Percutaneous alternative to the Maze procedure for the treatment of persistent or long-standing persistent atrial fibrillation (aMAZE trial): Rationale and design

BACKGROUND

Pulmonary vein antrum isolation (PVI) as a treatment of paroxysmal atrial fibrillation (AF) is associated with a high rate of success; however, outcomes for treating persistent and long-standing persistent AF with PVI alone are substantially lower and often require multiple procedures to maintain long-term freedom from atrial arrhythmias. Foci and/or substrate outside the pulmonary veins, particularly in the left atrial appendage (LAA), has been identified as a key mechanism in the maintenance of persistent AF and long-standing persistent AF.

OBJECTIVE

The goals of the study are to evaluate the safety and effectiveness of the LARIAT System to percutaneously isolate and ligate the LAA and to determine if LAA ligation as adjunctive therapy to PVI improves maintenance of sinus rhythm in patients with persistent and long-standing persistent AF.

STUDY DESIGN

The trial is a prospective, multicenter, randomized controlled study. The trial design incorporates a Bayesian adaptive design that will randomize a maximum of 600 patients with persistent or long-standing persistent AF to LAA ligation and PVI vs PVI alone in a 2:1 randomization. The primary end points include 30-day safety of the LARIAT procedure and freedom from documented AF, atrial flutter, or atrial tachycardia of more than 30 seconds at 12 months after the PVI off antiarrhythmic drugs. Key secondary outcomes include a composite of cardiovascular death and stroke, as well as quality of life.

CONCLUSION

The aMAZE trial will determine if LAA ligation as adjunctive therapy to PVI increases the efficacy of maintaining sinus rhythm in patients with persistent and long-standing persistent AF.

Living with Atrial Fibrillation: An Analysis of Patients' Perspectives

PURPOSE

The aim of this study was to determine the perceptions of patients with atrial fibrillation regarding the disease, to reveal their feelings, thoughts and wishes, and to investigate their perspectives and coping behaviors towards their condition.

METHODS

Phenomenological methodology was used. The study population consisted of a total of 225 patients treated by the cardiology department of a university hospital, while the study sample consisted of 32 patients who met the inclusion criteria. A semistructured interview addressed perceptions of patients with atrial fibrillation regarding the disease. Data were collected by asking the participants the three questions on the In-depth Individual Interview Form. Data were analyzed using the continuous comparative method of Colaizzi.

RESULTS

In the study sample, 50.0% of participants were female, 69.0% were married, and the mean age was 66.90 years (± 7.90 years). As a result of the content analysis, four main themes and 15 subthemes were identified: patient's mental status regarding the disease, patient's social status regarding the disease, patient's physical condition regarding the disease, and disease management and coping with the disease. The study found that individuals with atrial fibrillation faced major limitations in their daily living activities and social lives due to the disease symptoms and warfarin use.

CONCLUSIONS

Patients need to be provided with relevant individual training and counselling so that they lead more satisfactory lives. In addition, appropriate health appointment and monitoring systems should be developed for patients to reduce the problems associated with frequent follow-up appointments.

Patients' attitude and knowledge about oral anticoagulation therapy: results of a self-assessment survey in patients with atrial fibrillation conducted by the European Heart Rhythm Association

The purpose of this European Heart Rhythm Association survey was to assess the attitude, level of education, and knowledge concerning oral anticoagulants (OACs) among patients with atrial fibrillation (AF) taking vitamin K antagonists (VKAs), non-VKA oral anticoagulants (NOACs) or antiplatelets. A total of 1147 patients with AF [mean age 66 ± 13 years, 529 (45%) women] from 8 selected European countries responded to this survey. The overall use of OACs and antiplatelets was 77 and 15.3%, respectively. Of the patients taking OACs, 67% were on VKAs, 33% on NOACs, and 17.9% on a combination of OACs and antiplatelets. Among patients on VKAs, 91% correctly stated the target international normalized ratio (INR) level. The proportion of patients on VKA medication who were aware that monthly INR monitoring was required for this treatment and the proportion of patients on NOAC who knew that renal function monitoring at least annually was mandatory for NOACs was 76 and 21%, respectively. An indirect estimation of compliance indicated that 14.5% of patients temporarily discontinued the treatment, and 26.5% of patients reported having missed at least one dose. The survey shows that there is room for improvement regarding education and adherence of patients taking OACs, particularly regarding monitoring requirements for NOACs.

To treat or not to treat very elderly naïve patients with atrial fibrillation with vitamin K antagonists (VKA): results from the VENPAF cohort

Despite the recommendations in the guidelines, physicians still underuse warfarin in very elderly patients with non-valvular atrial fibrillation (NVAF). The risks of stroke and major bleeding both increase with age, but it is still not clear whether the beneficial effects of vitamin K antagonists (VKA) in preventing stroke outweigh the related bleeding risks in fragile, very elderly patients. The bleeding rates reported in real-world observational studies differ considerably. The aim of this study was to retrospectively assess the incidence of major bleeding in VKA-naïve patients over 80 years old with NVAF at a large anticoagulation clinic. Significant predictors of major bleeding were also investigated. Sixty-five major bleeding events (3.4 per 100 patient-years) and 25 thromboembolic events (1.3 per 100 patient-years) were recorded in a sample of 798 patients with a median follow-up of 2.2 years. Patients over 85 years old had significantly more major bleeding events than the 80- to 84-year olds (4.7 vs. 2.6 per 100 patient-years, p 0.014). Spontaneous bleeding was also significantly more common (3.0 vs. 1.3 per 100 patient-years, p 0.008) in the very elderly group. Age and diabetes were the only independent risk factor for bleeding on multivariate Cox analysis (Age HR 1.80, 95% CI 1.10-2.93; diabetes HR 1.76, 95% CI 1.00-3.09). These data show a sharp increase in major bleeding episodes among the very elderly with atrial fibrillation. Further studies are warranted with a view to identifying patients at risk.

Differences in Quality of Life Between Atrial Fibrillation Patients with Low Stroke Risk Treated With and Without Catheter Ablation

BACKGROUND

Impacts of a single radiofrequency ablation (RFA) on quality of life (QoL) were not well investigated in atrial fibrillation (AF) patients with low stroke risk.

METHODS AND RESULTS

Nine hundred AF patients with low CHADS2 score (ie, CHADS2 ≤1) who completed both a baseline and 6-month Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire were selected from The Chinese Atrial Fibrillation Registry between 2011 and 2013. A final cohort of 222 patients was constructed after a propensity score matching with 74 in the RFA group and 148 in the non-RFA group. Domains of AFEQT were balanced at baseline between the 2 groups. No statistically significant differences were noted in QoL (all P>0.05) when AFEQT at 6 months was compared between groups, except for the symptoms domain (83.07±12.37 units in the RFA group vs. 77.68±17.14 units in the non-RFA group; P=0.008) and treatment satisfaction domain (76.34±14.92 units in the RFA group vs. 70.38±16.81 units in the non-RFA group; P=0.01). Within-group changes in all domains and the global score of the questionnaire were moderate to large, whereas between-group comparisons in baseline to 6-month changes and QoL at 6 months were small to moderate according to Cohen effect sizes.

CONCLUSIONS

QoL was balanced at baseline and improved at 6 months in both groups from this observational propensity-matched cohort based on the AFEQT questionnaire. However, RFA treatment was only associated with small-to-moderate superiorities over non-RFA treatment. The role of RFA in QoL improvement among AF patients with low stroke risk requires further research.

Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making

OBJECTIVE

Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision.

MATERIALS AND METHODS

CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy.

RESULTS

Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups.

KEY LIMITATIONS

Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy.

CONCLUSIONS

We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.

The criteria of the Italian Federation of Thrombosis Centres on DOACs: a "real world" application in nonvalvular atrial fibrillation patients already on vitamin K antagonist

The aim of this study was to evaluate the number of patients with nonvalvular atrial fibrillation (NVAF), anticoagulated with vitamin K antagonists (VKA), and monitored in our Thrombosis Centre, who could replace VKA with direct oral anticoagulants (DOACs) based on the Italian Federation of Thrombosis Centres (FCSA) consensus criteria. A total of 525 NVAF patients treated with VKA were studied. Therapeutic range (TTR) assessment and a capillary test for serum creatinine measure were carried out. The patients' preference was evaluated through the administration of a dedicated questionnaire. A history of intracranial bleeding was also taken into account. DOACs would cover 29 % of the patients considering a TTR <70 %; the percentage falls to 10 % if a TTR <55 % is considered. Only 20 % of the patients would move from VKA to DOACs because of the lack of an antidote and laboratory checks during DOACs therapy. Thirty-three percent of patients were worried that they would forget to take the tablets twice a day. About 2 % of patients could not use DOACs since their glomerular filtration rate was less than 30 ml/min, while in 23.6 %, a reduction in the daily dose of DOACs would have been required due to renal failure. TTR assessment, renal function and a previous history of intracranial bleeding would reduce the percentage of patients who could switch from VKA to DOACs, but it is the patients' preference that strongly influences the percentage of those who would benefit from DOACs treatment. However, if laboratory controls were available, it would rise considerably.

Psychological effects of treatment with new oral anticoagulants in elderly patients with atrial fibrillation: a preliminary report

BACKGROUND AND AIMS

Atrial fibrillation (AF) is the most common arrhythmia in elderly people, yet oral anticoagulation is underused in the aged. We tried to determine whether new oral anticoagulants (NOA) have greater psychological tolerability than warfarin.

METHODS

Age-, gender-matched groups of AF patients receiving NOA (N = 15) or warfarin (N = 15) were assessed with the Anti-Clot Treatment Scale (ACTS) and the Perceived Stress Scale (PSS).

RESULTS

Patients were old (81 ± 9 years). NOA group showed greater psychological satisfaction, with lower therapy-related burden (ACTS burdens: 16.3 ± 4.5 vs. 32.9 ± 10.2, p < 0.001) and higher awareness of benefits (ACTS benefits: 13.0 ± 1.3 vs. 10.8 ± 1.9, p = 0.001). Even stress was lower (PSS: 13.1 ± 4.0 vs. 17.1 ± 4.2, p = 0.013). The multivariate analysis confirmed these findings, showing that higher levels of anxiety and depression could justify more stress in warfarin patients.

CONCLUSIONS

The results of this preliminary study show that NOA have an improved psychological impact compared with warfarin in elderly patients.

Diagnostic evaluation and follow-up of patients with atrial fibrillation

In this article, a review of the diagnostic evaluation and outpatient follow-up of patients with atrial fibrillation is presented. After exploring details of symptoms, past medical history, quality of life, and physical exam findings, diagnostic tools are then discussed. Furthermore, important considerations after the initial diagnosis and treatment of patients with atrial fibrillation are discussed.

Assessment of health-related quality of life in a greek symptomatic population with atrial fibrillation: correlation with functional status and echocardiographic indices

INTRODUCTION

Atrial fibrillation (AF) is known to have an unfavorable impact on quality of life. The purpose of this study was to assess the health-related quality of life (HRQOL) in a symptomatic population with AF seeking medical advice in a tertiary hospital, as well as to explore the relationship between HRQOL, functional status, and echocardiographic indices of left ventricular (LV) systolic and diastolic function.

METHODS

The study sample consisted of 108 symptomatic patients suffering from AF who presented in the emergency department or were admitted to the cardiology department in an urban Greek tertiary hospital between January 1 and May 31, 2012. HRQOL was assessed using the SF-36 and EQ-5D instruments.

RESULTS

In the study sample, AF was newly diagnosed in 16.5% of the patients, paroxysmal/persistent in 43.6% and permanent in 39.9%. The mean levels of physical and mental summary components of the SF-36 were 40.28 and 40.89, respectively. The EQ-VAS mean score was 59.63%, while the EQ-5D Europe VAS index and the York A1 Tariff index were 0.586 and 0.547, respectively. Reliability analysis found Cronbach's to be 0.890 for the SF-36 and 0.701 for the EQ-5D. Convergent validity was proved to be at satisfactory levels. Impaired HRQOL was associated with worse NYHA class and echocardiographic indices of impaired LV systolic and diastolic function. Apart from higher NYHA class, other predisposing factors for lower HRQOL were female sex, advanced age, low physical activity, and higher levels of brain natriuretic peptide.

CONCLUSIONS

Symptomatic AF patients report impaired HRQOL. Functional status and echocardiographic indices of LV systolic and diastolic function appear to affect HRQOL significantly in these patients. The SF-36 and the EQ-5D are shown to be reliable and valid instruments in assessing HRQOL in patients with AF.

Preferences for oral anticoagulants in atrial fibrillation: a best-best discrete choice experiment

BACKGROUND

Atrial fibrillation (AF) is recognised as a growing clinical and public health problem in many countries, owing to disability and death from stroke associated with the condition, high hospitalisation costs and an increasing prevalence with ageing populations. Under-treatment with oral anticoagulants has been a significant challenge of treatment, historically related to patient concerns over the safety and convenience of warfarin, which until recently was the only oral anticoagulant available.

OBJECTIVES

The aim of this study is to examine: (1) patient preferences for attributes of warfarin and the new oral anticoagulants (dabigatran, rivaroxaban, apixaban) in AF; (2) which attributes are most important; and (3) whether current under-treatment is likely to improve with the new oral anticoagulants.

METHODS

This study was conducted in Melbourne, Australia, with members of the general public with or without AF aged ≥40 years, where those without AF proxy for newly-diagnosed patients. Participants completed a computerised best-best discrete choice experiment (and follow-up interview) as if they had AF with a moderate-to-high risk of stroke. Choice data were modelled using mixed rank-ordered logit. Relative value was explored via estimation of marginal rates of substitution with predicted probability analysis used to simulate potential uptake of oral anticoagulants.

RESULTS

Seventy-six participants were recruited and completed the study. Efficacy (stroke risk) was more important than safety (bleed risk, antidote), which were both considerably more important than convenience factors (blood tests, dose frequency, drug or food interactions). Cost was also important. Predicted use of the new oral anticoagulants (and under-treatment of AF) using simulation, given moderate-to-high risk of stroke, is 25 % (52 %), 54 % (29 %) and 70 % (21 %) assuming a market price of AUD$120/month, AUD$30/month (subsidised price) and AUD$30/month with an antidote, respectively.

CONCLUSIONS

Based on the study sample and the modelled attributes, the overall profiles of the new oral anticoagulants were preferred to warfarin as their cost decreased. Public subsidisation and the development of antidotes (such as vitamin K for warfarin) for the new oral anticoagulants may have a positive effect on the under-treatment of AF.

Rate versus rhythm control for atrial fibrillation

Treatment of patients with symptomatic atrial fibrillation (AF) with antiarrhythmic drug therapy in general improves their symptom scores and exercise tolerance; however, large randomized trials have failed to show a mortality benefit with a rhythm-control compared with a rate-control strategy. Catheter ablation in patients who have failed or not tolerated medical therapy has been shown to alleviate symptoms and improve quality of life. However, catheter ablation cannot undo the structural remodeling that contributed to the arrhythmia in the first place. Patients should be alerted to modifiable factors that may decrease the likelihood of unchecked structural remodeling and AF recurrence.

Have a high index of suspicion for atrial fibrillation

The lifetime risk of atrial fibrillation (AF) for men and women over the age of 40 is about 25%. The condition affects around 800,000 people in the UK, of which it is estimated that 250,000 are undiagnosed. A rapid heart rate may result in palpitations, dyspnoea or chest tightness, whereas loss of atrial contractility may lead to fatigue and reduced exercise capacity. There is a five-fold increased risk of ischaemic stroke, transient ischaemic attack or systemic embolism. AF strokes are larger, more disabling and have a higher mortality rate than those with other causes. The risk of stroke is not related to the presence or absence of symptoms, or whether the AF is paroxysmal or persistent. When an irregular pulse is detected it should precipitate further assessment with a 12-lead ECG. In patients with intermittent palpitations that may represent AF, prolonged ECG monitoring can be used to increase the chance of diagnosis. In patients with a confirmed diagnosis of AF, three areas need to be considered, stroke risk, symptoms, and risk of tachycardia cardiomyopathy. The CHA2DS2-VASc score is used to assess the stroke risk in patients with AF. Oral anticoagulation should be offered to those with a CHA2DS2-VASc score of 2 or more, and considered for men with a score of 1. The risk of severe bleeding with warfarin should also be assessed using the HAS-BLED score. A score of 3 or more indicates that caution is required when starting any anticoagulant therapy. Oral anticoagulant therapy can reduce the risk of stroke by around 50-70%. It should be started when the patient reaches 65 or if he/she develops any of the risk factors for stroke.

[Informed consent for the Maze Procedure for atrial fibrillation]

It is important to explain the benefits and risks of surgery thoroughly to patients and their families. This paper describes the benefits and risks of the Maze procedure for atrial fibrillation (AF). The purpose of the Maze procedure is the restoration of sinus rhythm from AF, recovery of cardiac function by atrial contraction, and prevention of stroke. The AF cure ratio is 70-90% after the Maze procedure. It was reported that atrial function improves due to atrial contraction after surgery, and the risk of a stroke is reduced to about 2-4 events per 1,000 patients per year after surgery. On the other hand, bleeding is the most common complication after the Maze procedure. The use of alternative surgical ablation devices instead of the cut-and-sew technique decreases the risk of bleeding. Pacemakers are implanted in 5-10% of patients after the Maze procedure due to sick sinus syndrome. In approximately 40% of patients, transient AF occurs during the first month after surgery. However, the addition of the Maze procedure to cardiac surgery for structural heart disease does not increase the surgical risk.

Quality of life in patients with atrial fibrillation: how to assess it and how to improve it

Atrial fibrillation (AF) is the most frequent cardiac rhythm disorder and presents a considerable public health burden that is likely to increase in the next decades due to the ageing population. Current management strategies focus on the heart rate and rhythm control, thromboembolism prevention, and treatment of underlying diseases. The concept of quality of life (QoL) has gained significant importance in recent years as an outcome measure in AF studies evaluating therapeutic interventions and as a relevant component of a comprehensive treatment plan. Quality of life is impaired in the majority of patients with AF, and both rate and rhythm control strategies show significant improvement in QoL measures in highly symptomatic patients. This article reviews generic and specialized instruments for measuring QoL in the context of AF, discusses their applications and limitations to integration in clinical practice, and addresses the potential of early therapy for improving QoL outcomes. The development and validation of new QoL assessment tools will have a central role in the advancement of therapies and treatment guidelines for AF.

Nursing and quality of life in patients with atrial fibrillation before and after radiofrequency ablation

The importance of nursing and patient quality of life is a top concern for medical professionals. Therefore, participation by medical professionals in raising awareness and continuously supporting improvements in nursing care is an essential part of improving patient quality of life. Modern medical techniques and procedures are changing rapidly, particularly in the field of cardiology. This has resulted in changing roles and increased responsibility for nurses and confirms the necessity for changing the perception of nurses relative to their role in the medical environment and to patient care. This paper presents the results from the first phase of a research project and focuses on quality of life and problematic areas associated with the needs of patients with atrial fibrillation before and after radiofrequency catheter ablation. Atrial fibrillation is one of the most common supraventricular arrhythmias. Its incidence in the general population has risen significantly over the last twenty years. The objective of this research was to assess those areas, which are considered by patients to be problematic before therapeutic intervention. The research was realized through a quantitative survey using a modified questionnaire. Results showed that AF reduced the quality of life both physically and psychologically (i.e. increased levels of anxiety and depression). Results also showed that radiofrequency catheter ablation was able to alleviate symptoms associated with AF and was also able to increase patient quality of life.

Depression in atrial fibrillation in the general population

Background

Initial evidence suggests that depressive symptoms are more frequent in patients with atrial fibrillation. Data from the general population are limited.

Methods and Results

In 10,000 individuals (mean age 56±11 years, 49.4% women) of the population-based Gutenberg Health Study we assessed depression by the Patient Health Questionnaire (PHQ-9) and a history of depression in relation to manifest atrial fibrillation (n = 309 cases). The median (25th/75th percentile) PHQ-9 score of depressive symptoms was 4 (2/6) in atrial fibrillation individuals versus 3 (2/6) individuals without atrial fibrillation, . Multivariable regression analyses of the severity of depressive symptoms in relation to atrial fibrillation in cardiovascular risk factor adjusted models revealed a relation of PHQ-9 values and atrial fibrillation (odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01–1.08; P = 0.023). The association was stronger for the somatic symptom dimension of depression (OR 1.08, 95% CI 1.02–1.15; P = 0.0085) than for cognitive symptoms (OR 1.05, 95% CI 0.98–1.11; P = 0.15). Results did not change markedly after additional adjustment for heart failure, partnership status or the inflammatory biomarker C-reactive protein. Both, self-reported physical health status, very good/good versus fair/bad, (OR 0.54, 95% CI 0.41–0.70; P<0.001) and mental health status (OR 0.61 (0.46–0.82); P = 0.0012) were associated with atrial fibrillation in multivariable-adjusted models.

Conclusions

In a population-based sample we observed a higher burden of depressive symptoms driven by somatic symptom dimensions in individuals with atrial fibrillation. Depression was associated with a worse perception of physical or mental health status. Whether screening and treatment of depressive symptoms modulates disease progression and outcome needs to be shown.

Educational intervention improves anticoagulation control in atrial fibrillation patients: the TREAT randomised trial

BACKGROUND

Stroke prevention in atrial fibrillation (AF), most commonly with warfarin, requires maintenance of a narrow therapeutic target (INR 2.0 to 3.0) and is often poorly controlled in practice. Poor patient-understanding surrounding AF and its treatment may contribute to the patient's willingness to adhere to recommendations.

METHOD

A theory-driven intervention, developed using patient interviews and focus groups, consisting of a one-off group session (1-6 patients) utilising an "expert-patient" focussed DVD, educational booklet, self-monitoring diary and worksheet, was compared in a randomised controlled trial (ISRCTN93952605) against usual care, with patient postal follow-ups at 1, 2, 6, and 12-months. Ninety-seven warfarin-naïve AF patients were randomised to intervention (n=46, mean age (SD) 72.0 (8.2), 67.4% men), or usual care (n=51, mean age (SD) 73.7 (8.1), 62.7% men), stratified by age, sex, and recruitment centre. Primary endpoint was time within therapeutic range (TTR); secondary endpoints included knowledge, quality of life, anxiety/depression, beliefs about medication, and illness perceptions.

MAIN FINDINGS

Intervention patients had significantly higher TTR than usual care at 6-months (76.2% vs. 71.3%; p=0.035); at 12-months these differences were not significant (76.0% vs. 70.0%; p=0.44). Knowledge increased significantly across time (F (3, 47) = 6.4; p<0.01), but there were no differences between groups (F (1, 47) = 3.3; p = 0.07). At 6-months, knowledge scores predicted TTR (r=0.245; p=0.04). Patients' scores on subscales representing their perception of the general harm and overuse of medication, as well as the perceived necessity of their AF specific medications predicted TTR at 6- and 12-months.

CONCLUSIONS

A theory-driven educational intervention significantly improves TTR in AF patients initiating warfarin during the first 6-months. Adverse clinical outcomes may potentially be reduced by improving patients' understanding of the necessity of warfarin and reducing their perception of treatment harm. Improving education provision for AF patients is essential to ensure efficacious and safe treatment. The trial is registered with Current Controlled Trials, ISRCTN93952605, and details are available at www.controlled-trials.com/ISRCTN93952605.

Quality of life assessment in the randomized PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial of patients at risk for stroke with nonvalvular atrial fibrillation

OBJECTIVES

This study sought to assess quality of life parameters in a subset of patients enrolled in the PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial.

BACKGROUND

The PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial demonstrated that in patients with nonvalvular atrial fibrillation (AF) and CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke, transient ischemic attack, or thromboembolism) score ≥1, a left atrial appendage closure device is noninferior to long-term warfarin for stroke prevention. Given this equivalency, quality of life (QOL) indicators are an important metric for evaluating these 2 different strategies.

METHODS

QOL using the Short-Form 12 Health Survey, version 2, measurement tool was obtained at baseline and 12 months in a subset of 547 patients in the PROTECT AF trial (361 device and 186 warfarin patients). The analysis cohort consisted of patients for whom either paired quality of life data were available after 12 months of follow-up or for patients who died.

RESULTS

With the device, the total physical score improved in 34.9% and was unchanged in 29.9% versus warfarin in whom 24.7% were improved and 31.7% were unchanged (p = 0.01). Mental health improvement occurred in 33.0% of the device group versus 22.6% in the warfarin group (p = 0.06). There was a significant improvement in QOL in patients randomized to device for total physical score, physical function, and in physical role limitation compared to control. There were significant differences in the change in total physical score among warfarin naive and not-warfarin naive subgroups in the device group compared to control, but larger gains were seen with the warfarin naive subgroup with a 12-month change of 1.3 ± 8.8 versus -3.6 ± 6.7 (p = 0.0004) device compared to warfarin.

CONCLUSIONS

Patients with nonvalvular AF at risk for stroke treated with left atrial appendage closure have favorable QOL changes at 12 months versus patients treated with warfarin. (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation [WATCHMAN PROTECT]; NCT00129545).