CARDIOVERSION METHODS AND OUTCOMES CARDIOVERSION AND ABLATION JASSIN M. JOURIA Dr. Jassin M. Jouria is a practicing Emergency Medicine physician, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT Atrial arrhythmias are serious disorders that can cause an irregular and/or rapid heartbeat, which can lead to serious clinical sequelae. Atrial fibrillation is an example of an atrial arrhythmia that can lead to blood clots, stroke, or heart failure. Electrical cardioversion and ablation are two procedures that can minimize these risks and treat atrial arrhythmia. Each of these treatments have risks and neither offers a complete success rate, but they can be very effective in providing greater quality of life, and extending the life expectancy of patients. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 0.5 hours (30 minutes). Statement of Learning Need Cardioversion and cardiac ablation for the treatment of resistant atrial arrhythmia has been analyzed in the medical literature, including benefits and risks. Clinicians need to understand the indications and efficacy of both procedures to treat atrial arrhythmia and to reduce cardiac system burden. Clinical research is growing with evolving recommendations for clinicians managing refractory atrial arrhythmia and to plan cardioversion or catheter ablation. Course Purpose To provide clinicians with knowledge of cardiac atrial arrhythmias and of the treatments of cardioversion and cardiac catheter ablation to reverse symptoms of atrial arrhythmia and potentially adverse outcomes. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. The external electrical cardioversion procedure is used to treat arrhythmias a. only if cardiac catheter ablation fails. b. as the first-line therapy. c. to reorganize the heart’s electrical rhythm. d. by delivering a “shock” directly to a mechanical pacemaker. 2. The electrical cardioversion procedure is contraindicated for patients with a. digitalis toxicity. b. mechanical pacemakers. c. very low blood pressure. d. breathing difficulties. 3. Planned cardioversion is usually performed a. in an outpatient setting. b. in an emergency setting because of the risks. c. with an analgesic, not a sedative. d. in a hospital setting. 4. Synchronized cardioversion uses ________________ delivered at a timed point in the cardiac cycle to reset an arrhythmia back to normal sinus rhythm. a. a high-energy shock b. a charged chemical c. a low-energy shock d. a random-level shock 5. Synchronized cardioversion means the electrical impulse is delivered a. during the T wave. b. during the QRS complex, at the peak of the R wave. c. to the SA node. d. to the atria. 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction When an arrhythmia develops, the heart may beat at a rate that is irregular and that is faster or slower than normal. If the heart rate is significantly abnormal, the affected person may experience distressing symptoms because not enough blood is being pumped to the tissues. Electrical cardioversion has been developed specifically to manage arrhythmias that are causing these symptoms and that are decreasing a patient’s quality of life. This procedure is designed to change how the heart contracts so that it resumes a normal rate and rhythm and resolves the arrhythmia. Electrical cardioversion is indicated for the treatment of various tachyarrhythmias. Electrical cardioversion may be performed in an emergency setting or as an elective, planned procedure. Electrical Cardioversion Electrical cardioversion is sometimes referred to as direct current (DC) cardioversion. The cardioversion machine emits an electrical current that is delivered through the chest to the heart. This is also referred to as “shocking” the heart. The electrical impulse delivered through cardioversion reaches all parts of the heart, including the heart muscle tissue, the various conduction nodes, and the internodal pathways, all at the same time. The delivery of a shock through the patient’s chest wall works to convert the heart’s rhythm from an arrhythmia into normal rate and rhythm once again. It is often administered after a stable patient has tried taking antiarrhythmic medications without success. When cardioversion becomes a necessary part of treatment, the method and circumstances surrounding the shock delivery depend on the patient’s condition and level of stability, as well as the equipment and instruments 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com available. Emergency cardioversion may be performed when a patient is hemodynamically unstable and the heart’s rhythm must be reset immediately. If a patient is experiencing symptoms of distress, altered mental status, chest pain or breathing difficulties, or has very low blood pressure, it is understood that the patient is not medically stable and needs emergent treatment, which may consist of cardioversion.8,26 Emergency cardioversion is often performed in the emergency department or intensive care unit. It is performed after a rapid assessment by a health clinician who determines that the patient needs prompt assistance, and the cardioversion machine and medications to administer for the procedure are gathered and used quickly. Alternatively, elective cardioversion is a planned procedure that is done after a health clinician has assessed the patient’s condition in a non-emergency setting. The clinician must assess whether there are underlying conditions contributing to the arrhythmia that should be treated before cardioversion is done.26,45 In this assessment, the clinician will also consider potential alternative treatments. Once this assessment is completed, a determination is made that cardioversion is appropriate or necessary. With planned cardioversion, the patient typically has an arrhythmia that needs treatment but is most likely in a stable enough condition that the arrhythmia is not an emergency. With elective cardioversion, there is time to plan and set up for the procedure, discuss the benefits of the process with the patient and the patient’s family, and deliver the appropriate medications that will be needed. Planned cardioversion is typically delivered under controlled conditions. The procedure may be performed on an outpatient basis but a patient is usually admitted to a hospital for the procedure. A patient who is already hospitalized may have cardioversion during an 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com inpatient stay. The process is set up so that the patient is closely monitored throughout the cardioversion, and this may take place in a procedure room or specialty suite that has the equipment needed for hemodynamic monitoring. To maintain controlled conditions, the patient’s blood pressure and oxygen saturations are monitored throughout the procedure. The patient’s heart is also monitored to evaluate the heart rate and the rhythm. The patient’s arrhythmia may exhibit a regular or irregular rate, and