Atrial Fibrillation (AFIB) and AFIB RVR are common conditions that you’ll see as a nurse within both inpatient and outpatient settings. These patients are often asymptomatic, but may have severe symptoms and even be unstable, especially with AFIB RVR.

Recognizing AFIB on the monitor/EKG and knowing how to treat it is important as the nurse, as you’ll be on the front line with these patients!

Atrial Fibrillation (AF or AFIB) is an “irregularly irregular” arrhythmia that usually occurs in a structurally diseased heart.

AFIB occurs when too many atrial impulses are usually coming from the pulmonary veins, causing rapid fibrillation or “quivering” of both the left and right atria.

Remember, the heart has four chambers: left and right atria on the top and left and right ventricle on the bottom. With AFIB, the top chambers are in a constant state of fibrillation.

During a normal heartbeat, the atria first contract, pushing blood into the ventricles, and the ventricles then pump the blood to the rest of the body. In AFIB, the atria lose this “atrial kick,” leading to ineffective atrial filling and decreased cardiac output, especially at rapid rates.

It is helpful to remember how the cardiac conductions system works to understand what is going on with AFIB.

Remember, the heart has specific electrical conduction tissue, which creates and moves the electrical signal throughout the heart to produce an organized rhythm. This organization lets the heart fill and pump effectively.

The heart’s pacemaker is the sinus node located in the right atrium. This region of cells creates the “normal” impulse and sends it throughout the atria and then through the AV node. This AV node normally slows the conduction to allow for ventricular filling. The PR interval on the EKG denotes this slowing of the conduction.

Once traveling through the AV node, the impulse goes through the Bundle of His. It splits down the left and right bundle branches towards each ventricle, then through the Purkinje fibers and eventually the ventricles, causing a heartbeat.

In AFIB, rapid-firing comes from the atria, usually where the pulmonary veins meet the left atria. This leads to the quivering of both atria and ineffective atrial filling and atrial kick.

While the AV node does slow down conduction, it can only do so much on its own. With such rapid firing from the atria, many of these impulses want to make it down to the ventricles and cause heartbeats.

As you can imagine, this can lead to very fast heart rates – what we call AFIB RVR or rapid ventricular response.

AFIB RVR (Rapid Ventricular Response) occurs due to the frequent electrical impulses from the atria.

The AV node is only able to slow the frequent electrical impulses down so much, so many of the impulses are conducted through to the ventricles, leading to a rapid ventricular response or a fast heart rate >100bpm and often much faster.

Patients with these fast rates are often symptomatic and may become hypotensive. These patients will usually require IV medications to slow down their rate, and possibly even electrical cardioversion (more on that later!).

Symptoms of AFIB

Up to 44% of patients with Afib are asymptomatic. Patients with faster rates are more likely to develop symptoms, and those with CHF are more likely to experience hemodynamic instability and severe symptoms (aka low BP and possible code situation).

Some symptoms of AFIB can include:

The Physical Exam

Initial Nursing Interventions

The workup will depend if the patient is in new-onset AF or already has chronic AF and if they are in RVR or not.

Patients with a known history of AFIB who have controlled rates don’t need any specific testing. They are usually on chronic medications to control their heart rates and anticoagulants to prevent blood clots.

Patients with new AFIB or AFIB RVR require more extensive testing, and the workup may depend on their symptoms.

General workup for new AFIB includes:

So why do we even care about AFIB? Well, there can be disastrous consequences if we do not treat it appropriately.

Treatment of AFIB differs and depends on the patient’s symptoms and quality of life. This will involve at least one, but possibly all three of the following:

• Rate control: Control the heart rate with AFIB (preventing RVR)
• Rhythm Control: Convert and maintain the patient in a normal sinus rhythm
• Anticoagulation: Giving blood thinners to prevent blood clot formation within the atria

Which the Provider team and Cardiology will ultimately choose treatment options. We’ll dive a little deeper into each of these treatment options.

Rate Control

Rate-control is achieved via medications to slow down the ventricular response to the AFIB. Common medications include Metoprolol, Diltiazem, Digoxin, Esmolol, Amiodarone, and even magnesium sulfate.

For AFIB RVR, we often give the following medications to control the rate:

Rhythm Control

Rhythm-control is achieved via medications or electrical cardioversion. If the patient is unstable, they will be electrically cardioverted. Otherwise, the cardiologist may choose to start the patient on an antiarrhythmic such as amiodarone, Flecainide, multaq, etc.

Many elderly patients who do not have significant symptoms will not undergo rhythm control. This is ultimately up to the cardiologist.

Anticoagulation

Anticoagulation is almost always used in patients with AFIB, unless there is acute bleeding or a significant risk of bleeding.

Anticoagulation is used to prevent thrombus formation which can cause PEs and Strokes as explained above. Within the hospital, anticoagulation will include either:

Before being discharged, the patient is then transitioned onto an oral anticoagulant such as coumadin, Eliquis, Xarelto, Pradaxa, or ASA/Plavix.

The CHADSVASC score is used to gauge risk for thrombus formation, which factors in age, sex, h/o CHF, HTN, Stroke/TIA/DVT/PE, Vascular disease, or Diabetes. If the patient does not have a high risk of bleeding such as intracranial bleeding, GIB, or frequent falls, then they are usually started on an anticoagulant.

Want to learn more?

If you want to learn more about cardiac arrhythmias, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.

With this course you will be able to:

• Identify all cardiac rhythms inside and out
• Understand the pathophysiology of why and how arrhythmias occur
• Learn how to manage arrhythmias like an expert nurse
• Become proficient with emergency procedures like transcutaneous pacing, defibrillation, synchronized shock, and more!

I also include some great free bonuses with the course, including:

• ECG Rhythm Guide eBook (190 pages!)
• Code Cart Med Guide (code cart medication guide)
• Code STEMI (recognizing STEMI on an EKG)

Check out more about the course here!

Also check out:

• VTACH + VFIB | A Nurse’s Guide to Ventricular Arrhythmias
• How to Read an EKG Rhythm Strip
• The Ultimate ABGs Blood Gas Guide you Need to Calm Your Nerves
• Intravenous Fluids: Types of IV Fluids
• Blood Pressure Crash Course for nurses