The impact of atrial fibrillation on quality of life of the elderly: the calm before the storm?

Abstract

This editorial refers to ‘A cross-sectional study of quality of life in an elderly population (75 years and over) with atrial fibrillation: secondary analysis of data from the Birmingham Atrial Fibrillation Treatment of the Aged study’ by A.K. Roalfe et al., on page 1420 Over the last couple of years we have seen great focus, efforts, and—fortunately—breakthroughs concerning the antithrombotic (under)treatment of patients with atrial fibrillation (AF). The occurrence of AF-related stroke is probably the most feared complication of the arrhythmia and deserves all the attention it receives. However, we must not forget other potentially lifedisabling aspect of AF which also happens to be the driving force of the other cornerstone in the management of the arrhythmia, that is deciding whether or not to pursue more than rate control alone: AF-related symptoms. 1 Although much research has gone into developing successful and safe methods to apply rate and/or rhythm control as well as studies on their impact on mortality and morbidity, this does not hold true for understanding the onset and ‘perpetuation’ of symptoms. Thus, studies such as that by Roalfe et al. 2 in this issue of the journal are very much welcome and will hopefully help increase awareness of this important, yet underreported, aspect. They present a secondary analysis of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study. 2 The aim of this cross-sectional study in 1762 (38%) patients from the original cohort was to identify factors impacting the patients’ perceived quality of life (QoL) using the Short Form 12 (SF-12) and EuroQol 5D (EQ-5D) and to compare their QoL with that of the general population of the UK. The authors found, rather paradoxically, elderly patients in AF with limited disability (Rankin score 0–1) to have a small but statistically significant increase in QoL compared with the general UK population, whereas the outcome of this comparison was in the opposite direction for those with a Rankin score .2. Among the elderly patients with AF, being female, being more disabled (i.e. higher Rankin scores), and being prescribed ≥7 drugs significantly lowered the QoL score. 1 Consistent with previous findings, 3,4 gender has proven to significantly impact the QoL indices. 2 Among these elderly patients in AF, females had lower QoL compared with men. Furthermore, although elderly women with AF did have slightly better QoL compared with the general population measured by the SF-12 physical component sub-score, they had a lower QoL based on the SF-12 mental component sub-score (MCS) and EQ-5D. The authors explain this by pointing out the observed higher morbidity and disability among females with AF. 2 However, they observed that women (and also men) in AF with limited disability had higher QoL scores compared with the general population. 2 Perhaps this can be regarded as a super(wo)man effect: the presence of significant cardiovascular disease (AF) is apparently incapable to substantially disrupt their daily lives. The Euro Heart Survey on AF (EHS-AF) also found lower QoL scores for women who were similar to the BAFTA cohort, i.e. those being older and having more co-morbidity. 4 Interestingly, data from the EHS-AF revealed that gender apparently also influenced the actual AF treatment. Women had worse symptoms, mostly driven by palpitations and dyspnoea. It turned out that in case of typical AF complaints (e.g. palpitations), men and women are treated equally for AF. However, in case of less typical complaints, women significantly more often received a more conservative (rate control) treatment and were less often scheduled for AF-related interventions such as electrical cardioversion. 4 The latter may add to the current discussion on presumed undertreatment of cardiovascular disease in women. 5