Illness Perceptions, Coping Strategies, and Symptoms Contribute to Psychological Distress in Patients With Recurrent Symptomatic Atrial Fibrillation

Illness Perceptions and Health-Related Quality of Life in Women and Men With Atrial Fibrillation

BACKGROUND

Health-related quality of life (HRQoL) is worse in patients with atrial fibrillation (AF) compared with other populations. Factors affecting HRQoL in patients with AF are not fully clarified. Illness perceptions are important determinants of disease management and may affect HRQoL.

OBJECTIVE

The aims of this study were to describe illness perceptions and HRQoL in women and men with AF and to explore the relationship between illness perceptions and HRQoL in patients with AF.

METHODS

This cross-sectional study included 167 patients with AF. Patients completed the Revised Illness Perception Questionnaire and HRQoL questionnaires: Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias, the three-level version of the EuroQol 5-dimensional questionnaire, and EuroQol visual analog scale. Subscales of the Revised Illness Perception Questionnaire significant in correlation analysis with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias HRQoL total scale were included in a multiple linear regression model.

RESULTS

Mean age was 68.7 ± 10.4 years, and 31.1% were women. Women reported lower personal control ( P = .039) and worse HRQoL measured with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias physical subscale ( P = .047) and the EuroQol visual analog scale ( P = .044) compared with men. Illness identity ( P < .001), consequences ( P = .031), emotional representation ( P = .014), and timeline cyclical ( P = .022) were related to and adversely affected HRQoL.

CONCLUSIONS

This study found a relationship between illness perceptions and HRQoL. Some subscales of illness perceptions negatively affected HRQoL in patients with AF, which indicates that efforts to change illness perceptions may be helpful in improving HRQoL. Patients should be given the opportunity to talk about the disease, their symptoms, their emotions, and the consequences of the disease to enable increased HRQoL. A challenge for healthcare will be to design support for each patient based on his/her illness perceptions.

The effects of cognitive behavioral therapy on health-related quality of life, anxiety, depression, illness perception, and in atrial fibrillation patients: a six-month longitudinal study

BACKGROUND

Atrial fibrillation (AF) often leads to an impaired Health-Related Quality of Life (HRQoL) in many patients. Moreover, psychological factors such as depression, anxiety, and illness perception have been found to significantly correlate with HRQoL. This study aims to evaluate the long-term effectiveness of Cognitive Behavioral Therapy (CBT) in enhancing HRQoL and mitigating psychological distress among AF patients.

METHODS

Employing a prospective, open design with pseudo-randomization, this study encompassed pre-tests, post-treatment evaluations, and a 6-month follow-up. A total of 102 consecutive patients diagnosed with paroxysmal AF were initially enrolled. Out of these, 90 were assigned to two groups; one to receive a 10-week CBT treatment specifically focusing on anxiety, and the other to receive standard care. Outcome measures were evaluated using tools such as the Item Short Form Health Survey (SF-12), General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), University of Toronto Atrial Fibrillation Severity Scale (AFSS), and Brief Illness Perception Questionnaire (BIPQ). These assessments were conducted at pre-treatment, post-treatment, and at the 6-month follow-up mark. We explored the effectiveness of CBT using Generalized Estimating Equations (GEE).

RESULTS

Our analysis revealed a notable improvement in the CBT group relative to the control group. All metrics displayed consistent improvement across a 6-month duration. At the 6-month checkpoint, the CBT group exhibited a more favorable SF-12 Mental Component Score (MCS) (50.261 ± 0.758 vs. 45.208 ± 0.887, p < 0.001), reduced GAD-7 (4.150 ± 0.347 vs. 8.022 ± 0.423, p < 0.001), BIPQ (34.700 ± 0.432 vs. 38.026 ± 0.318, p < 0.001), and AFSS (9.890 ± 0.217 vs. 10.928 ± 0.218, p = 0.001) scores when compared to the TAU group. Conversely, the SF-12 PCS (44.212 ± 0.816 vs. 47.489 ± 0.960, p = 0.139) and PHQ-9 scores (8.419 ± 0.713 vs. 10.409 ± 0.741, p = 0.794) manifested no significant difference between the two groups.

CONCLUSION

The findings suggest that CBT is effective in improving HRQoL and reducing psychological distress among patients with AF at 6 month follow-up. This highlights the potential benefits of integrating CBT into the therapeutic regimen for AF patients.

TRIAL REGISTRATION

Retrospectively registered with ClinicalTrials.gov (NCT05716828). The date of registration : 5 June 2023.

Comparing Patient and Provider Experiences with Atrial Fibrillation to Highlight Gaps and Opportunities for Improving Care

BACKGROUND

Atrial fibrillation (AF), the most common abnormal heart rhythm, places a considerable burden on patients, providers, and the US healthcare system.

OBJECTIVE

The purpose of this qualitative study was to compare patients' and providers' interpretations and responses to AF symptoms and to identify where treatment can be improved to better address patient needs and well-being.

DESIGN

Qualitative design using focus groups with patients (3 groups) and providers (3 groups).

PARTICIPANTS

Patients with physician-confirmed AF (n=29) and cardiologists, primary care physicians, and cardiac nurses (n=24).

APPROACH

Focus groups elicited patient and provider perspectives regarding the symptom experience of AF, treatment goals, and gaps in care. Patient and provider transcripts were analyzed separately, using a thematic content analysis approach, and then compared.

KEY RESULTS

While patients and providers described similar AF symptoms, patients' illness experiences included a wider range of symptoms that elicited anxiety and impacted quality of life (QOL) across many biopsychosocial domains. Patients and providers prioritized different treatment goals. Providers tended to focus on controlling symptoms congruent with objective findings, minimizing stroke risk, and restoring sinus rhythm. Patients focused on improving QOL by reducing medication use or procedures. Both patients and providers struggled with patients' cardiac-related anxiety. Patients expressed an unmet need for education and support.

CONCLUSION

Patients with AF experience a range of symptoms and QOL issues. While guidelines recommend shared-decision making, discordance between patient and provider perspectives on the importance, priority, and impact of patients' perceived AF symptoms and consequent cardiac anxiety may result in differing treatment priorities. Starting from a perspective that contextualizes AF in the broader context of patients' lives, prioritizes QOL, and addresses symptom-specific anxiety as a prime concern may better address patients' unmet needs.

Educational Needs of People Living with Atrial Fibrillation: A Qualitative Study

Background

This study explored the educational and self‐management needs of adults living with atrial fibrillation (AF).

Methods and Results

This is a qualitative study of adults living with AF, clinicians, and expert key stakeholders. Interviews were conducted via a one‐to‐one semistructured videoconference or phone and transcribed verbatim for thematic analysis. A total of 34 participants were recruited and included in analyses (clinicians n=13; experts n=13, patients n=8). Interviews were on average 40 (range 20–70) minutes in duration. Three key themes were identified: (1) “Patient‐centered AF education”; (2) “Prioritizing AF education”; and (3) “Timing AF education.” The availability of credible information was perceived as highly variable. Information primarily focused on anticoagulation, or procedural information, as opposed to other aspects of management, such as risk factor reduction. Factors to optimize learning, such as multimedia, apps, case studies, or the use of visuals were perceived as important. Continuity of care, including engagement of caregivers, was important to help develop relationships, and facilitate understanding, while concurrently creating opportunities for timely targeted education. Clinicians described acute care as a suboptimal setting to deliver education. Competing interests aligned with the time‐pressured context of acute care were prioritized over patient education. In contrast, patients valued continuity of care. AF education strategies need to pivot from a “one size fits all” approach and modernize to implement a range of approaches.

Conclusions

There remain many unmet needs in the provision of quality AF education to support self‐management. Multimodal offerings and the ability to tailor to individual patient needs are important design considerations for new education programs.

Fatigue severity and avoidance among individuals with chronic disease: A meta-analysis

OBJECTIVE

Fatigue is a common, debilitating symptom experienced by individuals with chronic disease. Avoidance, or the act of evading unwanted experiences, is associated with fatigue across chronic disease samples. The current study sought to determine the strength of association between fatigue severity and avoidance in individuals with chronic disease.

METHODS

PubMed, PsycINFO, CINAHL, and ProQuest Dissertations and Theses databases were searched. Eligible studies measured fatigue and avoidance in chronic disease samples. Sixty-six studies were included. Data analyses were conducted in Rstudio. A random effects model was employed, and a weighted mean effect size was computed for fatigue severity and avoidance. Mixed-effects meta-regression analyses were conducted to examine moderating variables, including patient, clinical, and measurement characteristics. Publication bias was examined using funnel plot, trim-and-fill, and p-curve.

RESULTS

The meta-analysis comprised of 71 unique patient samples from 66 studies. The total number of included participants was 13,024. A small, positive association was found between fatigue severity and avoidance, r(71) = 0.22, p < .001, 95% CI [0.18-0.27], SE = 0.02. There was also significant heterogeneity, Q(70) = 349.96, p < .001. Moderator analyses examining age, sex, illness duration, avoidance type, and disease sample were all non-significant. Regarding publication bias, trim-and-fill resulted in a modified weighted mean effect size (r(83) = 0.18, p < .001) and a p-curve analysis supported the evidential value of the current analysis.

CONCLUSION

Findings support that among individuals with chronic disease, fatigue severity and avoidance are positively associated, which has implications for behavioral interventions in this population.

Atrial fibrillation, quality of life and distress: a cluster analysis of cognitive and behavioural responses

PURPOSE

Few studies have examined specific cognitive and behavioural responses to symptoms, which may impact health-related outcomes, in conjunction with illness representations, as outlined by the Common-Sense-Model. Patients with atrial fibrillation (AF) report poor quality-of-life (QoL) and high distress. This cross-sectional study investigated patterns/clusters of cognitive and behavioural responses to illness, and illness perceptions, and relationships with QoL, depression and anxiety.

METHODS

AF patients (N = 198) recruited at cardiology clinics completed the AF-Revised Illness Perception Questionnaire, Atrial-Fibrillation-Effect-on-Quality-of-Life Questionnaire, Patient Health Questionnaire-8 and Generalized Anxiety Disorder Questionnaire. Cluster analysis used Ward's and K-means methods. Hierarchical regressions examined relationships between clusters with QoL, depression and anxiety.

RESULTS

Two clusters of cognitive and behavioural responses to symptoms were outlined; (1) 'high avoidance'; (2) 'low symptom-focussing'. Patients in Cluster 1 had lower QoL (M = 40.36, SD = 18.40), greater symptoms of depression (M = 7.20, SD = 5.71) and greater symptoms of anxiety (M = 5.70, SD = 5.90) compared to patients in Cluster 2 who had higher QoL (M = 59.03, SD = 20.12), fewer symptoms of depression (M = 3.53, SD = 3.56) and fewer symptoms of anxiety (M = 2.56, SD = 3.56). Two illness representation clusters were outlined; (1) 'high coherence and treatment control', (2) 'negative illness and emotional representations'. Patients in Cluster 2 had significantly lower QoL (M = 46.57, SD = 19.94), greater symptoms of depression (M = 6.12, SD = 5.31) and greater symptoms of anxiety (M = 4.70, SD = 5.27), compared with patients in Cluster 1 who had higher QoL (M = 61.52, SD = 21.38), fewer symptoms of depression (M = 2.85, SD = 2.97) and fewer symptoms of anxiety (M = 2.16, SD = 3.63). Overall, clusters of cognitive and behavioural responses to symptoms, and illness perceptions significantly explained between 14 and 29% of the variance in QoL, depression and anxiety.

CONCLUSION

Patterns of cognitive and behavioural responses to symptoms, and illness perceptions are important correlates of health-related outcomes in AF patients.

Effects of Cognitive Behavior Therapy on Depression, Illness Perception, and Quality of Life in Atrial Fibrillation Patients

BACKGROUND

AF Patients with depression resulted in a markedly reduced quality of life. The purpose of this study was to evaluate the efficacy of cognitive behavior therapy (CBT) on the health-related quality of life (HRQoL).

METHODS

It was A longitudinal randomized controlled trial with a pre and 12-weeks post-test. Ninety persons were randomly assigned to either a CBT group (CBT) (n = 45) or a treatment as usual (TAU) group (n = 45). The outcome were changes in the HRQoL [12-item Short Form Health Survey, SF12, divided into two domains: the physical component summary (PCS) and the mental component summary (MCS)], changes in psychological distress [Hamilton Depression Rating Scale (HAM-D) and Patient Health Questionnaire-9 (PHQ-9)], and Illness Perception [Brief Illness Perception Questionnaire (BIPQ)].

RESULTS

There were statistically significant differences in score reduction for PHQ-9 (t = 3.186, P = 0.002), HAMD (t = 2.611, P = 0.011), BIPQ (t = 7.660, P < 0.001), and MCS (t = 4.301, P < 0.001) between CBT group and TAU group.

CONCLUSIONS

CBT improved HRQoL, Illness Perception and reduced Depressive symptoms in atrial fibrillation.

Medical students' positive perception towards vaccination is strongly correlated to protective diphtheria antibody after Td vaccination

Negative perception towards vaccination is one of the reasons for low coverage of diphtheria immunization in Indonesia. Perception, which is difficult to change, is related to stress level, possibly influences outcome of diseases, and also vaccination. This study aims to identify the correlation between perception of diphtheria vaccination and antibody response after vaccination. This study used secondary data from two unpublished studies on 30 medical interns in Hasan Sadikin Hospital, Bandung, West Java, after diphtheria outbreak, from June to July 2019. Antibody level after diphtheria emergency vaccination was measured using ELISA and perception towards vaccination was measured using a questionnaire. Perception towards vaccination was expressed as perception score and was divided into 4 components: perceived threat, benefit, barrier, and cues to action. Higher perception score indicated more positive perception towards vaccination. Diphtheria antibody level was grouped into reliable protection (≥0,10 IU/mL) or unreliable protection (<0,10 IU/mL). Statistical correlation analysis was done with GraphPad Prism version 7.0. Most of our subjects were female. Median age was 22 (20-24) years old. Median time elapsed between vaccination date and measurement of antibody level was 18 (6-18) months. Median antibody level was 0,28 (0,09-3,47) IU/mL. Twenty-three subjects (82,1%) had reliable protection. Subjects with reliable protection had more positive perception compared to unreliable protection (perception score 80,6 ​± ​5,4 vs 69,0 ​± ​1,8, p ​= ​0,0001). Subjects with reliable protection had less perceived barrier for vaccination (15,6 ​± ​2,1 vs 13,0 ​± ​1,8, p ​= ​0,0083). Perception score showed strong, positive correlation to reliable protection against diphtheria (R ​= ​0,705, p ​< ​0,001). Perceived barrier and threat showed positive correlation to reliable protection (R ​= ​0,489, p ​= ​0,008 and R ​= ​0,402, p ​= ​0,034). In conclusion, perception towards diphtheria vaccination is strongly correlated to protective antibody. Improving perception of vaccination are needed to overcome vaccine hesitancy.

Measurement of patient confidence in self-management of atrial fibrillation: Initial validation of the Confidence in Atrial fibriLlation Management (CALM) Scale

BACKGROUND

The patient experience of atrial fibrillation (AF) involves several daily self-care behaviors and ongoing confidence to manage their condition. Currently, no standardized self-report measure of AF patient confidence exists. The purpose of this study is to provide preliminary support for the reliability and validity of a newly developed confidence in AF management measure.

METHODS

This study provides preliminary analysis of the Confidence in Atrial FibriLlation Management (CALM) scale, which was rationally developed to measure patient confidence related to self-management of AF. The scale was provided to a sample of AF patients N = 120, (59% male) electronically through a patient education platform. Principal component analysis (PCA) and Cronbach's α were employed to provide preliminary assessment of the validity and reliability of the measure.

RESULTS

PCA identified a four-factor solution. Internal consistency of the CALM was considered excellent with Cronbach's α = .910. Additional PCA confirmed the value of a single factor solution to produce a total confidence score for improved utility and ease of clinical interpretation.

CONCLUSIONS

Initial assessment of a novel scale measuring patient confidence in managing AF provided promising reliability and validity. Patient confidence in self-management of AF may prove useful as a key marker and endpoint of the patient experience beyond QOL.

Clinically Meaningful Change in Quality of Life and Associated Factors Among Older Patients With Atrial Fibrillation

Background

Among older patients with atrial fibrillation, there are limited data examining clinically meaningful changes in quality of life (QoL). We examined the extent of, and factors associated with, clinically meaningful change in QoL over 1‐year among older adults with atrial fibrillation.

Methods and Results

Patients from cardiology, electrophysiology, and primary care clinics in Massachusetts and Georgia were enrolled in a cohort study (2015–2018). The Atrial Fibrillation Effect on Quality‐of‐Life questionnaire was used to assess overall QoL and across 3 subscales: symptoms, daily activities, and treatment concern. Clinically meaningful change in QoL (ie, difference between 1‐year and baseline QoL score) was categorized as either a decline (≤−5.0 points), no clinically meaningful change (−5.0 to +5.0 points), or an increase (≥+5.0 points). Ordinal logistic models were used to examine factors associated with QoL changes. Participants (n=1097) were on average 75 years old, 48% were women, and 87% White. Approximately 40% experienced a clinically meaningful increase in QoL and 1 in every 5 patients experienced a decline in QoL. After multivariable adjustment, women, non‐Whites, those who reported depressive and anxiety symptoms, fair/poor self‐rated health, low social support, heart failure, or diabetes mellitus experienced clinically meaningful declines in QoL.

Conclusions

These findings provide insights to the magnitude of, and factors associated with, clinically meaningful change in QoL among older patients with atrial fibrillation. Assessment of comorbidities and psychosocial factors may help identify patients at high risk for declining QoL and those who require additional surveillance to maximize important clinical and patient‐centered outcomes.

Can nurses help improve self-care of patients living with atrial fibrillation? A focus group study exploring patients' disease knowledge gaps

Aims

To identify knowledge gaps and preferences for educational material to improve nurse-patient communication and self-care.

Design

Using a mixed-methods design, we conducted focus groups and quantitative surveys.

Methods

We conducted three focus groups with atrial fibrillation (AF) patients and support persons (N = 17 participants; 66 ± 16 years) at critical treatment junctures (recent diagnosis or medication switch). Patients and support persons were also surveyed on patient activation (self-management skills and knowledge), medication adherence, AF knowledge and health literacy. Iterative thematic analysis was performed using focus group transcripts.

Results

Although most participants had adequate health literacy, most reported gaps in AF knowledge. Participants lacked disease-related knowledge and were unsure how to manage health behaviours (e.g. diet and exercise). Few felt they received adequate education from their healthcare provider. Results emphasize the need for consistent information from nursing staff, in lay language, via both electronic and printed means.

Health-Related Quality of Life and Associated Factors in Patients with Atrial Fibrillation: An Integrative Literature Review

Atrial fibrillation (AF) is a common cardiac arrhythmia associated with poor health-related quality of life (HRQoL). However, the factors influencing HRQoL in patients with AF are not well understood. The purpose of integrative review was to investigate the factors affecting HRQoL in patients with AF based on the six domains of Ferrans and colleagues’ HRQoL model. A total of 23 relevant articles published between January 2000 and March 2018 were identified using four databases and analyzed in this study. Our review showed that the HRQoL in patients with AF was consistently lower than both healthy individuals and patients with other cardiovascular diseases. The most common factor associated with HRQoL in patients with AF was anxiety-specific to AF in the symptoms domain, followed by frequency and severity of symptoms and the New York Heart Association functional class. This study highlights that monitoring and assessing patients’ symptoms is vital for improving HRQoL in patients with AF. Disease-specific and cross-culturally validated tools can allow healthcare professionals to provide tailored interventions for patients with AF.

I am a total failure: associations between beliefs and anxiety and depression in patients with inflammatory bowel disease with poor mental quality of life

BACKGROUND

According to cognitive behavioural theory, cognitive factors (i.e. underlying general dysfunctional beliefs and (situation) specific illness beliefs) are theorized to lead to outcomes like anxiety and depression. In clinical practice, general dysfunctional beliefs are generally not tackled directly in short-term-therapy.

AIMS

The goal of the present study was to investigate the associations of general versus specific illness beliefs on anxiety and depressive symptoms and psychiatric disorders among a subgroup of patients with inflammatory bowel disease (IBD) with poor mental quality of life (QoL).

METHOD

This study concerns cross-sectional data, collected at baseline from a randomized clinical trial. One hundred and eighteen patients, recruited at four Dutch hospitals, with poor QoL (score ≤23 on the mental health subscale of the Short-Form 36-item Health-Survey; SF-36) were included. General dysfunctional beliefs were measured by the Dysfunctional Attitude Scale (DAS), specific illness beliefs by the Illness Perceptions Questionnaire-Revised (IPQ-R), anxiety and depressive symptoms by the Hospital Anxiety and Depression Scale (HADS), and psychiatric disorders by the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I).

RESULTS

Univariate analyses showed associations between the level of anxiety and/or depression and general dysfunctional beliefs and four specific illness beliefs (consequences, personal control, emotional representations and treatment control). Among patients with IBD with psychiatric disorders, only the DAS was significantly associated with anxiety and depression (DAS added to IPQ-R and IPQ-R added to DAS).

CONCLUSIONS

Psychological interventions may have to target general dysfunctional beliefs of patients with IBD with co-morbid psychiatric disorders to be effective. These patients with IBD are especially in need of psychological treatment.

Atrial Fibrillation Symptoms and Sex, Race, and Psychological Distress: A Literature Review

BACKGROUND

Atrial fibrillation (AF) symptoms are a major component of treatment decisions for patients with AF and impact quality of life and functional ability yet are poorly understood.

OBJECTIVE

This review aimed to determine what is known about the prevalence of symptoms and the association of symptoms to AF characteristics, psychological distress, sex, and race.

METHODS

We performed a structured review of AF symptoms as of March 2016 using PubMed, EMBASE, and CINAHL and reference searches of retrieved articles. Full-text, published, peer-reviewed, English-language articles were examined. Articles were included if they reported original research data on symptom prevalence and type among patients with AF.

RESULTS

The 3 most common symptoms were dyspnea, palpitations, and fatigue. The results suggested that, although AF characteristics are not a significant predictor of symptoms, tachycardia, female sex, race, and psychological distress have a positive association to symptoms.

CONCLUSIONS

There is a scarcity of research examining symptoms in AF. Furthermore, the inconsistency in measurement methods and the failure to include diverse populations in AF research make it difficult to draw definitive conclusions from the current literature. Given the prevalence of AF in the United States and the impact of symptoms on quality of life and healthcare use, further research examining predictors of symptoms and interventions to alleviate symptoms is crucial.

Association of sex, age and education level with patient reported outcomes in atrial fibrillation

BACKGROUND

In atrial fibrillation (AF), there are known sex and sociodemographic disparities in clinical outcomes such as stroke. We investigate whether disparities also exist with respect to patient-reported outcomes. We explored the association of sex, age, and education level with patient-reported outcomes (AF-related quality of life, symptom severity, and emotional and functional status).

METHODS

The PaTH AF cohort study recruited participants (N = 953) with an AF diagnosis and age ≥ 18 years across 4 academic medical centers. We performed longitudinal multiple regression with random effects to determine if individual characteristics were associated with patient-reported outcomes.

RESULTS

Women reported poorer functional status (β - 2.23, 95% CI: -3.52, - 0.94) and AF-related quality of life (β - 4.12, 95% CI: -8.10, - 0.14), and higher symptoms of anxiety (β 2.08, 95% CI: 0.76, 3.40), depression (β 1.44, 95% CI: 0.25, 2.63), and AF (β 0.29, 95% CI: 0.08, 0.50). Individuals < 60 years were significantly (p < 0.05) more likely to report higher symptoms of depression, anxiety, and AF, and poorer AF-related quality of life. Lack of college education was associated with reporting higher symptoms of AF (β 0.42, 95% CI: 0.17, 0.68), anxiety (β 1.86, 95% CI: 0.26, 3.45), and depression (β 1.11, 95% CI: 0.15, 2.38), and lower AF-related quality of life (β - 4.41, 95% CI: -8.25, - 0.57) and functional status.

CONCLUSION

Women, younger adults, and individuals with lower levels of education reported comparatively poor patient-reported outcomes. These findings highlight the importance of understanding why individuals experience AF differently based on certain characteristics.

Patient activation for self-management is associated with health status in patients with atrial fibrillation

BACKGROUND

Higher levels of patient activation for self-managing health are associated with positive clinical and health care utilization outcomes. Identifying a patient's activation level can guide clinicians to tailor interventions to improve their health. Effective self-management of atrial fibrillation (AF) requires patient activation to participate in treatment decisions, prevent complications, and manage risk factors. Yet, little is known about activation in patients with AF. The purpose of this descriptive study was to identify patient activation levels and factors associated with activation in patients with AF.

METHODS

Patients (N=123), 66% male, with a mean (SD) age of 59.9 (11.3) years seeking treatment for AF at an arrhythmia clinic completed the Patient Activation Measure (PAM), Atrial Fibrillation Severity Scale, Knowledge about Atrial Fibrillation test, Hospital Anxiety Depression Scale, Godin Leisure-Time Exercise Questionnaire, and Patient Assessment of Chronic Illness Care. Sociodemographic and clinical data were obtained from medical records. PAM scores were categorized into Levels 1-4. Associations among patient-reported outcomes, sociodemographic, and clinical variables were analyzed using Fisher's exact tests and Kruskal-Wallis procedures.

RESULTS

The PAM scores of nearly half (45.5%) of the patients were at Level 3, while the scores of 38% were at Level 4. Male sex (P=0.02), higher education (P=0.004), being employed (P=0.005), lower body mass index (P=0.03), tobacco abstinence (P=0.02), less AF symptom burden (P=0.006), less depression (P≤0.0001) and anxiety (P=0.006), greater knowledge of AF (P=0.01), and higher levels of physical activity (P=0.02) were associated with higher activation levels.

CONCLUSION

Higher levels of patient activation in those with AF were associated with a more positive health status and educational attainment. Additional research to describe activation in patients with AF is warranted to identify patients at risk for low activation and to tailor interventions to activation level.

Factors associated with confidence in decision making and satisfaction with risk communication among patients with atrial fibrillation

Background:

Atrial fibrillation is a prevalent cardiac arrhythmia. Effective communication of risks (e.g. stroke risk) and benefits of treatment (e.g. oral anticoagulants) is crucial for the process of shared decision making.

Aim:

The aim of this study was to explore factors associated with confidence in decision making and satisfaction with risk communication after a follow-up visit among patients who three months earlier had visited an emergency room for atrial fibrillation related symptoms.

Methods:

A cross-sectional design was used and 322 patients (34% women), mean age 66.1 years (SD 10.5 years) with atrial fibrillation were included in the south of Sweden. Clinical examinations were done post an atrial fibrillation episode. Self-rating scales for communication (Combined Outcome Measure for Risk Communication and Treatment Decision Making Effectiveness), uncertainty in illness (Mishel Uncertainty in Illness Scale–Community), mastery of daily life (Mastery Scale), depressive symptoms (Hospital Anxiety and Depression Scale) and vitality, physical health and mental health (36-item Short Form Health Survey) were used to collect data.

Results:

Decreased vitality and mastery of daily life, as well as increased uncertainty in illness, were independently associated with lower confidence in decision making. Absence of hypertension and increased uncertainty in illness were independently associated with lower satisfaction with risk communication. Clinical atrial fibrillation variables or depressive symptoms were not associated with satisfaction with confidence in decision making or satisfaction with risk communication. The final models explained 29.1% and 29.5% of the variance in confidence in decision making and satisfaction with risk communication.

Conclusion:

Confidence in decision making is associated with decreased vitality and mastery of daily life, as well as increased uncertainty in illness, while absence of hypertension and increased uncertainty in illness are associated with risk communication satisfaction.

'It's like a frog leaping about in your chest': Illness and treatment perceptions in persistent atrial fibrillation

OBJECTIVES

Persistent atrial fibrillation (AF) is an abnormal heart rhythm associated with low quality of life (QoL) and significant health-related costs. The purpose of the study was to examine patients' illness and treatment beliefs and ways of coping with AF symptoms, to provide insight into promoting better QoL and treatment-specific management.

DESIGN

Beliefs were explored across three procedural treatment groups using a qualitative cross-sectional design.

METHODS

Thirty semi-structured interviews were carried out with patients undertaking cardioversion (n = 10), catheter ablation (n = 11) and atrioventricular node ablation (n = 9). Interviews were transcribed and analysed using inductive thematic analysis with elements of grounded theory.

RESULTS

An overarching theme of a vicious cycle was evident, which related to perceived lack of knowledge and understanding of AF, attempts to control symptoms and negative emotional reactions to failed control attempts. This vicious cycle related to three subordinate themes: (1) unpredictability and uncertainty of AF and symptoms; (2) coping with symptoms through (a) avoidance (b) all-or-nothing- (c) slowing down behaviours; and (3) concerns and expectations about treatment.

CONCLUSIONS

Patients outlined a need to gain control of unpredictable symptoms by monitoring and varying activity levels. These behaviours were often appraised as ineffective at controlling symptoms, leading to heightened uncertainty and increased activity avoidance. Treatment concerns escalated with increasing number and invasiveness of procedures. Improving AF patients' perceived understanding of their illness and treatment and promoting more effective symptom-management strategies may alleviate psychological distress and improve QoL. Themes elaborated on the common-sense model whereby patients' beliefs about illness and treatment interact with coping behaviours. Statement of contribution What is already known about this subject? Quality of life (QoL) is disproportionately low in people with persistent atrial fibrillation (psAF). The common-sense model suggests illness perceptions and coping predict QoL in chronic illnesses. No previous studies have examined the idiosyncratic beliefs and coping behaviours of psAF patients. What does this study add? A vicious cycle of perceived lack of understanding of AF, attempts to control AF and distress at failed attempts at control, was a key theme. PsAF patients reported continued avoidance/all-or-nothing behaviours despite symptomatic relief post-procedure, and disengagement from enjoyable activities. PsAF patients reported procedure-specific concerns/expectations, which could be targeted in future interventions aimed at reducing distress.

The heart is a representation of life: an exploration of illness beliefs in couples living with atrial fibrillation

AIMS AND OBJECTIVES

To explore illness beliefs in couples where one spouse has atrial fibrillation.

BACKGROUND

Beliefs are the lenses through which we view the world, guiding our behaviour and constructing our lives. Couples evolve an ecology of beliefs from their interaction whereby their actions and choices arise from their beliefs. Atrial fibrillation is a common cardiac arrhythmia that has implications for both patients and partners. A couple's illness beliefs play an important role in convalescence and illness management, and no previous studies have explored illness beliefs in couples living with atrial fibrillation.

DESIGN

A qualitative hermeneutic design.

METHODS

Data collection constituted in-depth interviews with nine couples (patient and partner together). Hermeneutic philosophy as described by Gadamer was used to interpret and to understand illness beliefs in couples living with atrial fibrillation.

RESULTS

The findings revealed both core illness beliefs and secondary illness beliefs. From the core illness belief 'The heart is a representation of life', two secondary illness beliefs were derived: atrial fibrillation is a threat to life and atrial fibrillation can and must be explained. From the core illness belief 'Change is an integral part of life', two secondary illness beliefs were derived: atrial fibrillation is a disruption in our lives and atrial fibrillation will not interfere with our lives. Finally, from the core illness belief 'Adaptation is fundamental in life', two secondary illness beliefs were derived: atrial fibrillation entails adjustment in daily life and atrial fibrillation entails confidence in and adherence to professional care.

CONCLUSION

Couples' interaction has developed mutual illness beliefs regarding atrial fibrillation that guide them in their daily lives and influence their decisions. The adoption of a family-centred perspective in cardiovascular care settings is warranted.

'What else can I do?': Insights from atrial fibrillation patient communication online

BACKGROUND

Many patients with atrial fibrillation experience uncertainty and psychological distress. Internet support groups for atrial fibrillation have yet to be studied.

AIM

To determine the content and dialogue on an online message board for atrial fibrillation with the purpose of elucidating information and support needs from patient perspectives.

METHODS

Interpretative description methodology was undertaken to explore conversation from a publicly available website for atrial fibrillation over a 3-month period.

RESULTS

Individuals interacted with the message board to make sense of their atrial fibrillation events by sharing experiences with medications, complementary and alternative medicine, trigger avoidance and ablation. The opinions of lay experts on the message board, anecdotal stories and hyperlinked Internet data were all highly valued sources of information in the messages. Using the learning gained from the board, individuals proceeded with strategies to treat their atrial fibrillation, often in a trial and error fashion. Throughout the process, individuals came back to the board, to update on their progress and gain assistance from others.

CONCLUSION

The studied atrial fibrillation population had unmet needs for education regarding non-pharmacological approaches to treat atrial fibrillation. In the absence of opportunity to discuss these needs with healthcare professionals, patients may be vulnerable to unproved approaches advocated by Internet peers. Further research is suggested to examine the prevalence of complementary and alternative medicine use in the atrial fibrillation population and to understand better how social media can be utilised to support atrial fibrillation patients.

Associations of Emotional Distress and Perceived Health in Persons With Atrial Fibrillation and Their Partners Using the Actor-Partner Interdependence Model

Individual behavior affects and is affected by other people. The aim of this study was to examine if emotional distress in patients with atrial fibrillation (AF) and their spouses was associated with their own and their partner's perceived health. Participants included 91 dyads of patients and their spouses. Emotional distress was measured using the Hospital Anxiety and Depression Scale and perceived health was measured with the Short Form 36 Health Survey. The Actor-Partner Interdependence Model was used for dyad-level analyses of associations, using structural equation modeling. Higher levels of anxiety and depression were associated with lower levels of perceived health in patients and spouses. Higher levels of depression in patients were associated with lower levels of vitality in spouses and vice versa. As AF patients and their spouses influence each other, health-care interventions should consider the dyad to address dyadic dynamics. This may benefit the health of the individual patient and of the couple.

Effectiveness of structured, hospital-based, nurse-led atrial fibrillation clinics: a comparison between a real-world population and a clinical trial population

Objective

A previous randomised trial showed that structured, nurse-led atrial fibrillation (AF) care is superior to conventional AF care, although further research is needed to determine the outcomes of such care in a real-world setting. We compared the outcomes of patients in real-world, nurse-led, structured hospital AF clinics with the outcomes of a randomised trial of the efficacy of a nurse-led AF clinic, with respect to a composite outcome of cardiovascular-related hospitalisation and death.

Methods

All patients were referred to the AF nurse specialist by cardiologists. The AF nurse specialist provided patient education, risk-factor control and stimulated empowerment and compliance. During follow-up, treatment was adjusted according to clinical guidelines. Patient education was repeated, and compliance with medical treatment was controlled. The study size was powered as a non-inferiority study. Outcome measures were adjudicated by the same principles in both cohorts.

Results

A total of 596 patients from the real world and 356 patients from a clinical trial were included in this study. No significant difference between groups with respect to age, type of AF or CHA₂DS₂VASc score was found. The composite primary end point occurred with an incidence rate of 8.0 (95% CI 6.1 to 10.4) per 100 person-years in the real-world population and 8.3 (95% CI 6.3 to 10.9) per 100 person-years in the clinical trial, with a crude HR of 0.83 (95% CI 0.56 to 1.23).

Conclusions

Structured, nurse-led, hospital-based AF care appears to be effective, and patient outcomes in an actual, hospital-based, structured AF care are as least as good as those in trial settings.

Illness perceptions and coping in physical health conditions: A meta-analysis

OBJECTIVE

There is a considerable body of research linking elements of Leventhal's Common Sense Model (CSM) to emotional well-being/distress outcomes among people with physical illness. The present study aims to consolidate this literature and examine the evidence for the role of coping strategies within this literature.

METHODS

A systematic review was conducted where the outcomes of interest were: depression, anxiety and quality of life. A total of 1050 articles were identified and 31 articles were considered eligible to be included in the review.

RESULTS

Across a range of illnesses, perceptions of consequences of the illness and emotional representations were consistently the illness perceptions with the strongest relationship with the outcomes. Coping variables tend to be stronger predictors of outcomes than the illness perception variables. The evidence for the mediating effect of coping was inconsistent.

CONCLUSIONS

Illness perceptions and coping have an important role to play in the explanation of distress outcomes across a range of physical health conditions. However, some clarity about the theoretical position of coping in relation to illness perceptions, and further longitudinal work is needed if we are to apply this information to the design of interventions for the improvement of psychological health among people with physical health conditions.

The Association between Job Strain and Atrial Fibrillation: Results from the Swedish WOLF Study

Introduction. Atrial fibrillation (AF) is a common heart rhythm disorder. Several life-style factors have been identified as risk factors for AF, but less is known about the impact of work-related stress. This study aims to evaluate the association between work-related stress, defined as job strain, and risk of AF. Methods. Data from the Swedish WOLF study was used, comprising 10,121 working men and women. Job strain was measured by the demand-control model. Information on incident AF was derived from national registers. Cox proportional hazard regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between job strain and AF risk. Results. In total, 253 incident AF cases were identified during a total follow-up time of 132,387 person-years. Job strain was associated with AF risk in a time-dependent manner, with stronger association after 10.7 years of follow-up (HR 1.93, 95% CI 1.10–3.36 after 10.7 years, versus HR 1.11, 95% CI 0.67–1.83 before 10.7 years). The results pointed towards a dose-response relationship when taking accumulated exposure to job strain over time into account. Conclusion. This study provides support to the hypothesis that work-related stress defined as job strain is linked to an increased risk of AF.

The Stressors and Coping Strategies of Older Adults With Persistent Atrial Fibrillation Prior to and Following Direct Current Cardioversion

Objective:The purpose of this study was to explore the stressors and coping strategies of older adults with persistent atrial fibrillation (AF) before and after direct current cardioversion. Method: The study used a qualitative descriptive design. Sixteen patients were recruited through an AF clinic to participate in individual interviews prior to the cardioversion and at 6 and 12 weeks post procedure. Results: Pre-cardioversion, older adults experienced symptom and health care–related stressors superimposed on existing non-AF stressors. They used a range of emotion and problem-focused coping. Non-AF stressors increased post procedure at the same time that participants perceived less need for coping strategies with a return to regular rhythm. Discussion: There was a shift from AF to non-AF related stressors following the cardioversion but a decrease in coping strategies. Older adults with AF should be encouraged to maintain use of coping strategies to manage ongoing stress and reduce the risk of AF recurrence.

Managing uncertainty in couples living with atrial fibrillation

BACKGROUND

Living with a chronic disease such as atrial fibrillation (AF) not only affects the patient but also has implications for the partner. There is a lack of research on couples living with AF and, in particular, how they experience and deal with the disease.

OBJECTIVE

The aim of this study was to explore couples' main concerns when one of the spouses is afflicted with AF and how they continually handle it within their partner relationship.

METHODS

Classical grounded theory was used throughout the study for data collection and analysis. Interviews were conducted with 12 couples (patient and partner together). There were follow-up interviews with 2 patients and 2 partners separately.

RESULTS

Couples living with AF experience uncertainty as a common main concern. This uncertainty was fundamentally rooted in not knowing the cause of AF and apprehension about AF episodes. Couples managed this uncertainty by either explicitly sharing concerns related to AF or through implicitly sharing their concerns. Explicit sharing incorporated strategies of mutual collaboration and finding resemblance, whereas implicit sharing incorporated strategies of keeping distance and tacit understanding. Time since diagnosis and time being symptom-free were factors influencing afflicted couples' shifting between implicit and explicit sharing.

CONCLUSIONS

Atrial fibrillation affects the partner relationship by bringing uncertainty into couples' daily lives. Even though this study shares similarities with previous studies on couples living with chronic disease, it contributes to the existing knowledge by presenting a set of strategies used by couples in managing uncertainty when living with AF.

Patients' experiences from symptom onset to initial treatment for atrial fibrillation

AIMS AND OBJECTIVES

To describe patients' experiences from symptom onset to initial treatment for atrial fibrillation.

BACKGROUND

The estimated number of individuals with atrial fibrillation globally in 2010 was 33·5 million. World-wide, each year, new cases of atrial fibrillation approach 5 million, and prevalence will increase 2·5-fold by 2050. As a result, clinicians worldwide will treat a growing number of patients with atrial fibrillation. Early intervention to promote atrial fibrillation self-management is critical to reduce associated complications of stroke and heart failure. Greater understanding of patients' experiences from symptom onset to initial treatment for atrial fibrillation is needed to guide development of interventions to promote early effective self-management.

DESIGN

A descriptive qualitative design was used.

METHODS

Twenty females and 21 males at an academic medical centre were interviewed using open-ended questions to explore their experiences from symptom onset to initial treatment for atrial fibrillation. Data were analysed using qualitative content analysis.

RESULTS

Participants' mean age was 64·3 (SD = 10·1) years. Four themes were identified: (1) misinterpreting symptoms; (2) discovering the meaning of atrial fibrillation; (3) facing fears, uncertainty, and moving to acceptance; and (4) receiving validation and reassurance. Participants lacked knowledge of atrial fibrillation and took cues from providers' responses to appraise symptoms and diagnosis. Fear and uncertainty were reduced when providers initiated prompt treatment and took time to explain atrial fibrillation. Patients appreciated receiving clear information about atrial fibrillation, were engaged in learning, and motivated to participate in their care.

CONCLUSIONS

Providers played a critical role in helping patients to develop an accurate understanding of atrial fibrillation, to cope with the new diagnosis, and motivated them to engage in effective self-management.

RELEVANCE TO CLINICAL PRACTICE

Insight into participant experiences from symptom onset to initial treatment for atrial fibrillation may inform development of interventions to promote effective atrial fibrillation self-management.

The well-being of relatives of patients with atrial fibrillation: a critical incident technique analysis

Background:

The well-being of relatives of patients having chronic heart diseases (CHD) has been found to be negatively affected by the patient’s condition. Studies examining relatives of patients with atrial fibrillation (AF) indicate that their well-being may be affected in a similar manner, but further research is needed.

Aim:

To explore and describe critical incidents in which relatives of patients experience how AF affects their well-being and what actions they take to handle these situations. Design and method: An explorative, descriptive design based on the critical incident technique (CIT) was used. Interviews were conducted with 19 relatives (14 women and five men) of patients hospitalised in southern Sweden due to acute symptoms of the AF.

Results:

The well-being of relatives was found to be affected by their worries (patient-related health), as well as the sacri-ficing of their own needs (self-related health). In handling their own well-being, these relatives adjusted to and supported the patient (practical involvement), along with adjusting their own feelings and responding to the mood of the patients (emotional involvement).

Conclusion:

The well-being of relatives of patients with AF was affected depending on the patients’ well-being. In their attempt to handle their own well-being, the relatives adjusted to and supported the patients. Further research is needed in order to evaluate the effects of support to relatives and patients respectively and together.

The effect of a telephone follow-up intervention on illness perception and lifestyle after myocardial infarction in China: a randomized controlled trial

BACKGROUND

Lifestyle modification is an integral component of cardiac secondary prevention, while it has been confirmed that myocardial infarction (MI) patients' health-related behaviors are heavily influenced by their illness perception.

OBJECTIVES

To evaluate the effect of a telephone follow-up intervention for improving MI patients' illness perception and lifestyle.

DESIGN

A randomized controlled trial, longitudinal research design was employed.

SETTINGS

Cardiac care units in four major general hospitals in Guangzhou, China.

PARTICIPANTS

Inclusion criteria were being diagnosed with an initial acute MI, being able to communicate orally in Mandarin or Cantonese and read in Chinese, and living in Guangzhou. Exclusion criteria were with continuing uncontrolled arrhythmias or heart failure, being illiteracy, or with a history of major psychiatric illness, exercise-induced asthma, uncontrolled diabetes, or evidence of dementia.

METHOD

124 patients admitted with the first acute MI were randomized to receive either routine care or routine care plus a telephone follow-up intervention, which consist of a pre-discharge education and three telephone follow-up instructions. Data were collected before discharge, at the 6th and the 12th week after discharge from hospital, respectively.

RESULTS

At the 6th and the 12th week after discharge, patients in the intervention group had significantly positive perceptions about symptoms of MI (mean difference 3.27, 95% confidence interval 2.48-4.07, p<.001; mean difference 2.12, 95% confidence interval 1.34-2.89, p<.001 respectively) and how long their illness would last (mean difference -0.69, 95% confidence interval -0.91 to -0.47, p<.001; mean difference -0.74, 95% confidence interval -0.96 to -0.51, p<.001 respectively) compared with the control group. The intervention group also had more positive beliefs about the controllability (F=4.23, p=.04) and more improved beliefs about the causes of MI than the control group. Moreover, the intervention improved the patients' nutrition (F=5.16, p=.03) and physical activity at the 12-week follow-up (mean difference 0.37, 95% confidence interval 0.17-0.58, p<.001).

CONCLUSION

This telephone follow-up intervention can result in improved illness perception and lifestyle after MI. It could be incorporated into current hospital treatment regimens for MI to improve patients' quality of life.

A systematic review of depression and anxiety in patients with atrial fibrillation: the mind-heart link

Atrial fibrillation (AF) is the most commonly seen arrhythmia in clinical practice. At present, few studies have been conducted centering on depression and anxiety in AF patients. Our aim in this systematic review is to use the relevant literature to (1) describe the prevalence of depression and anxiety in AF patients, (2) assess the impact that depression and anxiety have on illness perception in patients with AF, (3) provide evidence to support a hypothetical connection between the pathophysiology of AF and depression and anxiety, (4) evaluate the benefit of treatment of AF on depression and anxiety, and (5) give insight on medically managing a patient with AF and concomitant depression and anxiety.

Illness perceptions of adults with congenital heart disease and their predictive value for quality of life two years later

BACKGROUND

To improve patients' quality of life (QoL) we need to identify modifiable determinants, such as illness perceptions. Patients' illness perceptions are known to regulate emotional responses and health-behaviour. Illness perceptions comprise several components: consequences, control, coherence, changeability and emotional representations.

AIMS

To examine (a) the relation between patient characteristics and illness perceptions, and (b) the independent predictive value of illness perceptions for future QoL.

METHODS

A longitudinal study in 845 patients with congenital heart disease was conducted. Patients completed three questionnaires: the IPQ-R (illness perceptions) and two years later the SF-36 and TAAQOL-CHD (QoL). Linear regression analyses were performed relating illness perceptions to patient characteristics (sex, age, disease complexity and functional status) and QoL.

RESULTS

Patients with a complex defect or poor functional status reported poor illness perceptions. Independent of patient characteristics, poor illness perceptions (i.e. a strong belief that the illness has severe consequences; a weak belief that you have a coherent illness understanding and that the illness can be controlled by treatment; and a strong belief that the illness is changeable and causes negative emotions) were predictive of future QoL.

CONCLUSION

Illness perceptions independently predict QoL, suggesting that QoL may be improved by altering patients' beliefs about their illness. For example, increasing patients' knowledge regarding their disease and informing them about treatment opportunities may enhance their QoL.