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Structured care of patients with atrial fibrillation improves guideline adherence
Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Internal Medicine, County hospital Ryhov, Jönköping, Sweden;Jönköping Academy, Jönköping University,Jönköping, Sweden..
Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0003-3059-4404
Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Internal Medicine, County hospital Ryhov, Jönköping, Sweden;Jönköping Academy, Jönköping University,Jönköping, Sweden..
2016 (English)In: Journal of Atrial Fibrillation, ISSN 1941-6911, Vol. 9, no 4Article in journal (Refereed) Published
Abstract [en]

There are many reports of lack of guideline adherence in the treatment of patients with atrial fibrillation (AF), and AF affects health-related quality of life (HRQoL) negatively. The aim of this study was to investigate whether structured care compared to standard care of a general AF population could improve guideline adherence and HRQoL, and reduce symptoms,anxiety and depression.

Methods

In total, 176 patients were recruited to the intervention and 146 patients to the control group.The intervention consisted of a structured follow-up program, while patients serving as controls received standard care. The primary outcome was guideline adherence evaluated through: appropriate use of oral anticoagulants (OAC) and antiarrhythmics, whether echocardiogram and thyroid lab tests were performed, and patient-reported outcome measures (PROMs), assessed with the questionnaires SF-36, EQ-5D, HADS and ASTA at baseline and after one year.

Results

Guideline adherence was significantly better in the intervention group, 91% vs. 63% (p < 0.01), mainly due to appropriate OAC treatment 94% vs. 74% (p < 0.01). Symptoms assessed with ASTA were less frequent and the negative impact of AF was reduced in the intervention group after one year/ at follow-up. Five scales in SF-36, and the visual analogue scale for current health status in EQ-5D (EQ-VAS), improved significantly in both groups.

Conclusion

Structured care of patients with AF significantly improved guideline adherence and patients reported fewer symptoms and a reduced negative impact on disease-specific HRQoL compared to standard care at one year follow-up.

Place, publisher, year, edition, pages
Overland Park, KS, United States: CardioFront LLC , 2016. Vol. 9, no 4
Keywords [en]
Atrial fibrillation, Guideline Adherence, Anticoagulants, Health-related Quality of life, Symptoms, Anxiety.
National Category
Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-157019DOI: 10.4022/jafib.1498OAI: oai:DiVA.org:liu-157019DiVA, id: diva2:1317501
Available from: 2019-05-23 Created: 2019-05-23 Last updated: 2019-06-12Bibliographically approved
In thesis
1. Structured management, Symptoms, Health-related Quality of Life and Alcohol in Patients with Atrial Fibrillation
Open this publication in new window or tab >>Structured management, Symptoms, Health-related Quality of Life and Alcohol in Patients with Atrial Fibrillation
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting at least 2.9 % of the Swedish population. Although AF is associated with increased risk of ischaemic stroke, there have been many reports on the underuse of oral anticoagulants (OAC) and non-adherence to guidelines in other areas as well. AF is also associated with disabling symptoms and decreased health-related quality of life (HRQoL), but some patients are asymptomatic. The reasons for the great variation of symptoms remain unclear. Furthermore, although research on AF has increased, studies have mainly focused on treatment, while studies on risk factors, such as alcohol consumption, have only recently gained attention.

The aim of this thesis was to investigate whether structured care of patients with AF could improve guideline adherence and HRQoL compared to standard care, and to determine which factors affect symptoms and HRQoL prior to treatment with radiofrequency catheter ablation (RFA), as well as improvement after RFA. Furthermore, we aimed to examine the associations of alcohol consumption with cardiac biomarkers, the size of the left atrium (LA), and re-ablation.

This thesis is based on two studies. In the ‘Structured Management and Coaching – Patients with Atrial Fibrillation’ (SMaC-PAF) study, 176 patients were recruited to the intervention group, receiving a structured follow-up programme, and 146 patients were recruited to the control group, receiving standard care. The two groups were compared in regard to adherence to guidelines and patient-reported outcome measures (PROMs) assessing symptoms and HRQoL.

In the ‘Symptom burden, Metabolic profile, Ultrasound findings, Rhythm, neurohormonal activation, haemodynamics and health-related quality of life in patients with atrial Fibrillation’ (SMURF) study, 192 patients referred for their first RFA of AF were included. PROMs questionnaires were filled out, echocardiography was performed, and cardiac biomarkers were analysed. Alcohol consumption was assessed through interview and through analysis of ethyl glucuronide in hair (hEtG). AF recurrence and re-ablation within 12 months were examined.

In the first study, after one year, 94% (n=112) and 74% (n=87) of patients with indication for OAC in the intervention and the control groups, respectively, actually received treatment with OAC (p <0.01). Both groups improved in anxiety and HRQoL scores over the year, but in the intervention group, arrhythmia-specific symptoms were less frequently experienced and the SF-36 scores were more similar to the norm population.

In the second study, the most important predictors of arrhythmia-related symptoms and HRQoL prior to RFA were anxiety, depression and low-grade inflammation, while frequent AF attacks prior to RFA, freedom from AF recurrence after RFA, female gender, no enlarged LA, absence of diabetes, and the presence of heart failure were significant predictors of improvement in symptoms and HRQoL after RFA. Men with hEtG ≥7 pg/mg had higher levels of cardiac biomarkers, larger LA volumes and a higher re-ablation rate than men with hEtG <7 pg/mg, while no such findings were present in women.

In conclusion, structured management was superior to standard care in patients with AF, emphasising the importance of structured care, adjusted to local requirements, in order to improve the care and well-being of patients with AF. Although the reasons for the great variety of symptoms in patients with AF still are not yet fully understood, it seems that psychological factors and inflammation play a role, and that improvement in symptoms and HRQoL after RFA is influenced by gender, diabetes, heart failure, LA size and the frequency of attacks before, as well as freedom from AF after, RFA. Finally, alcohol consumption corresponding to hEtG ≥7 pg/mg was associated with higher levels of cardiac biomarkers, larger LA size and a higher rate of re-ablation in men, implying that men with an hEtG-value ≥7 pg/mg have a higher risk for LA remodelling that could potentially lead to a deterioration of the AF situation.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. p. 99
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1673
National Category
Cardiac and Cardiovascular Systems Surgery Nursing
Identifiers
urn:nbn:se:liu:diva-156364 (URN)10.3384/diss.diva-156364 (DOI)9789176851029 (ISBN)
Public defence
2019-05-24, Aulan, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2019-04-17 Created: 2019-04-17 Last updated: 2019-06-20Bibliographically approved

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