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

Factors Associated with Quality of Life among People with Atrial Fibrillation: Jordan Atrial Fibrillation Registry Study

Background and Objectives: Atrial fibrillation (AF) is a common arrhythmia that may adversely affect the quality of life (QoL). Several factors could be associated with the QoL among patients with AF; however, evidence regarding these factors is still limited and controversial. Therefore, this study aimed to identify the level of QoL and its associated factors among Jordanian patients with AF. Subjects and methods: A case study design was implemented. A sample of 620 participants were recruited from 28 outpatient clinics registered in the Jordan atrial fibrillation registry AF (JoFIB). Data on QoL were gathered through the self-reported Atrial Fibrillation Effect on Quality-of-life tool (AFEQT). A QoL questionnaire was validated in this population before starting this study. The cardiac nurse then provided the research assistant with data relating to patients' characteristics and associated comorbidities. Results: The overall AFEQT scores were positively skewed (median 21.3, IQR: 14.4-31.9). This pattern was reflected for the AFEQT sub-scales 'Symptoms' (20.8, 8.3-33.3), 'Daily activities' (16.7, 10.4-27.1), and 'Treatment concerns' (27.8, 19.4-41.7), whereas 'Treatment satisfaction' was negatively skewed (91.7, 83.3-91.7). Patients in the higher quartiles, indicating a better QoL, tended to be younger and were less likely to experience dyslipidemia, stroke, pulmonary hypertension, or other comorbidities. Over 90% of patients were currently experiencing AF, and patients with a better QoL tended to be less likely to be currently experiencing AF and more likely to have had their latest episode of AF more than a month ago (compared to less than a month ago). Age, BMI, dyslipidemia, heart failure, COPD, CAD, history of ablation, and the use of anticoagulants were significantly associated with the overall AFEQT score (R2 = 0.278). Conclusions: This study demonstrates that AF Jordanian patients had low levels of QoL. Patients in higher quartiles for the overall AFEQT score were younger, with fewer disease comorbidities and less experience of current AF episodes. Several modifiable and non-modifiable factors were associated with QoL in AF patients. Age, BMI, dyslipidemia, heart failure, COPD, CAD, history of ablation, and the use of oral anticoagulants were significantly associated with the overall AFEQT score. Healthcare providers should target these factors as indicators or interventions for which QoL is continuously monitored.

Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics

The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.

Correlation between family function and quality of life in patients with atrial fibrillation

OBJECTIVES

Many studies have shown that the quality of life for patients with atrial fibrillation (AF) is significantly impaired, but the impact on family function is still unclear. This study aims to evaluate the family function and quality of life in patients with AF using scales, to analyze the correlation between family function and quality of life, and to predict the influencing factors of quality of life.

METHODS

A total of 223 patients with AF who were admitted to the Department of Cardiology and General Medicine of the Lanzhou University Second Hospital from January 1, 2021 to May 1, 2022, were selected as research subjects, the general information of patients with AF were collected via a questionnaire, the family function and quality of life were assessed by the Family Assessment Device (FAD) and Atrial Fibrillation Effect on Quality-of-Life (AFEQT) scale. The patients were divided into a non-family functional disorder group and a family functional disorder group on the basis of their FAD scores. The above data were analyzed using SPSS 26.0 statistical software.

RESULTS

Among the 223 patients, 64 (28.70%) were in the non-family functional disorder group, and 159 (71.30%) were in the family functional disorder group. The total score of FAD and scores of all dimensions in the family functional disorder group were higher than those in the non-family functional disorder group (all P<0.01). AFEQT total score and symptoms, treatment concerns and daily activities in the non-family functional disorder group were significantly higher than those in the family functional disorder group (all P<0.01). The Pearson linear analysis showed that there was a linear negative correlation between the total score and each dimension of FAD with the total score and each dimension of AFEQT (all P<0.01). The variables with statistical significance in the univariate analysis were included in the multiple linear regression analysis, and the result showed that female, and the problem solving, role, affective involvement, and general functioning dimensions of family function had an impact on the quality of life (all P<0.01).

CONCLUSIONS

Most patients with AF have different degrees of family dysfunction. The quality of life in patients with family functional disorder group is generally low. Female, and the problem solving, role, affective involvement, and general functioning of family function have a significant impact on the quality of life in patients with AF. In clinical treatment of AF, attention should be paid to the family function of patients, and family members can be involved in clinical intervention to improve family function and improve the quality of life.

Isa WYH. 24-Hour Holter Monitoring for Identification of an Ideal Ventricular Rate for a Better Quality of Life in Atrial Fibrillation Patients

Introduction Atrial fibrillation (AF) is the most common persistent cardiac arrhythmia. The impact of AF on quality of life (QoL) is significant, and much has related to the achieved resting ventricular rate (VR). Strategies to control VR can improve QoL in AF patients. However, the ideal VR target remains unclear. Therefore, we aimed to identify the ideal VR target by comparing the QoL of AF patients with different VR cut-off means from the 24-hour Holter (Holter). Methods A cross-sectional study was conducted on AF patients in the international normalized ratio (INR) clinic at Hospital Universiti Sains Malaysia. Patients were fixed with a Holter monitor while QoL was measured using the SF-36v2 Health Survey. Patients were repeatedly divided into mean 24-hour Holter VR above and below 60, 70, 80, 90, and 100 beats per minute (bpm). The differences in the total SF-36v2 score and its components were examined. Results A total of 140 patients completed the study. There was a significant difference in physical role, vitality, mental health, mental component summary, and total SF-36v2 scores for VR above and below 90 bpm. The total SF-36v2 score difference was also significant in the covariate analysis, while other VR cut-offs (60, 70, 80, and 100 bpm) did not show significant changes in total SF-36v2 scores. Conclusion Significant differences were observed in the QoL scores among AF patients, with a cut-off VR of 90 bpm favoring patients with the higher rate. Hence, higher VR is better in terms of QoL among stable AF patients.

Perception of atrial fibrillation symptoms: Impact on quality of life and treatment in older adults

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.

Between-group minimally important change versus individual treatment responders

PURPOSE

Estimates of the minimally important change (MIC) can be used to evaluate whether group-level differences are large enough to be important. But responders to treatment have been based upon group-level MIC thresholds, resulting in inaccurate classification of change over time. This article reviews options and provides suggestions about individual-level statistics to assess whether individuals have improved, stayed the same, or declined.

METHODS

Review of MIC estimation and an example of misapplication of MIC group-level estimates to assess individual change. Secondary data analysis to show how perceptions about meaningful change can be used along with significance of individual change.

RESULTS

MIC thresholds yield over-optimistic conclusions about responders to treatment because they classify those who have not changed as responders.

CONCLUSIONS

Future studies need to evaluate the significance of individual change using appropriate individual-level statistics such as the reliable change index or the equivalent coefficient of repeatability. Supplementing individual statistical significance with retrospective assessments of change is desirable.

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

Background

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

Methods and Results

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

Conclusions

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