Association of sex and atrial fibrillation therapies with patient-reported outcomes

Stroke risk in women with atrial fibrillation

BACKGROUND AND AIMS

Female sex is associated with higher rates of stroke in atrial fibrillation (AF) after adjustment for other CHA2DS2-VASc factors. This study aimed to describe sex differences in age and cardiovascular care to examine their relationship with stroke hazard in AF.

METHODS

Population-based cohort study using administrative datasets of people aged ≥66 years diagnosed with AF in Ontario between 2007 and 2019. Cause-specific hazard regression was used to estimate the adjusted hazard ratio (HR) for stroke associated with female sex over a 2-year follow-up. Model 1 included CHA2DS2-VASc factors, with age modelled as 66-74 vs. ≥ 75 years. Model 2 treated age as a continuous variable and included an age-sex interaction term. Model 3 further accounted for multimorbidity and markers of cardiovascular care.

RESULTS

The cohort consisted of 354 254 individuals with AF (median age 78 years, 49.2% female). Females were more likely to be diagnosed in emergency departments and less likely to receive cardiologist assessments, statins, or LDL-C testing, with higher LDL-C levels among females than males. In Model 1, the adjusted HR for stroke associated with female sex was 1.27 (95% confidence interval 1.21-1.32). Model 2 revealed a significant age-sex interaction, such that female sex was only associated with increased stroke hazard at age >70 years. Adjusting for markers of cardiovascular care and multimorbidity further decreased the HR, so that female sex was not associated with increased stroke hazard at age ≤80 years.

CONCLUSION

Older age and inequities in cardiovascular care may partly explain higher stroke rates in females with AF.

Generalized anxiety is a predictor of impaired quality of life in patients with atrial fibrillation: Findings from the prospective observational ARENA study

OBJECTIVE

Atrial fibrillation (AF) is associated with impaired health-related quality of life (HRQoL), an increased risk of morbidity, and mortality. Traditional AF-related outcomes (e.g., AF recurrence) primarily demonstrate the physiological benefits of AF management but do not focus on the benefits experienced subjectively by the patient (i.e., patient-reported outcomes), which have been suggested as optimal endpoints in AF intervention studies. The aim of this study is to identify medical and psychological factors associated with impaired HRQoL at 1-year follow-up.

METHODS

Using data from the prospective observational multicenter ARENA study in patients with AF, we analyzed associations between medical factors, anxiety, and HRQoL at 1-year follow-up assessed using 5-level EuroQoL-5D.

RESULTS

In 1353 AF patients (mean age 71.4 ± 10.3 years, 33.8% female), none of the medical predictors (e.g., heart disease) or history of cardioversion were associated with HRQoL at the 1-year follow-up. Higher generalized anxiety (β = -0.114, p < .001) but not cardiac anxiety (β = -0.006, p = .809) at baseline predicted decreased HRQoL, independent of confounding variables and patients' medical status. Furthermore, the worsening of patients' generalized anxiety was associated with decreased HRQoL (ß = -0.091, p < .001). In contrast, the improvement of generalized anxiety over time predicted higher HRQoL (ß = 0.097, p < .001). Finally, the worsening of patients' cardiac anxiety over time was associated with decreased HRQoL (ß = -0.081, p < .001).

CONCLUSION

Our results highlight the importance of anxiety as a predictor of future HRQoL in patients with AF. Additional studies to examine the impact of anxiety treatment on HRQoL in this population are needed.

CLINICAL TRIAL REGISTRATION

The investigators registered on ClinicalTrials.gov (NCT02978248) on November 30, 2016 https://clinicaltrials.gov/ct2/show/NCT02978248.

Gender-Based Clinical, Therapeutic Strategies and Prognosis Differences in Atrial Fibrillation

BACKGROUND

There are limited data on gender-based differences in atrial fibrillation (AF) treatment and prognosis. We aimed to examine gender-related differences in medical attention in an emergency department (ED) and follow-up (FU) among patients diagnosed with an AF episode and to determine whether there are gender-related differences in clinical characteristics, therapeutic strategies, and long-term adverse events in this population.

METHODS

We performed a retrospective observational study of patients who presented to a tertiary hospital ER for AF from 2010 to 2015, with a minimum FU of one year. Data on medical attention received, mortality, and other adverse outcomes were collected and analyzed.

RESULTS

Among the 2013 patients selected, 1232 (60%) were female. Women were less likely than men to be evaluated by a cardiologist during the ED visit (11.5% vs. 16.6%, p = 0.001) and were less likely to be admitted (5.9% vs. 9.5%, p < 0.05). Electrical cardioversion was performed more frequently in men, both during the first episode (3.4% vs. 1.2%, p = 0.001) and during FU (15.9% vs. 10.6%, p < 0.001), despite a lower AF recurrence rate in women (9.9% vs. 18.1%). During FU, women had more hospitalizations for heart failure (26.2% vs. 16.1%, p < 0.001).

CONCLUSIONS

In patients with AF, although there were no gender differences in mortality, there were significant differences in clinical outcomes, medical attention received, and therapeutic strategies. Women underwent fewer attempts at cardioversion, had a lower probability of being evaluated by cardiologists, and showed a higher probability of hospitalization for heart failure. Being alert to these inequities should facilitate the adoption of measures to correct them.

Sex Differences in Atrial Fibrillation

PURPOSE OF REVIEW

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The estimated lifetime risk of developing AF is higher in men; however, due to differences in life expectancy, the overall prevalence is higher among women, particularly in the older age group. Sex differences play an important role in the pathophysiology, presentation, and clinical outcomes of AF. Awareness of these differences minimizes the potential for disparities in AF management. Our review summarizes the current literature on sex differences in AF, including the epidemiology, pathophysiology, risk factors, clinical symptomatology, mechanisms, treatment, and outcomes. We also explore the implications of these differences for clinical practice and future research.

RECENT FINDINGS

Women are more likely to present with atypical symptoms, have a higher stroke risk, and have a worse quality of life with AF when compared to men. Despite this, they are less likely to receive rhythm control strategies and anticoagulants. The sex-based differences in AF pathology and management might be a combination of inherent biological and hormonal differences, and implicit bias of the research entities and treating clinicians. Our review stresses the need for further sex-specific research in the pathophysiology of AF and opens a dialogue on personalized medicine, where management strategies can be tailored to individual patient characteristics, including sex.

Review: Sex-related differences in the treatment of cardiac arrhythmia

Cardiac arrhythmias are a common and potentially serious cardiovascular disorders that affect both men and women. However, there is evidence to suggest that there may be sex-related differences in the prevalence, clinical presentation, and management of cardiac arrhythmias. Hormonal and cellular factors may play a role in these sex-specific differences. In addition, there are differences in the types of arrhythmias that men and women experience, with men more likely to experience ventricular arrhythmias and women more likely to experience supraventricular arrhythmias. The management of cardiac arrhythmias also differs between men and women. For example, some studies have found that women are less likely to receive appropriate treatment for arrhythmias and are more likely to have adverse outcomes following treatment. Despite these sex-related differences, the majority of research on cardiac arrhythmias has been conducted in men, and there is a need for more research to specifically examine the differences between men and women. This is especially important given that the prevalence of cardiac arrhythmia is increasing, and it is essential to understand how to effectively diagnose and treat these conditions in both men and women. In this review, we examine the current understanding of sex-related differences in cardiac arrhythmias. We also review the available data on sex-specific management strategies for cardiac arrhythmias and highlight areas of future research.

Poststroke Disability: Association Between Sex and Patient-Reported Outcomes

BACKGROUND

Ischemic stroke (IS) is a leading cause of long-term disability with sex-specific differences in outcomes. Identifying the influential factors that contribute to sex-specific disparities in stroke outcomes, therefore, holds potential to develop individualized interventions for reducing long-term disability. Further, investigating the association between sex and Patient-Reported Outcome Measures (PROMs) provides additional information on the individual impact and heterogeneity of IS. We aimed to identify sex-specific differences in stroke outcomes and relationship with PROMs in IS patients with 3-month follow-up.

METHODS

Between February 2017 and February 2020, a total of 410 patients admitted with IS to the Massachusetts General Hospital, in Boston, were enrolled in this prospective cohort. At 3-month poststroke, patients were assessed for Barthel Index, modified Rankin Scale, and PROM-10 questionnaires. T scores for physical and mental health were determined from the summing of PROM-10 responses in each domain. Regression analysis was performed to identify sex-specific determinants of functional and patient-reported outcomes.

RESULTS

At baseline, 242 participants were male (mean age, 65 years) and 168 were female (mean age, 70 years). Groups had similar rates of cardiovascular risk factors, admission National Institutes of Health Stroke Scale, and discharge modified Rankin Scale. At follow-up, male participants were more likely to have better rates of T Physical and Barthel Index. In regression analysis, PROMs T Physical (odds ratio, 1.06; P=0.01), Barthel Index (odds ratio, 1.06; P=0.01), and modified Rankin Scale score of ≥2 (odds ratio, 2.60; P=0.01) were associated with female sex. Female sex was also associated with lower scores for PROMs Physical subcomponents and with patient-reported general health and emotional problems.

CONCLUSIONS

Women have worse outcomes after ischemic stroke, including objective measures of functional disability and patient-reported outcomes. Incorporating PROMs into IS outcome measures may offer additional insight into sex-specific differences in stroke recovery and outcomes.

Gender, ethnic, and socioeconomic differences in access to catheter ablation therapy in patients with atrial fibrillation

Introduction

Female patients, patients from racial minorities, and patient with low socioeconomic status have been noted to have less access to catheter ablation for atrial fibrillation.

Methods

This is a cross-sectional, retrospective study using a large population database (Explorys) to evaluate the gender, racial and socioeconomic differences in access of catheter ablation therapy in patient with atrial fibrillation.

Results

A total of 2.2 million patients were identified as having atrial fibrillation and 62,760 underwent ablation. Females had ablation in 2.1% of cases while males received ablation in 3.4% of cases. Caucasians had ablation in 3.3% of cases, African Americans in 1.5% of cases and other minorities in 1.2% of cases. Individuals on medicaid underwent ablation in 1.6% of cases, individuals on medicare and private insurance had higher rates (2.8 and 2.9%, respectively). Logistic regression showed that female patients (OR 0.608, CI 0.597-0.618, p < 0.0001), patients who are African American (OR 0.483, CI 0.465-0.502, p < 0.0001), or from other racial minorities (OR 0.343, CI 0.332-0.355, p < 0.0001) were less likely to undergo ablation. Patient with medicare (OR 1.444, CI 1.37-1.522, p < 0.0001) and private insurance (OR 1.572, CI 1.491-1.658, p < 0.0001) were more likely to undergo ablation.

Conclusion

Female gender, racial minorities, low socioeconomic status are all associated with lower rates of catheter ablation in management of atrial fibrillation.

Quality of life and mental health of women who had cardiac disease in pregnancy and postpartum

Purpose

Cardiac disease is a leading cause of maternal morbidity and mortality yet there is limited research on women’s experiences and quality of life (QoL) outcomes. The aim of this study is to explore the general and health-related QoL (HRQoL) and mental health outcomes for women who have experienced cardiac disease in pregnancy and the first 12 months postpartum (CDPP).

Methods

This exploratory descriptive study recruited 43 women with acquired, genetic and congenital CDPP. Patient reported outcomes measures (PROMs) used were: WHOQoL-Bref, a Kansas City Cardiac Questionnaire (KCCQ), the Depression, Anxiety and Stress Scales-21 (DASS-21), the Cardiac Anxiety Questionnaire (CAQ) plus newly developed questions.

Results

Women reported low health satisfaction (51.7/100), physical health (55.2/100) and low HRQoL (63.1/100). Women had clinically significant scores for depression (24%), anxiety (22%) and stress (19.5%) (DASS-21) and 44.5% scored at least moderate anxiety on the CAQ. Most women (83.7%) were advised to avoid pregnancy which 88.9% found “upsetting” to “devastating”; 10.0% were offered counselling. Most women were concerned about reduced longevity (88.1%), offspring developing a cardiac condition (73.8%), and the limitations on enjoyment of life (57.1%). Women missed medical appointments due to cost (25.03%) and difficulty arranging childcare (45.5%).

Conclusion

The majority of women reported inadequate information and counselling support, with women with CDPP having sustained impaired QoL and mental health outcomes. The new and modified questions relating to mothering and children reflected the primacy of mothering to women’s identity and needs.

Supplementary information

The online version contains supplementary material available at 10.1186/s12884-022-05123-x.

Reflections on the usefulness of today's atrial fibrillation ablation procedure endpoints and patient-reported outcomes

The improvement of Patient-reported outcomes, such as health-related quality of life, is the main indication for atrial fibrillation ablation. Despite this guideline derived indication for an AF ablation procedure the current standardized primary endpoint in AF ablation trials is still rhythm-related, and primarily a 30-second long AF episode. The review presents reflections on the non-rational arguments of using rhythm related endpoints rather than Patient-reported outcomes in AF ablation procedure trials despite the mismatch between many of the rhythm related variables and symptoms. Arguments for health-related quality of life as the most optimal primary endpoint in clinical trials are presented while atrial fibrillation burden is presented as the most optimal electrical complementary endpoint, apart from being the major variable in mechanistic trials.

Fear of Recurrence of Atrial Fibrillation: Translating a Cancer Fear Model to the Atrial Fibrillation Patient Experience

BACKGROUND

Atrial fibrillation occurs when rapid and disorganized electrical signals cause the atria in the heart to beat irregularly and is associated with an increased risk for stroke. Despite medical advancements, first and second line atrial fibrillation treatments exhibit significant recurrence rates. Because of this, atrial fibrillation patients often experience disease-specific fears that are not routinely assessed and targeted in clinical management. Fear of recurrence models in cancer research and other cardiac-specific fears have paved the way for a patient-centric approach to disease intervention.

PURPOSE

Clinical assessment focused solely on the taxonomy of anxiety disorders may miss key components unique to the atrial fibrillation patient experience. An anxiety disorder diagnosis in the presence of an arrhythmia could be misleading and ultimately fail to address patient needs. Modeled from the cancer literature, providers may benefit from a broader disease specific conceptualization for AF patients that differs from a general DSM-5 diagnosis.

AIMS

The objectives of this paper are: (1) to review the medical aspects of atrial fibrillation, (2) to examine the comparability of fear of recurrence concept from cancer literature to the atrial fibrillation patient, and (3) to suggest considerations of these novel concepts in patient care.

FUTURE DIRECTIONS

Increased understanding of fear of recurrence among atrial fibrillation patients aims to define and assess fear of recurrence components, determine treatment targets, and ultimately improve patient outcomes.

Impact of Catheter Ablation on Quality of Life and Healthcare Utilisation

Impairment of quality of life (QoL) is a well-known complication of AF. Because of the association of AF with older age and many other cardiovascular comorbidities, there are multiple factors that could influence QoL score even after successful AF intervention. However, substantial improvement in QoL has been reported following catheter ablation for AF regardless of ablation outcomes. In terms of healthcare resource utilisation, the expenses associated with AF are very high because of the hospitalisations for AF-related thromboembolic complications, aggravation of heart failure, AF interventions, and emergency room visits for incessant arrhythmia episodes, and they represent a large economic burden worldwide. Several trials have shown a drastic reduction in healthcare costs following successful AF ablation. In this review, the authors discuss this evidence systematically.

Sex differences in atrial fibrillation: patient-reported outcomes and the persistent toll on women

Patient-reported outcomes (PRO) in atrial fibrillation (AF) differ by sex.

We compared general and disease-specific PRO in women and men with AF.

Comorbidity, treatment, and social factors did not change differences.

Modification of such factors by sex also did not change differences in PRO.

Sex-specific assessment of PRO is essential to improve how women experience AF.

Background

Women have worse patient-reported outcomes in atrial fibrillation (AF) than men, but the reasons remain poorly understood. We investigated how comorbid conditions, treatment, social factors, and their modification by sex would attenuate sex-specific differences in patient-reported outcomes in AF.

Methods

In a cohort with prevalent AF we measured patient-reported outcomes with the Short-Form-12 (SF-12, an 8-domain quality of life measure), and the AF Effect on QualiTy of Life (AFEQT), an instrument specific to AF, both with range 0-100 and higher scores indicating superior outcomes. We examined sex-specific differences in patient-reported outcomes in multivariable-adjusted regression analyses incorporating demographics, comorbid conditions, treatment, social factors, and their sex-based modification.

Results

In 339 individuals (age 72±10, 45% women), women (vs. men) reported worse physical functioning on the SF-12 (49.7±39.0 versus 65.0±34.0), social functioning (69.8±31.8 versus 79.7±25.8), and mental health (67.4±20.2 versus 75.0±18.6). These differences were attenuated with adjustment for comorbid conditions and depression. Women had worse composite AFEQT scores (73.8±18.4 versus 78.5±16.6) and symptoms and treatment scores than men with differences remaining significant after multivariable adjustment. There were not significant interactions by sex and the array of covariates when examining differences in patient-reported outcomes between women and men.

Conclusions

We identified sex-specific differences in patient-reported outcomes assessed with general and AF-specific measures. Compared to men, women with AF reported worse overall health-related quality of life, even after consideration of both relevant covariates and their modification by sex. Our research indicates the importance of consideration of sex-based inequities when evaluating patient-reported outcomes in AF.

Racial and Sex Disparities in Anticoagulation After Electrical Cardioversion for Atrial Fibrillation and Flutter

Background Anticoagulation is indicated for 4 weeks after cardioversion in patients with atrial fibrillation/flutter. We sought to examine whether there is evidence of sex or racial disparity in anticoagulant prescription following cardioversion, and whether postcardioversion anticoagulation affects outcomes. Methods and Results We identified a representative sample of Medicare patients who underwent elective electric cardioversion in an outpatient setting from 2015 to 2017. We identified patients who had an anticoagulant prescription for 3 months after the cardioversion date. Multivariable logistic regression was used to assess factors associated with a prescription of an anticoagulant after cardioversion. Cox regression analysis was used to test association of anticoagulation with a composite end point of 90-day mortality, ischemic stroke, or arterial embolism. The final study cohort included 7860 patients. Overall, 5510 patients (70.1%) received any anticoagulation following cardioversion, while 2350 (29.9%) did not. Patients who did not receive anticoagulation were younger, with a lower burden of most comorbidities. Patients were less likely to receive anticoagulation if they had dementia or atrial flutter, while patients with valvular heart disease, obesity, heart failure, peripheral vascular or coronary disease, or hypertension were more likely to receive anticoagulation. Female sex (adjusted odds ratio, 0.84; 95% CI, 0.75-0.92; P<0.001), Black and Hispanic race (adjusted odds ratio, 0.50; 95% CI, 0.38-0.65; and odds ratio, 0.56; 95% CI, 0.41-0.75, respectively; P<0.001) were independently associated with lower probability of anticoagulant prescription. Postcardioversion anticoagulation was associated with lower risk of the composite end point (adjusted hazard ratio, 0.38; 95% CI, 0.27-0.52; P<0.001). Conclusions Racial and sex disparities exist in anticoagulant prescription after outpatient elective cardioversion for atrial fibrillation.

Factors Influencing Sex-Related Differences in the Quality of Life of Patients With Atrial Fibrillation: A Systematic Review

Atrial fibrillation (AF) is a growing public health concern, the impact of which is frequently underestimated. It has a profound effect on the quality of life (QoL) which appears to be disproportionately lower in female patients compared to men. We aim to explore the factors contributing to sex-related disparities in the QoL of AF patients by conducting a systematic review using the PubMed electronic search database. We used the following combination of medical subject heading (MeSH) parameters: “atrial fibrillation” and “sex” and “quality of life” with specific inclusion and exclusion criteria. We identified 13 relevant studies published between 2010 and 2020 for our review. These studies evaluated sex-related differences in QoL scores, symptom burden, and AF-related complications originating across different continents in Asia, Europe, and North America. We found that female patients reported a reduced QoL as compared to men and they were more likely to be older with multiple co-morbidities at presentation. Women also reported more frequent and severe symptoms, potentially explained by the greater prevalence of anxiety and depression and thus enhancing symptom perception. Moreover, they were less likely to be managed by anti-arrhythmic medications and invasive rhythm control strategies such as catheter ablation. Female patients with AF experienced more severe strokes, but no sex disparities were found in AF-related cognitive decline. We determined that the more prominent contributory factors towards a lowered QoL in female AF patients appear to be secondary to a higher burden and perception of symptoms as well as under-utilization of invasive treatment modalities. However, further studies are warranted to confirm these findings.

Sex-specific and gender-specific aspects in patient-reported outcomes

Patient-reported outcomes (PROs) are important tools in patient-centred medicine and allow for individual assessment of symptom burden and aspects of patients’ quality of life. While sex and gender differences have emerged in preclinical and clinical medicine, these differences are not adequately represented in the development and use of patient-reported outcome measures. However, even in personalised approaches, undesirable biases may occur when samples are unbalanced for certain characteristics, such as sex or gender. This review summarises the current status of the literature and trends in PROs with a focus on sex and gender aspects.

Effectiveness and safety of atrial fibrillation ablation in females

BACKGROUND

Existing data on the effectiveness and safety of atrial fibrillation (AF) ablation in females are limited to studies of small sample size, lacking longer term follow-up or adjustment for potential confounders.

METHODS

A total of 6421 patients (2072 females) undergoing a first AF ablation procedure after enrollment in the Chinese Atrial Fibrillation Registry (China-AF) study between August 2011 and December 2017 were analyzed. We evaluated the effectiveness (recurrence of documented [symptomatic or not] atrial tachyarrhythmia (AT)) and the safety (incidence of procedure-related complications) of AF ablation in female patients compared to male patients. Sensitivity analyses based on routine data were also utilized to avoid potential sex differences in reporting of AF symptoms.

RESULTS

Females were about 5 years older than males at the time of ablation (mean age 63.4 ± 9.5 vs 58.3 ± 10.8, P < .0001). A higher proportion of female patients had paroxysmal AF (74.3% vs 56.7%, P < .0001), hypertension (69.7% vs 61.3%, P < .0001), and hyperlipidemia (57.2% vs 52.9%, P = .001). Female sex was found to be an independent risk factor of AT recurrence in multivariate analyses (HR = 1.26, 95% CI 1.15-1.38, P < .0001). These findings were confirmed in sensitivity analyses using only Holter data. Female sex was also associated with a higher risk of periprocedural complications after adjustment for baseline variables (OR = 1.41, 95% CI 1.03-1.94, P = .03).

CONCLUSIONS

Female sex is an independent risk factor of AT recurrence and periprocedural complications after AF ablation.

Gaps in patient-reported outcome measures in randomized clinical trials of cardiac catheter ablation: a systematic review

The aim of this systematic review was to evaluate randomized clinical trials (RCTs) of cardiac catheter ablation (CCA) and to assess the prevalence, characteristics and reporting standards of clinically relevant patient-reported outcome measures (PROMs). Electronic database searches of Medline, Embase, CENTRAL, and the WHO Trial Registry were conducted in March 2019. The study protocol was registered on PROSPERO (CRD42019133086). Of 7125 records identified, 237 RCTs were included for analysis, representing 35 427 patients with a mean age of 59 years. Only 43 RCTs (18%) reported PROMs of which 27 included a generic PROM that measured health-related quality of life (HRQL) necessary to conduct comparative effectiveness research. There was notable under-representation of certain patient groups—only 31% were women and only 8% were of non-Caucasian ethnicity, in trials which reported such data. The reporting standard of PROMs was highly variable with 8–62% adherence against CONSORT PRO-specific items. In summary, PROMs play a crucial role in determining the clinical and cost-effectiveness of treatments which primarily offer symptomatic improvement, such as CCA. Their underuse significantly limits evaluation of the comparative effectiveness of treatments. Using CCA as an exemplar, there are additional issues of infrequent assessment, poor reporting and under-representation of many population groups. Greater use of PROMs, and specifically validated HRQL questionnaires, is paramount in giving patients a voice in studies, generating more meaningful comparisons between treatments and driving better patient-centred clinical and policy-level decision-making.