Pharmaceutical Care of People with Atrial Fibrillation. Course information

Transcription

1 Pharmaceutical Care of People with Atrial Fibrillation Course information

2 Pharmaceutical Care of People with Atrial Fibrillation Course information page 3 Introduction 5 Teaching plan 6 Needs Assessment Tool 7 Aide Memoire Atrial Fibrillation 9 Questions for Heart Failure

3 Introduction Atrial fibrillation is the most common cardiac arrhythmia. It is caused by chaotic electrical activity in the atria which results in inefficient cardiac emptying and a variable ventricular rate. The most common form seen in primary care is permanent AF. In patients with permanent AF, a decision has been made not to attempt restoration of normal sinus rhythm. Management of such patients consists of controlling ventricular rate and reducing the risk of thromboembolic complications, namely ischaemic stroke. Other forms of AF include persistent, which may be managed by restoration of sinus rhythm, and paroxysmal which may spontaneously convert to sinus rhythm. Acute AF is defined as AF that has occurred in the last 24 hours. It may ultimately be classed as paroxysmal, persistent or permanent. Paroxysmal AF is characterised by repeated episodes of AF which may either spontaneously cardiovert, or cardioversion may be induced, often with drug therapy. Persistent AF however does not spontaneously cardiovert, but sinus rhythm may be induced by drug therapy or by direct current cardioversion. In both these forms, restoration of sinus rhythm is usually attempted. However in permanent AF, either cardioversion is not feasible, or has failed, and rate control is the preferred method of symptom control. No matter the form of AF, or the approach to symptom control, all patients should be treated with either antiplatelet or anticoagulant therapy to reduce the risk of thromboembolic complications. The choice of therapy will depend on a number of factors such as age and co-morbidities. The evidence base, and subsequent recommendations for the management of atrial fibrillation are summarised in SIGN Guideline number 94 although a fuller discussion of the evidence is presented in NICE Clinical Guideline Pharmaceutical care of people with Atrial Fibrillation Course information

4 Aim Objectives To update pharmacists on the current management of atrial fibrillation and explore ways to implement pharmaceutical care for this patient group as part of normal working practice. At the end of the session participants will be able to: define the current strategies for the management of patients with atrial fibrillation identify pharmaceutical care issues, respond to symptoms in patient scenarios and identify appropriate management solutions explore how to implement the principles of a pharmaceutical care needs assessment tool in practice References Useful contacts Have you noticed any of the following? increase in weight over several days development or worsening of ankle swelling development or worsening of breathlessness on exertion development or worsening of breathlessness at night development of a productive cough 1 Cardiac arrhythmias in coronary heart disease: A national clinical guideline. 2 For patients: arrhythmias. 3 Atrial fibrillation: The management of atrial fibrillation. British Heart Foundation Chest Heart and Stroke Scotland British Cardiac Patients Association 4 Pharmaceutical care of people with Atrial Fibrillation Course information

5 Teaching plan Introduction to the evening Lecture 10 minutes 50 minutes Comfort break 10 minutes Workshop 80 minutes Split the group into smaller groups of about 7 or 8. There are 4 cases but in the time it is probably only possible to cover three of these. The three cases to be covered should be chosen in consultation with the local tutors. Each of the groups should be encouraged to cover all three cases; this should take about 15 to 20 minutes for each case and then about 10 to 20 minutes for general feedback to cover the main discussion points for each case. 5 Pharmaceutical care of people with Atrial Fibrillation Course information

6 Pharmaceutical Care Needs Assessment Atrial Fibrillation Name Date of birth or CHI no. Doctor s name Date 1 Can you tell me what medical condition(s) you have? Or have had? dose frequency no ordered monthly 2 What is/are the name(s) of the medication you take for your condition(s) and how do you take it/them? yes no 3 4 Do you ever forget or choose not to take your medication? If yes, how often weekly/monthly? Do you know what to do if you have missed a dose of your medication? 5 What, if any, side-effects do you experience from your medication? yes no Do you feel that your medication is controlling your symptoms or have you noticed any changes since you started taking your medication? Do you know the trigger signs? Do you have a regular check/blood test/review? Can you tell me when that was, and the outcome? Would you like any information/advice on anything about your condition/medication/health promotion areas? Do you smoke? If yes how many cigarettes and for how long? Specific Atrial Fibrillation questions 10 Have you noticed any change in symptoms of palpitations or feeling as if your heart is racing? Have you noticed any change in symptoms of dizziness or lightheadedness? Have you noticed new symptoms of bleeding (where from) or bruising? Have you noticed new symptoms of weakness in your arms or legs or difficulty speaking? Issue or action Note any follow up action required and any outcome Understanding Compliance Other Effectiveness Health/self help Safety Referral 6 Pharmaceutical care of people with Atrial Fibrillation Course information

7 Pharmaceutical Care Needs Assessment Aide Memoire Atrial Fibrillation 1 Can you tell me what medical condition(s) you have? This helps to clarify their understanding of their condition(s). Length of diagnosis can be important. People are provided with lots of support and information at initial diagnosis the amount of information and support received at diagnosis will vary, also they may or may not be attending appropriate clinics. Over time, people can forget key information or the messages may change over time. Note answer and offer patient general information on conditions. 2 What is/are the name(s) of the medication you take for your condition(s) and how do you take it/them? Check with prescription or patient medication records. Confirm that the patient is taking the medication as instructed on the prescription with any appropriate counselling instructions, e.g. swallowed whole. Note how person takes medication and offer appropriate advice. 3 Do you ever forget or choose not to take your medication? If yes, how often weekly/monthly? Clarify which drugs are missed and when. Offer appropriate verbal advice depending on response. 4 5 Do you know what to do if you have missed a dose of your medication? Document response. Offer appropriate verbal advice depending on response. What, if any, side effects do you think you are experiencing from your medication? Adverse effects are common; most are dose-related and predictable. Idiosyncratic adverse effects are potentially dangerous and usually occur in the first weeks of treatment. Some people erroneously link medication to adverse effects and this can affect their adherence to their regimen. It is possible to manage some adverse effects. Note any adverse effects and confirm that they are as a result of their medication and reassure patient accordingly. 7 Pharmaceutical care of people with Atrial Fibrillation Course information

8 6 Do you feel that your medication is controlling your symptoms or have you noticed any changes since you started taking your medication? Do you know the trigger signs? Document response. Consider and offer appropriate advice. Offer appropriate verbal advice depending on response. 7 8 Do you have a regular check/blood test/review? Can you tell me when that was, and the outcome? Document response. Consider and offer appropriate advice. Offer appropriate verbal advice depending on response. Would you like any information on anything about your condition/ medication/health promotion areas? This helps to identify any self-help or health issues. Offer advice and support on how the person can manage their lifestyle more effectively or signpost them to other organisations. Offer general healthy eating advice as appropriate. 9 Do you smoke? How many cigarettes do you smoke and how long have you smoked? Smoking exacerbates respiratory conditions by causing damage to the airways and increasing the risk of an attack. All patients should be encouraged to stop smoking. Identify what stage they are at in the cycle of change model. In patients suspected of having COPD, it is important to have a smoking history as this may help to confirm the diagnosis. Offer appropriate support or refer to local support agency depending on local arrangements. This aide memoire is for guidance and the pharmacist should use their professional judgement at all times. 8 Pharmaceutical care of people with Atrial Fibrillation Course information

9 Questions for Atrial Fibrillation The additional questions included in the needs assessment tool help pharmacists recognise, during a patient consultation, whether the patient may need adjustment of their medication, or referral to a GP or cardiologist. 1 These questions are: Have you noticed any change in symptoms of palpitations or feeling as if your heart is racing? Patients with atrial fibrillation may experience episodes of fast heart rate either during a paroxysm or if the rate is not well controlled in permanent AF. Some patients with paroxysmal AF may self-manage the condition. If patient is self-managing their AF therapy, prompt them to start treatment or adjust their dose. If patient is not self-managing, advise patient to seek advice from their GP. 2 Have you noticed any change in symptoms of dizziness or light-headedness? Dizziness or light-headedness may be due to a drop in blood pressure associated with atrial fibrillation. It may indicate loss of rate control in the absence of other symptoms. If patient is self-managing their AF therapy, prompt them to start treatment or adjust their dose. If patient is not self-managing, advise patient to seek advice from their GP. 3 Have you noticed new symptoms of bleeding (where from) or bruising? Patients on antithrombotic therapy (antiplatelets or anticoagulants) are at risk of haemorrhage or excessive bruising. The latter is of particular concern if it is new or is worse than normal. Minor haemorrhage, e.g. bleeding gums is not uncommon. Of particular concern is systemic bleeding (e.g. haemoptysis, haematemesis, haematuria or the development of black stools / fresh blood in the stools). Also of concern is any bleeding that fails to stop. Advise patient to seek urgent advice from their GP or if on anticoagulants, the anticoagulation clinic. Severe systemic bleeding should prompt a 999 call. 9 Pharmaceutical care of people with Atrial Fibrillation Course information

10 4 Have you noticed new symptoms of weakness in your arms or legs or difficulty speaking? One of the major complications of AF and its management is a cerebrovascular event. This may either be ischaemic, due to thromboembolism or haemorrhagic, due to antithrombotic therapy. Advise patient to seek urgent advice from their GP or prompt a 999 call. 10 Pharmaceutical care of people with Atrial Fibrillation Course information

11 NHS Education for Scotland (Pharmacy) 3rd Floor, 2 Central Quay 89 Hydepark Street Glasgow G3 8BW Tel: Fax: