atenolol 50-100 mg daily . • Nadolol (Beta 1& 2) 40 mg (low dose) daily= atenolol 25 mg daily or metoprolol tartate 25 mg bid . • Nadolol 120 mg (high dose) daily = atenolol 100mg daily or metoprolol tartate 100 mg bid .

*Not evidence-based**Intrinsic Sympathomimetic Activity

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