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Wang FJ, Zhang C, Cai MM, Zhang JQ, Wang HX. Personal mastery and quality of life in patients with atrial fibrillation after radiofrequency ablation: The mediating role of health promoting behavior. Heart Lung 2024; 67:46-52. [PMID: 38657400 DOI: 10.1016/j.hrtlng.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Improving quality of life is vital for patients with atrial fibrillation (AF) after radiofrequency ablation. Quality of life can be affected not only by personal mastery but also by health promoting behavior as previously studied. However, it remains unclear whether health promoting behavior mediates the relationship between personal mastery and quality of life. OBJECTIVES To explore whether health promoting behavior mediates the relationship between personal mastery and quality of life in patients with AF after radiofrequency ablation. METHODS A cross-sectional design and convenience sampling were conducted at a tertiary hospital in China. Self-reported questionnaires were used to assess personal mastery, health promoting behavior and quality of life. SPSS and AMOS software were used for statistical analysis. RESULTS A total of 202 patients with AF after radiofrequency ablation were enrolled (mean age 58.28 ± 12.70 years). The scores for personal mastery and quality of life were 22.52 ± 2.53 points and 62.58 ± 8.59 points, respectively, indicating a limited level. The health promoting behavior exhibited a moderate level, with scores averaging 103.82 ± 8.47 points. There was a positive correlation between the three variables (all P < 0.05). Health promoting behavior played a partial mediating role in the relationship between personal mastery and quality of life in patients with AF after radiofrequency ablation, accounting for 44.79 % of the total effect. CONCLUSIONS In order to improve quality of life and prognosis, it is necessary to consider enhancing personal mastery and increasing patient compliance with health promoting behavior, which are important ways to improve their quality of life.
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Affiliation(s)
- Feng-Juan Wang
- School of Nursing, Lanzhou University, Lanzhou 730000, China
| | - Chun Zhang
- School of Nursing, Lanzhou University, Lanzhou 730000, China; Department of Cardiology, Lanzhou University Second Hospital, Lanzhou 730000, China.
| | - Min-Min Cai
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou 730000, China
| | - Jie-Qiong Zhang
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou 730000, China
| | - Hai-Xia Wang
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou 730000, China
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2
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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3
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Frausing MHJP, Van De Lande M, Linz D, Crijns HJGM, Tieleman RG, Hemels MEW, De Melis M, Schotten U, Kronborg MB, Nielsen JC, Van Gelder I, Rienstra M. Healthcare utilisation and quality of life according to atrial fibrillation burden, episode frequency and duration. Heart 2024; 110:1030-1039. [PMID: 38944418 PMCID: PMC11287643 DOI: 10.1136/heartjnl-2024-324016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 06/04/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND We aimed to evaluate the association between atrial fibrillation (AF) burden, duration and number of episodes with healthcare utilisation and quality of life in patients with early paroxysmal AF without a history of AF. METHODS In this observational cohort study, we included 417 patients with paroxysmal AF from the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling and Vascular destabilisation in the progression of AF (RACE V) Study. Patients were monitored with an insertable cardiac monitor for 1 year. Outcomes collected were healthcare utilisation, and quality of life assessed using the Atrial Fibrillation Severity Scale and EuroQol EQ-5D-5L questionnaires. RESULTS During 1 year of follow-up, 63 973 AF episodes were detected in 353 (85%) patients. The median AF burden was 0.7% (IQR 0.1-4.0%). AF ablation was performed more frequently in patients with intermediate-to-high AF burdens (>0.2%) (16.2% vs 5.9%, p=0.01) and longer AF episode duration (>1 hour) (15.8% vs 2.0%, p=0.01), whereas cardioversions were more frequent in patients with longer episode duration (>1 hour) (9.5% vs 0%, p=0.04) and intermediate (0.2-1.9%) (but not high) AF burdens (13.6% vs 4.2%, p=0.01). Patients with many episodes (>147) reported higher symptom severity (p=0.001). No differences in symptom severity nor in EQ-5D-5L scores according to AF burden or duration were observed. CONCLUSION In patients with early paroxysmal AF, higher AF burden and longer episode duration were associated with increased rates of healthcare utilisation but not with symptoms and quality of life. Patients with a higher number of episodes experienced more severe symptoms. TRIAL REGISTRATION NUMBER NCT02726698.
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Affiliation(s)
- Maria Hee Jung Park Frausing
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Martijn Van De Lande
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Dominik Linz
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Harry J G M Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Robert G Tieleman
- Department of Cardiology, Martini Hospital Groningen, Groningen, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Ziekenhuis Arnhem, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mirko De Melis
- Cardiovascular Diagnostics, Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mads Brix Kronborg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Jens C Nielsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Isabelle Van Gelder
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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4
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Walli-Attaei M, Little M, Luengo-Fernandez R, Gray A, Torbica A, Maggioni AP, Bairami F, Huculeci R, Aboyans V, Timmis AD, Vardas P, Leal J. Health-related quality of life and healthcare costs of symptoms and cardiovascular disease events in patients with atrial fibrillation: a longitudinal analysis of 27 countries from the EURObservational Research Programme on Atrial Fibrillation general long-term registry. Europace 2024; 26:euae146. [PMID: 38807488 PMCID: PMC11164571 DOI: 10.1093/europace/euae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/14/2024] [Indexed: 05/30/2024] Open
Abstract
AIMS We examine the effects of symptoms and cardiovascular disease (CVD) events on health-related quality of life (HRQOL) and healthcare costs in a European population with atrial fibrillation (AF). METHODS AND RESULTS In the EURObservational Research Programme on AF long-term general registry, AF patients from 250 centres in 27 European countries were enrolled and followed for 2 years. We used fixed effects models to estimate the association of symptoms and CVD events on HRQOL and annual healthcare costs. We found significant decrements in HRQOL in AF patients in whom ST-segment elevation myocardial infarction (STEMI) [-0.075 (95% confidence interval -0.144, -0.006)], angina or non-ST-elevation myocardial infarction (NSTEMI) [-0.037 (-0.071, -0.003)], new-onset/worsening heart failure [-0.064 (-0.088, -0.039)], bleeding events [-0.031 (-0.059, -0.003)], thromboembolic events [-0.071 (-0.115, -0.027)], mild symptoms [0.037 (-0.048, -0.026)], or severe/disabling symptoms [-0.090 (-0.108, -0.072)] occurred during the follow-up. During follow-up, annual healthcare costs were associated with an increase of €11 718 (€8497, €14 939) in patients with STEMI, €5823 (€4757, €6889) in patients with angina/NSTEMI, €3689 (€3219, €4158) in patients with new-onset or worsening heart failure, €3792 (€3315, €4270) in patients with bleeding events, and €3182 (€2483, €3881) in patients with thromboembolic events, compared with AF patients without these events. Healthcare costs were primarily driven by inpatient costs. There were no significant differences in HRQOL or healthcare resource use between EU regions or by sex. CONCLUSION Symptoms and CVD events are associated with a high burden on AF patients and healthcare systems throughout Europe.
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Affiliation(s)
- Marjan Walli-Attaei
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mathew Little
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ramon Luengo-Fernandez
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | | | - Firoozeh Bairami
- European Heart Agency, European Society of Cardiology, Brussels, Belgium
| | - Radu Huculeci
- European Heart Agency, European Society of Cardiology, Brussels, Belgium
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, EpiMaCT, Inserm1094/IRD270, Limoges University, Limoges, France
| | - Adam D Timmis
- William Harvey Research Institute, Queen Mary University London, London UK
| | - Panos Vardas
- Hygeia Hospitals Group, HHG, Biomedical Research Foundation Academy of Athens (BRFAA), Athens, Greece
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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5
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Noujaim C, Assaf A, Lim C, Feng H, Younes H, Mekhael M, Chouman N, Shamaileh G, El Hajjar AH, Ayoub T, Isakadze N, Chelu MG, Marrouche N, Donnellan E. Comprehensive atrial fibrillation burden and symptom reduction post-ablation: insights from DECAAF II. Europace 2024; 26:euae104. [PMID: 38646912 PMCID: PMC11077606 DOI: 10.1093/europace/euae104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/15/2024] [Indexed: 04/23/2024] Open
Abstract
AIMS Traditional atrial fibrillation (AF) recurrence after catheter ablation is reported as a binary outcome. However, a paradigm shift towards a more granular definition, considering arrhythmic or symptomatic burden, is emerging. We hypothesize that ablation reduces AF burden independently of conventional recurrence status in patients with persistent AF, correlating with symptom burden reduction. METHODS AND RESULTS Ninety-eight patients with persistent AF from the DECAAF II trial with pre-ablation follow-up were included. Patients recorded daily single-lead electrocardiogram (ECG) strips, defining AF burden as the proportion of AF days among total submitted ECG days. The primary outcome was atrial arrhythmia recurrence. The AF severity scale was administered pre-ablation and at 12 months post-ablation. At follow-up, 69 patients had atrial arrhythmia recurrence and 29 remained in sinus rhythm. These patients were categorized into a recurrence (n = 69) and a no-recurrence group (n = 29). Both groups had similar baseline characteristics, but recurrence patients were older (P = 0.005), had a higher prevalence of hyperlipidaemia (P = 0.007), and had a larger left atrial (LA) volume (P = 0.01). There was a reduction in AF burden in the recurrence group when compared with their pre-ablation burden (65 vs. 15%, P < 0.0001). Utah Stage 4 fibrosis and diabetes predicted less improvement in AF burden. The symptom severity score at 12 months post-ablation was significantly reduced compared with the pre-ablation score in the recurrence group, and there was a significant correlation between the reduction in symptom severity score and the reduction in AF burden (R = 0.39, P = 0.001). CONCLUSION Catheter ablation reduces AF burden, irrespective of arrhythmia recurrence post-procedure. There is a strong correlation between AF burden reduction and symptom improvement post-ablation. Notably, elevated LA fibrosis impedes AF burden decrease following catheter ablation.
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Affiliation(s)
- Charbel Noujaim
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Ala Assaf
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Chanho Lim
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Han Feng
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Hadi Younes
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Mario Mekhael
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Nour Chouman
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Ghaith Shamaileh
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Abdel Hadi El Hajjar
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Tarek Ayoub
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Nino Isakadze
- Department of Cardiovascular Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mihail G Chelu
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
- Baylor St Luke’s Medical Center, Houston, TX, USA
- Texas Heart Institute, Houston, TX, USA
| | - Nassir Marrouche
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
| | - Eoin Donnellan
- Tulane Research Innovation for Arrhythmia Discovery, 1430 Tulane Avenue, New Orleans, LA, USA
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6
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Reading Turchioe M, Volodarskiy A, Guo W, Taylor B, Hobensack M, Pathak J, Slotwiner D. Characterizing atrial fibrillation symptom improvement following de novo catheter ablation. Eur J Cardiovasc Nurs 2024; 23:241-250. [PMID: 37479225 PMCID: PMC11008952 DOI: 10.1093/eurjcn/zvad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/05/2023] [Accepted: 07/18/2023] [Indexed: 07/23/2023]
Abstract
AIMS Atrial fibrillation (AF) symptom relief is a primary indication for catheter ablation, but AF symptom resolution is not well characterized. The study objective was to describe AF symptom documentation in electronic health records (EHRs) pre- and post-ablation and identify correlates of post-ablation symptoms. METHODS AND RESULTS We conducted a retrospective cohort study using EHRs of patients with AF (n = 1293), undergoing ablation in a large, urban health system from 2010 to 2020. We extracted symptom data from clinical notes using a natural language processing algorithm (F score: 0.81). We used Cochran's Q tests with post-hoc McNemar's tests to determine differences in symptom prevalence pre- and post-ablation. We used logistic regression models to estimate the adjusted odds of symptom resolution by personal or clinical characteristics at 6 and 12 months post-ablation. In fully adjusted models, at 12 months post-ablation patients, patients with heart failure had significantly lower odds of dyspnoea resolution [odds ratio (OR) 0.38, 95% confidence interval (CI) 0.25-0.57], oedema resolution (OR 0.37, 95% CI 0.25-0.56), and fatigue resolution (OR 0.54, 95% CI 0.34-0.85), but higher odds of palpitations resolution (OR 1.90, 95% CI 1.25-2.89) compared with those without heart failure. Age 65 and older, female sex, Black or African American race, smoking history, and antiarrhythmic use were also associated with lower odds of resolution of specific symptoms at 6 and 12 months. CONCLUSION The post-ablation symptom patterns are heterogeneous. Findings warrant confirmation with larger, more representative data sets, which may be informative for patients whose primary goal for undergoing an ablation is symptom relief.
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Affiliation(s)
| | - Alexander Volodarskiy
- Department of Cardiology, NewYork-Presbyterian Queens Hospital, 56-45 Main St, Queens, NY 11355, USA
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67th St, New York, NY 10065, USA
| | - Winston Guo
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67th St, New York, NY 10065, USA
| | - Brittany Taylor
- Columbia University School of Nursing, 560 W. 168th Street, New York, NY 10032, USA
| | - Mollie Hobensack
- Columbia University School of Nursing, 560 W. 168th Street, New York, NY 10032, USA
| | - Jyotishman Pathak
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67th St, New York, NY 10065, USA
| | - David Slotwiner
- Department of Cardiology, NewYork-Presbyterian Queens Hospital, 56-45 Main St, Queens, NY 11355, USA
- Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67th St, New York, NY 10065, USA
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7
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AlTurki A, Essebag V. Atrial Fibrillation Burden: Impact on Stroke Risk and Beyond. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:536. [PMID: 38674182 PMCID: PMC11051719 DOI: 10.3390/medicina60040536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/07/2024] [Accepted: 03/14/2024] [Indexed: 04/28/2024]
Abstract
Atrial fibrillation (AF) is an important independent risk factor for stroke. Current guidelines handle AF as a binary entity with risk driven by the presence of clinical risk factors, which guides the decision to treat with an oral anticoagulant. Recent studies in the literature suggest a dose-response relationship between AF burden and stroke risk, in both clinical AF and subclinical atrial fibrillation (SCAF), which differs from current guidance to disregard burden and utilize clinical risk scores alone. Within clinical classification and at the same risk levels in various scores, the risk of stroke increases with AF burden. This opens the possibility of incorporating burden into risk profiles, which has already shown promise. Long-term rhythm monitoring is needed to elucidate SCAF in patients with stroke. Recent data from randomized trials are controversial regarding whether there is an independent risk from AF episodes with a duration of less than 24 h, including the duration of SCAF greater than six minutes but less than 24 h.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Montreal, QC H3G1A4, Canada
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya 13110, Kuwait
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Montreal, QC H3G1A4, Canada
- Division of Cardiology, Hopital Sacre-Coeur de Montreal, Montreal, QC H4J 1C5, Canada
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8
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Masterson Creber R, Benda N, Dimagli A, Myers A, Niño de Rivera S, Omollo S, Sharma Y, Goyal P, Turchioe MR. Using Patient Decision Aids for Cardiology Care in Diverse Populations. Curr Cardiol Rep 2023; 25:1543-1553. [PMID: 37943426 PMCID: PMC10914300 DOI: 10.1007/s11886-023-01953-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE OF REVIEW Patient decision aids (PDAs) are tools that help guide treatment decisions and support shared decision-making when there is equipoise between treatment options. This review focuses on decision aids that are available to support cardiac treatment options for underrepresented groups. RECENT FINDINGS PDAs have been developed to support multiple treatment decisions in cardiology related to coronary artery disease, valvular heart disease, cardiac arrhythmias, heart failure, and cholesterol management. By considering the unique needs and preferences of diverse populations, PDAs can enhance patient engagement and promote equitable healthcare delivery in cardiology. In this review, we examine the benefits, challenges, and current trends in implementing PDAs, with a focus on improving decision-making processes and outcomes for patients from underrepresented racial and ethnic groups. In addition, the article highlights key considerations when implementing PDAs and potential future directions in the field.
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Affiliation(s)
- Ruth Masterson Creber
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA.
| | - Natalie Benda
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Arnaldo Dimagli
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Annie Myers
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Stephanie Niño de Rivera
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Shalom Omollo
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Yashika Sharma
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | | | - Meghan Reading Turchioe
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
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9
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van der Velden RMJ, Hereijgers MJM, Arman N, van Middendorp N, Franssen FME, Gawalko M, Verhaert DVM, Habibi Z, Vernooy K, Koltowski L, Hendriks JM, Heidbuchel H, Desteghe L, Simons SO, Linz D. Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation. Europace 2023; 25:euad193. [PMID: 37421318 PMCID: PMC10351574 DOI: 10.1093/europace/euad193] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/02/2023] [Accepted: 05/30/2023] [Indexed: 07/10/2023] Open
Abstract
AIMS Chronic obstructive pulmonary disease (COPD) negatively impacts the efficacy of heart rhythm control treatments in patients with atrial fibrillation (AF). Although COPD is recognized as a risk factor for AF, practical guidance about how and when to screen for COPD is not available. Herein, we describe the implementation of an integrated screening and management pathway for COPD into the existing pre-ablation work-up in an AF outpatient clinic infrastructure. METHODS AND RESULTS Consecutive unselected patients accepted for AF catheter ablation in the Maastricht University Medical Center+ were prospectively screened for airflow limitation using handheld (micro)spirometry at the pre-ablation outpatient clinic supervised by an AF nurse. Patients with results suggestive of airflow limitation were offered referral to the pulmonologist. Handheld (micro)spirometry was performed in 232 AF patients, which provided interpretable results in 206 (88.8%) patients. Airflow limitation was observed in 47 patients (20.3%). Out of these 47 patients, 29 (62%) opted for referral to the pulmonologist. The primary reason for non-referral was low perceived symptom burden. Using this screening strategy 17 (out of 232; 7.3%) ultimately received a diagnosis of chronic respiratory disease, either COPD or asthma. CONCLUSION A COPD care pathway can successfully be embedded in an existing AF outpatient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although one out of five patients had results suggestive of an underlying chronic respiratory disease, only 62% of these patients opted for a referral. Pre-selection of patients as well as patient education might increase the diagnostic yield and requires further research.
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Affiliation(s)
- Rachel M J van der Velden
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Maartje J M Hereijgers
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Nazia Arman
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Naomi van Middendorp
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - Frits M E Franssen
- Department of Research and Development, Ciro, 6085 NM Horn, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, 6200 MD Maastricht, the Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, the Netherlands
| | - Monika Gawalko
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Dominique V M Verhaert
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Centre, 6525 GA Nijmegen, the Netherlands
| | - Zarina Habibi
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Centre, 6525 GA Nijmegen, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Centre, 6525 GA Nijmegen, the Netherlands
| | - Lukasz Koltowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Jeroen M Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, 5001 Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, 5000 Adelaide, Australia
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, 2650 Antwerp, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, 2650 Antwerp, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, 3590 Hasselt, Belgium
| | - Lien Desteghe
- Department of Cardiology, Antwerp University Hospital, 2650 Antwerp, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, 2650 Antwerp, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, 3590 Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, 3500 Hasselt, Belgium
| | - Sami O Simons
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, 6200 MD Maastricht, the Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, the Netherlands
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Centre, 6525 GA Nijmegen, the Netherlands
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, 5000 Adelaide, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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10
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Association of Health Status Metrics with Clinical Outcomes in Patients with Adult Congenital Heart Disease and Atrial Arrhythmias. J Clin Med 2022; 11:jcm11206181. [PMID: 36294501 PMCID: PMC9605619 DOI: 10.3390/jcm11206181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
The prognostic value of health status metrics in patients with adult congenital heart disease (ACHD) and atrial arrhythmias is unclear. In this retrospective cohort study of an ongoing national, multicenter registry (PROTECT-AR, NCT03854149), ACHD patients with atrial arrhythmias on apixaban are included. At baseline, health metrics were assessed using the physical component summary (PCS), the mental component summary (MCS) of the Short-Form-36 (SF-36) Health Survey, and the modified European Heart Rhythm Association (mEHRA) score. Patients were divided into groups according to their SF-36 PCS and MCS scores, using the normalized population mean of 50 on the PCS and MCS as a threshold. The primary outcome was the composite of mortality from any cause, major thromboembolic events, major/clinically relevant non-major bleedings, or hospitalizations. Multivariable Cox-regression analyses using clinically relevant parameters (age greater than 60 years, anatomic complexity, ejection fraction of the systemic ventricle, and CHA₂DS₂-VASc and HAS-BLED scores) were performed to examine the association of health metrics with the composite outcome. Over a median follow-up period of 20 months, the composite outcome occurred in 50 of 158 (32%) patients. The risk of the outcome was significantly higher in patients with SF-36 PCS ≤ 50 compared with those with PCS > 50 (adjusted hazard ratio (aHR), 1.98; 95% confidence interval [CI], 1.02−3.84; p = 0.04) after adjusting for possible confounders. The SF-36 MCS ≤ 50 was not associated with the outcome. The mEHRA score was incrementally associated with a higher risk of the composite outcome (aHR = 1.44 per 1 unit increase in score; 95% CI, 1.03−2.00; p = 0.03) in multivariable analysis. In ACHD patients with atrial arrhythmias, the SF-36 PCS ≤ 50 and mEHRA scores predicted an increased risk of adverse events.
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11
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Abu HO, Wang W, Otabil EM, Saczynski JS, Mehawej J, Mishra A, Tisminetzky M, Blanchard G, Gurwitz JH, Goldberg RJ, McManus DD. Perception of atrial fibrillation symptoms: Impact on quality of life and treatment in older adults. J Am Geriatr Soc 2022; 70:2805-2817. [PMID: 35791806 PMCID: PMC9588564 DOI: 10.1111/jgs.17954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/09/2022] [Accepted: 06/08/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND In managing older adults with atrial fibrillation (AF), their symptomatology impacts their well-being and may inform treatment decision-making. We examined AF symptom perception, its impact on quality of life (QoL), and its relation to treatment strategies in older adults with AF. METHODS Data were obtained from older adults with AF enrolled in a multicenter study conducted at clinic sites in Massachusetts and Georgia between 2016 and 2018. Participants were stratified into three age groups: 65-74 (youngest-old), 75-84 (middle-old), and ≥85 (oldest). Perception of AF symptoms was assessed by participant self-report during their clinic visit and at study enrollment by the Atrial Fibrillation Effect on Quality-of-Life Questionnaire which assessed cardiac-specific and non-specific, non-cardiac AF symptoms and their impact on QoL. Treatment strategies (rate or rhythm control) utilized were ascertained from electronic medical records. RESULTS Among the 1184 participants (mean age 75 years, 48% women, 86% Non-Hispanic White), 51% were aged 65-74 years, 36% were 75-84 years, and 13% were ≥ 85 years. The most commonly reported AF symptoms were non-specific, non-cardiac symptoms (fatigue, dyspnea, lightheadedness) with similar prevalence and impact on QoL in all age groups. Cardiac-specific AF symptoms (palpitations, irregular heartbeat, pause in heart activity) were less prevalent, but most commonly reported by the youngest participants (65-74 years), who endorsed considerable impact of these symptoms on their QoL. Overall, those who reported experiencing any AF symptoms during their clinic visit were more likely to have received rhythm compared with rate control (OR: 1.56; 95% CI: 1.18-2.04) with similar findings for all age groups except those aged ≥85 years. CONCLUSIONS Our findings suggest a high prevalence of non-specific, non-cardiac symptoms among older adults with AF and that cardiac-specific AF symptoms may exert considerable impact on their QoL. The presence of any AF symptoms may drive more rhythm control in a majority of older adults.
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Affiliation(s)
- Hawa O. Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Edith M. Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Ajay Mishra
- Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Mayra Tisminetzky
- Division of Geriatric Medicine and Meyers Health Care Institute. Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Gary Blanchard
- Division of Geriatrics, Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Jerry H. Gurwitz
- Division of Geriatric Medicine and Meyers Health Care Institute. Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
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12
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Jurgens CY, Lee CS, Aycock DM, Masterson Creber R, Denfeld QE, DeVon HA, Evers LR, Jung M, Pucciarelli G, Streur MM, Konstam MA. State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e173-e184. [PMID: 35979825 DOI: 10.1161/cir.0000000000001089] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.
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13
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Reading Turchioe M, Mangal S, Ancker JS, Gwyn J, Varosy P, Slotwiner D. "Replace uncertainty with information": Shared decision-making and decision quality surrounding catheter ablation for atrial fibrillation. Eur J Cardiovasc Nurs 2022; 22:430-440. [PMID: 36031860 PMCID: PMC10111971 DOI: 10.1093/eurjcn/zvac078] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/12/2022]
Abstract
AIMS As a first step in developing a decision aid to support shared decision-making (SDM) for patients with atrial fibrillation (AF) to evaluate treatment options for rhythm and symptom control, we aimed to measure decision quality and describe decision-making processes among patients and clinicians involved in decision-making around catheter ablation for AF. METHODS AND RESULTS We conducted a cross-sectional, mixed-methods study guided by a SDM model outlining decision antecedents, processes, and outcomes. Patients and clinicians completed semi-structured interviews about decision-making around ablation, feelings of decision conflict and regret, and preferences for the content, delivery, and format of a hypothetical decision aid for ablation. Patients also completed surveys about AF symptoms and aspects of decision quality. Fifteen patients (mean age 71.1 ± 8.6 years; 27% female) and five clinicians were recruited. For most patients, decisional conflict and regret were low, but they also reported low levels of information and agency in the decision-making process. Most clinicians report routinely providing patients with information and encouraging engagement during consultations. Patients reported preferences for an interactive, web-based decision aid that clearly presents evidence regarding outcomes using data, visualizations, videos, and personalized risk assessments, and is available in multiple languages. CONCLUSION Disconnects between clinician efforts to provide information and bolster agency and patient experiences of decision-making suggest decision aids may be needed to improve decision quality in practice. Reported experiences with current decision-making practices and preferences for decision aid content, format, and delivery can support the user-centered design and development of a decision aid.
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Affiliation(s)
| | - Sabrina Mangal
- Division of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine; New York, NY
| | - Jessica S Ancker
- Department of Biomedical Informatics, Vanderbilt University Medical Center; Nashville, TN
| | - Jaslynn Gwyn
- Division of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine; New York, NY
| | - Paul Varosy
- University of Colorado Anschutz Medical Campus, Aurora, CO
| | - David Slotwiner
- Division of Health Informatics, Department of Population Health Sciences, Weill Cornell Medicine; New York, NY.,NewYork Presbyterian Hospital-Queens; New York, NY
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14
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Blomström-Lundqvist C, Svedung Wettervik V. Reflections on the usefulness of today's atrial fibrillation ablation procedure endpoints and patient-reported outcomes. Europace 2022; 24:ii29-ii43. [PMID: 35661867 DOI: 10.1093/europace/euab318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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15
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Sadlonova M, Senges J, Nagel J, Celano C, Klasen-Max C, Borggrefe M, Akin I, Thomas D, Schwarzbach CJ, Kleeman T, Schneider S, Hochadel M, Süselbeck T, Schwacke H, Alonso A, Haass M, Ladwig KH, Herrmann-Lingen C. Symptom Severity and Health-Related Quality of Life in Patients with Atrial Fibrillation: Findings from the Observational ARENA Study. J Clin Med 2022; 11:jcm11041140. [PMID: 35207412 PMCID: PMC8877113 DOI: 10.3390/jcm11041140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 01/10/2023] Open
Abstract
Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with impaired health-related quality of life (HRQoL), high symptom severity, and poor cardiovascular outcomes. Both clinical and psychological factors may contribute to symptom severity and HRQoL in AF. Methods: Using data from the observational Atrial Fibrillation Rhine-Neckar Region (ARENA) trial, we identified medical and psychosocial factors associated with AF-related symptom severity using European Heart Rhythm Association symptom classification and HRQoL using 5-level EuroQoL- 5D. Results: In 1218 AF patients (mean age 71.1 ± 10.5 years, 34.5% female), female sex (OR 3.7, p < 0.001), preexisting coronary artery disease (CAD) (OR 1.7, p = 0.020), a history of cardioversion (OR 1.4, p = 0.041), cardiac anxiety (OR 1.2; p < 0.001), stress from noise (OR 1.4, p = 0.005), work-related stress (OR 1.3, p = 0.026), and sleep disturbance (OR 1.2, p = 0.016) were associated with higher AF-related symptom severity. CAD (β = −0.23, p = 0.001), diabetes mellitus (β = −0.25, p < 0.001), generalized anxiety (β = −0.30, p < 0.001), cardiac anxiety (β = −0.16, p < 0.001), financial stress (β = −0.11, p < 0.001), and sleep disturbance (β = 0.11, p < 0.001) were associated with impaired HRQoL. Conclusions: Psychological characteristics, preexisting CAD, and diabetes may play an important role in the identification of individuals at highest risk for impaired HRQoL and high symptom severity in patients with AF.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, 37075 Gottingen, Germany; (J.N.); (C.K.-M.); (C.H.-L.)
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, 37075 Gottingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Gottingen, 37075 Gottingen, Germany
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
- Correspondence: ; Tel.: +1-(617)-643-0119
| | - Jochen Senges
- Institute of Myocardial Infarction Research, Hospital of Ludwigshafen, 67063 Ludwigshafen, Germany; (J.S.); (S.S.); (M.H.)
| | - Jonas Nagel
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, 37075 Gottingen, Germany; (J.N.); (C.K.-M.); (C.H.-L.)
| | - Christopher Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
| | - Caroline Klasen-Max
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, 37075 Gottingen, Germany; (J.N.); (C.K.-M.); (C.H.-L.)
| | - Martin Borggrefe
- Department of Cardiology, Pneumology, Angiology, and Emergency Medicine, University of Mannheim Medical Center, 68167 Mannheim, Germany; (M.B.); (I.A.)
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany;
| | - Ibrahim Akin
- Department of Cardiology, Pneumology, Angiology, and Emergency Medicine, University of Mannheim Medical Center, 68167 Mannheim, Germany; (M.B.); (I.A.)
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany;
| | - Dierk Thomas
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany;
- Department of Internal Medicine III—Cardiology, Angiology and Pneumology, Medical University, Hospital Heidelberg, 69120 Heidelberg, Germany
| | | | | | - Steffen Schneider
- Institute of Myocardial Infarction Research, Hospital of Ludwigshafen, 67063 Ludwigshafen, Germany; (J.S.); (S.S.); (M.H.)
| | - Matthias Hochadel
- Institute of Myocardial Infarction Research, Hospital of Ludwigshafen, 67063 Ludwigshafen, Germany; (J.S.); (S.S.); (M.H.)
| | | | - Harald Schwacke
- Diakonissen-Stiftungs-Hospital Speyer, 67346 Speyer, Germany;
| | - Angelika Alonso
- Department of Neurology, Mannheim Center for Translational Neuroscience, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany;
| | - Markus Haass
- Department of Cardiology, Theresien Hospital and St. Hedwig Clinic GmbH, 68165 Mannheim, Germany;
| | - Karl-Heinz Ladwig
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Rechts der Isar, Technical University Munich, 81675 Munich, Germany;
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 81675 Munich, Germany
| | - Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, 37075 Gottingen, Germany; (J.N.); (C.K.-M.); (C.H.-L.)
- German Center for Cardiovascular Research (DZHK), Partner Site Gottingen, 37075 Gottingen, Germany
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16
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Zeren M, Karci M, Demir R, Gurses HN, Oktay V, Uzunhasan I, Yigit Z. Cut-off values of 6-min walk test and sit-to-stand test for determining symptom burden in atrial fibrillation. Ir J Med Sci 2022; 191:2587-2595. [PMID: 35066793 PMCID: PMC8783771 DOI: 10.1007/s11845-021-02901-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/17/2021] [Indexed: 11/30/2022]
Abstract
Background Since symptomatology is a major predictor of quality of life and an endpoint for the management of atrial fibrillation (AF), practical approaches for objectively interpreting symptom burden and functional impairment are needed. Aims We aimed to provide cut-off values for two frequently used field tests to be able to objectively interpret symptom burden in atrial fibrillation. Methods One hundred twenty-five patients with AF were evaluated with European Heart Rhythm Association (EHRA) score, 6-min walk test (6MWT), 30 s sit-to-stand test (30 s-STST), Short-Form 36 (SF-36), International Physical Activity Questionnaire-Short Form (IPAQ-SF), and spirometry. Patients with EHRA 1 were classified as “asymptomatic”, and those with EHRA 2–4 as “symptomatic”. Cut-off values of 6MWT and 30 s-STST for discriminating between these patients were calculated. Results The optimal cut-off value was “450 m” for 6MWT (sensitivity: 0.71; specificity of 0.79) and “11 repetitions” for 30 s-STST (sensitivity 0.77; specificity of 0.70). Area under ROC curve was 0.75 for both tests (p < 0.001). Discriminative properties of the two tests were similar, and they were significantly correlated (r = 0.58; p < 0.001). Subgroup analysis revealed patients below cut-off values also had worse outcomes in SF-36, IPAQ-SF, and spirometry. Conclusions In patients with AF, walking < 450 m in 6MWT or performing < 11 repetitions in 30 s-STST indicates increased symptom burden, as well as impaired exercise capacity, quality of life, physical activity participation, and pulmonary function. These cut-off values may help identifying patients who may require adjustments in their routine treatment or who may benefit from additional rehabilitative approaches.
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Affiliation(s)
- Melih Zeren
- Division of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Bakircay University, Kaynaklar St, 35665, Izmir, Turkey.
| | - Makbule Karci
- Department of Physiotherapy and Rehabilitation, School of Health Sciences, Istanbul Arel University, Istanbul, Turkey
| | - Rengin Demir
- Department of Cardiology, Cardiology Institute, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hulya Nilgun Gurses
- Division of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakif University, Istanbul, Turkey
| | - Veysel Oktay
- Department of Cardiology, Cardiology Institute, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Isil Uzunhasan
- Department of Cardiology, Cardiology Institute, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Zerrin Yigit
- Department of Cardiology, Cardiology Institute, Istanbul University-Cerrahpasa, Istanbul, Turkey
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17
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Ren L, Li W, Su X, Yang Y, Zhang Y, Liu X, Hu G, Ning B. Follow-up study of depressive state on patients with atrial fibrillation 1 year after radio-frequency ablation. Front Psychiatry 2022; 13:1046924. [PMID: 36620693 PMCID: PMC9813399 DOI: 10.3389/fpsyt.2022.1046924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze the effect of depression on the recurrence of atrial fibrillation (AF) 1 year after radio-frequency ablation. METHODS A total of 91 patients with AF admitted to our hospital from January 2020 to July 2021 were studied. All patients were followed up 1 year after radio-frequency ablation. A total of 91 subjects were divided into recurrence group (n = 30) and no recurrence group (n = 61) according to the recurrence situation 1 year after radio-frequency ablation. Age, disease course, body mass index (BMI), gender, echocardiography (left atrial diameter), blood inflammatory indicators (neutrophil count, lymphocyte count, and monocyte count), and Self-rating Depression Scale (SDS) scores were compared between the two groups. Logistic multivariate regression analysis was used to analyze the effect of SDS score and other indexes on the recurrence of AF 1 year after radio-frequency ablation. RESULTS The age of patients in relapse group was higher than that in no relapse group (P < 0.05) and the course of disease was longer than that of the no recurrence group (P < 0.05). The BMI was higher than that of the no recurrence group (P < 0.05) and the left atrial diameter was greater than that of the no recurrence group (P < 0.05). Neutrophil count and monocyte count were significantly higher than those in no recurrence group (P < 0.05) and the lymphocyte count was significantly lower than that in the no recurrence group (P < 0.05). There were significant differences in SDS score composition between the two groups (P < 0.05) and the composition ratio of patients with moderate and major depression in the relapsing group was significantly higher than that in the non-relapsing group. The composition ratio of patients without depression in the relapsing group was significantly lower than that in the non-relapsing group. Multivariate analysis showed that age, disease course, BMI, left atrial diameter, neutrophil count, lymphocyte count, monocyte count, and SDS score were all independent factors affecting the recurrence of AF patients 1 year after radio frequency ablation (P < 0.05). Compared with patients without depression, patients with mild, moderate and major depression had an increased risk of recurrence by 74.0, 98.2, and 151.2% 1 year after radio-frequency ablation, respectively (OR = 1.740, 1.982, and 2.512). CONCLUSION There is a high rate of depression in patients with AF. Depression is an important factor affecting the early recurrence of patients with AF after radio-frequency ablation.
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Affiliation(s)
- Lei Ren
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Anhui Medical University, Fuyang, China
| | - Wenjun Li
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Anhui Medical University, Fuyang, China
| | - Xin Su
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Anhui Medical University, Fuyang, China
| | - Yangyang Yang
- Department of Cardiovascular Medicine, Fuyang Hospital Affiliated to Bengbu Medical College, Fuyang, China
| | - Yuanzhuo Zhang
- Department of Cardiovascular Medicine, Fuyang Hospital Affiliated to Bengbu Medical College, Fuyang, China
| | - Xiaozhu Liu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guangquan Hu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Bin Ning
- Department of Cardiovascular Medicine, Fuyang People's Hospital Affiliated to Anhui Medical University, Fuyang, China
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18
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Ferreira D, Mikhail P, McGee M, Boyle A, Sverdlov A, William M, Jackson N, Barlow M, Leitch J, Collins N, Ford T, Wilsmore B. Investigating the efficacy of chest pressure for direct current cardioversion in atrial fibrillation: a randomised control trial protocol (Pressure-AF). Open Heart 2021; 8:openhrt-2021-001739. [PMID: 34556559 PMCID: PMC8461712 DOI: 10.1136/openhrt-2021-001739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/27/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. Direct current cardioversion is commonly used to restore sinus rhythm in patients with AF. Chest pressure may improve cardioversion success through decreasing transthoracic impedance and increasing cardiac energy delivery. We aim to assess the efficacy and safety of routine chest pressure with direct current cardioversion for AF. METHODS AND ANALYSIS Multicentre, double blind (patient and outcome assessment), randomised clinical trial based in New South Wales, Australia. Patients will be randomised 1:1 to control and interventional arms. The control group will receive four sequential biphasic shocks of 150 J, 200 J, 360 J and 360 J with chest pressure on the last shock, until cardioversion success. The intervention group will receive the same shocks with chest pressure from the first defibrillation. Pads will be placed in an anteroposterior position. Success of cardioversion will be defined as sinus rhythm at 1 min after shock. The primary outcome will be total energy provided. Secondary outcomes will be success of first shock to achieve cardioversion, transthoracic impedance and sinus rhythm at post cardioversion ECG. ETHICS AND DISSEMINATION Ethics approval has been confirmed at all participating sites via the Research Ethics Governance Information System. The trial has been registered on the Australia New Zealand Clinical Trials Registry (ACTRN12620001028998). De-identified patient level data will be available to reputable researchers who provide sound analysis proposals.
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Affiliation(s)
- David Ferreira
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia .,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Philo Mikhail
- Department of Cardiology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Michael McGee
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Department of Cardiology, Tamworth Rural Referral Hospital, Tamworth, New South Wales, Australia
| | - Andrew Boyle
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Aaron Sverdlov
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Maged William
- Department of Cardiology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Nicholas Jackson
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Malcolm Barlow
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - James Leitch
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Thomas Ford
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Department of Cardiology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Bradley Wilsmore
- Department of Cardiology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
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19
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Okutucu S, Gorenek B. Current Recommendations on Atrial Fibrillation: A Comparison of the Recent European and Canadian Guidelines. Cardiology 2021; 147:81-89. [PMID: 34547752 DOI: 10.1159/000519465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/24/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Guidelines for the diagnosis and management of atrial fibrillation (AF) are frequently published and updated, reflecting the rapid evolution in AF pathogenesis and treatment modalities. SUMMARY Recently, 2 important guidelines for the diagnosis and management of atrial AF have been published by the European Society of Cardiology (ESC), and Canadian Cardiovascular Society (CCS). Although the evidence-based recommendations and statements are quite similar, there are some important differences between the ESC and CCS guidelines for AF. Herein, we compared the current recommendations and highlighted the differences from the most recent guidelines for AF. Key Messages: Specifically, key differences can be observed in methods evaluating the recommendations; classifications and the definitions; the symptom score used to guide management decisions, longitudinal patient assessment, and structured characterization; the stroke risk stratification algorithm used to determine indications for oral anticoagulation therapy; the role of acetylsalicylic acid in stroke prevention in AF; the antithrombotic regimens that are employed in the setting of chronic coronary syndromes, acute coronary syndromes, and percutaneous coronary intervention; the target heart rate for rate control; and the algorithms for integrated or holistic management of AF. Differences are observed, particularly when the quality of evidence is moderate or low. More research and randomized controlled studies on major gaps identified in current guidelines will further clarify and modify our future management strategies in AF.
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Affiliation(s)
- Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Memorial Healthcare Group, Ankara, Turkey
| | - Bulent Gorenek
- Department of Cardiology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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[Atrial fibrillation]. Internist (Berl) 2021; 62:1065-1073. [PMID: 34185108 DOI: 10.1007/s00108-021-01067-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
Atrial fibrillation is frequent and has severe sequelae, such as stroke, cardiovascular death and cardiac insufficiency. These sequelae can be effectively reduced by anticoagulants, a meticulous recognition and treatment of cardiovascular comorbidities and an early rhythm-preserving treatment. Catheter ablation leads to a better preservation of the sinus rhythm and in symptomatic patients to a better quality of life in comparison to treatment with antiarrhythmic agents. This should be included in the planning of early rhythm-maintaining treatment.
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Bhat A, Khanna S, Chen HH, Gupta A, Gan GC, Denniss AR, MacIntyre CR, Tan TC. Integrated Care in Atrial Fibrillation: A Road Map to the Future. Circ Cardiovasc Qual Outcomes 2021; 14:e007411. [PMID: 33663224 PMCID: PMC7982130 DOI: 10.1161/circoutcomes.120.007411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice with an epidemiological coupling appreciated with advancing age, cardiometabolic risk factors, and structural heart disease. This has resulted in a significant public health burden over the years, evident through increasing rates of hospitalization and AF-related clinical encounters. The resultant gap in health care outcomes is largely twinned with suboptimal rates of anticoagulation prescription and adherence, deficits in symptom identification and management, and insufficient comorbid cardiovascular risk factor investigation and modification. In view of these shortfalls in care, the establishment of integrated chronic care models serves as a road map to best clinical practice. The expansion of integrated chronic care programs, which include multidisciplinary team care, nurse-led AF clinics, and use of telemedicine, are expected to improve AF-related outcomes in the coming years. This review will delve into current gaps in AF care and the role of integrated chronic care models in bridging fragmentations in its management.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (A.B., G.C.H.G., C.R.M.)
| | - Shaun Khanna
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
| | - Henry H.L. Chen
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
| | - Arnav Gupta
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
| | - Gary C.H. Gan
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (A.B., G.C.H.G., C.R.M.)
| | - A. Robert Denniss
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
- Department of Cardiology, Westmead Hospital, Australia (A.R.D., T.C.T.)
| | - C. Raina MacIntyre
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (A.B., G.C.H.G., C.R.M.)
| | - Timothy C. Tan
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
- Department of Cardiology, Westmead Hospital, Australia (A.R.D., T.C.T.)
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5324] [Impact Index Per Article: 1774.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Bhat A, Khanna S, Chen HHL, Gan GCH, MacIntyre CR, Tan TC. Drivers of hospitalization in atrial fibrillation: A contemporary review. Heart Rhythm 2020; 17:1991-1999. [PMID: 32565194 DOI: 10.1016/j.hrthm.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 01/07/2023]
Abstract
Atrial fibrillation (AF)-related hospitalization has risen over the last 2 decades and is the most influential determinant of total disease-related expenditure. In this review article, we describe several identified drivers of hospitalization from several registries and large-scale clinical trials, including key cardiovascular and non-traditional risk factors. We also discuss available assessment tools for discerning overall risk of hospitalization, including AF symptom scores, thrombosis and bleeding disposition, and non-invasive cardiac structural assessment. Finally, we highlight the different treatment paradigms that have been proven to reduce AF burden, progression, and hospitalization in the literature.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Shaun Khanna
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - C Raina MacIntyre
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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Jain SK, Novak PG, Sangrigoli R, Champagne J, Dubuc M, Adler SW, Svinarich JT, Essebag V, Martien M, Anderson C, John RM, Mansour M, Knight BP. Sustained quality-of-life improvement post-cryoballoon ablation in patients with paroxysmal atrial fibrillation: Results from the STOP-AF Post-Approval Study. Heart Rhythm 2020; 17:485-491. [DOI: 10.1016/j.hrthm.2019.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 10/25/2022]
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Heo R, Cha MJ, Kim TH, Lee JM, Park J, Park HW, Kang KW, Shim J, Uhm JS, Kim J, Kim JB, Kim C, Lee YS, Choi EK, Joung B, Park JK. Characteristics of symptom burden in atrial fibrillation with concomitant heart failure. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2020. [DOI: 10.1186/s42444-019-0009-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Symptom burden is an important factor in determining the treatment of atrial fibrillation (AF). AF is frequently accompanied by heart failure (HF). This study investigated the characteristics of AF symptoms with concomitant HF.
Methods
A total of 4885 patients with AF were consecutively enrolled through a prospective observational registry (the Comparison Study of Drugs for Symptom Control and Complication Prevention of Atrial Fibrillation [CODE-AF] registry). Clinically diagnosed HF was divided into three categories (preserved, mid-range, and reduced ejection fraction [EF]). Symptom severity was assessed using the European Heart Rhythm Association (EHRA) classification.
Results
The presence of AF-related symptoms was comparable irrespective of concomitant HF. Patients with HF with reduced EF demonstrated severe (EHRA classes 3 and 4) and atypical symptoms. HF with preserved EF was also associated with atypical symptoms. Female sex and AF type were associated with the presence of symptoms in AF without HF, and non-maintenance of sinus rhythm and increased left atrial pressure (E/e′ ≥ 15) were factors related to the presence of symptoms in AF with HF.
Conclusion
AF with concomitant HF presented with more severe and atypical symptoms than AF without HF. Maintaining the sinus rhythm and reducing the E/e’ ratio are important factors for reducing symptoms in AF with concomitant HF.
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