Knowledge Of Atrial Fibrillation Research Articles

Uptake of a Primary Care Atrial Fibrillation Screening Program (AF-SMART): A Realist Evaluation of Implementation in Metropolitan and Rural General Practice

Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016–June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice. A realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory. GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP ‘screening champion’ had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated. Introducing an AF screening program is likely to be successful in contexts where there is a senior GP ‘screening champion’, a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke. AF SMART (metropolitan): ACTRN12616000850471 (Australia New Zealand Clinical Trials Registry). AF SMART II (rural): ACTRN12618000004268 (Australia New Zealand Clinical Trials Registry).

Patient activation for self-management is associated with health status in patients with atrial fibrillation.

BackgroundHigher levels of patient activation for self-managing health are associated with positive clinical and health care utilization outcomes. Identifying a patient’s activation level can guide clinicians to tailor interventions to improve their health. Effective self-management of atrial fibrillation (AF) requires patient activation to participate in treatment decisions, prevent complications, and manage risk factors. Yet, little is known about activation in patients with AF. The purpose of this descriptive study was to identify patient activation levels and factors associated with activation in patients with AF.MethodsPatients (N=123), 66% male, with a mean (SD) age of 59.9 (11.3) years seeking treatment for AF at an arrhythmia clinic completed the Patient Activation Measure (PAM), Atrial Fibrillation Severity Scale, Knowledge about Atrial Fibrillation test, Hospital Anxiety Depression Scale, Godin Leisure-Time Exercise Questionnaire, and Patient Assessment of Chronic Illness Care. Sociodemographic and clinical data were obtained from medical records. PAM scores were categorized into Levels 1–4. Associations among patient-reported outcomes, sociodemographic, and clinical variables were analyzed using Fisher’s exact tests and Kruskal–Wallis procedures.ResultsThe PAM scores of nearly half (45.5%) of the patients were at Level 3, while the scores of 38% were at Level 4. Male sex (P=0.02), higher education (P=0.004), being employed (P=0.005), lower body mass index (P=0.03), tobacco abstinence (P=0.02), less AF symptom burden (P=0.006), less depression (P≤0.0001) and anxiety (P=0.006), greater knowledge of AF (P=0.01), and higher levels of physical activity (P=0.02) were associated with higher activation levels.ConclusionHigher levels of patient activation in those with AF were associated with a more positive health status and educational attainment. Additional research to describe activation in patients with AF is warranted to identify patients at risk for low activation and to tailor interventions to activation level.

Atrial fibrillation ablation using cryoballoon technology: Recent advances and practical techniques.

Atrial fibrillation (AF) affects 1-2% of the population, and its prevalence is estimated to double in the next 50 years as the population ages. AF results in impaired patients' life quality, deteriorated cardiac function, and even increased mortality. Antiarrhythmic drugs frequently fail to restore sinus rhythm. Catheter ablation is a valuable treatment approach for AF, even as a first-line therapy strategy in selected patients. Effective electrical pulmonary vein isolation (PVI) is the cornerstone of all AF ablation strategies. Use of radiofrequency (RF) catheter in combination of a three-dimensional electroanatomical mapping system is the most established ablation approach. However, catheter ablation of AF is challenging even sometimes for experienced operators. To facilitate catheter ablation of AF without compromising the durability of the pulmonary vein isolation, "single shot" ablation devices have been developed; of them, cryoballoon ablation, is by far the most widely investigated. In this report, we review the current knowledge of AF and discuss the recent evidence in catheter ablation of AF, particularly cryoballoon ablation. Moreover, we review relevant data from the literature as well as our own experience and summarize the key procedural practical techniques in PVI using cryoballoon technology, aiming to shorten the learning curve of the ablation technique and to contribute further to reduction of the disease burden.

Differences in knowledge among patients with atrial fibrillation receiving non-vitamin K antagonist oral anticoagulants and vitamin K antagonists.

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF) worldwide. Few articles have compared current understanding of AF patients about the disease and anticoagulant therapy in relation to the medications used. We sought to compare the knowledge of AF and anticoagulation between AF patients treated with NOACs and those on vitamin K antagonists (VKAs). We used the Jessa AF Knowledge Questionnaire (JAKQ), developed and validated in Belgium. Patients were re-cruited at a tertiary centre in Kraków, Poland. A total of 479 AF patients completed the JAKQ. Patients on NOACs (n = 276, 57.6%) compared with those on VKAs (n = 175, 36.5%) did not differ regarding demographic and clinical variables. The mean score of the JAKQ was very similar in the NOAC and VKA group (60.7 ± 17.0% vs. 61.6 ± 17.1%; p = 0.4, respectively). The differences in the proportion of correct responses referred to three questions. Consequences of AF, such as blood clots and cerebral infarction, were more obvious for patients on NOACs compared with those on VKAs (81.5% vs. 70.9%; p = 0.01). The patients on NOACs (78.7% vs. 67.6%; p = 0.009) more frequently considered consulting a physician for advice concerning anticoagulant treatment before surgery, while fewer patients on NOACs were aware of the need to take their medication even if they did not feel AF (76.1% vs. 89.7%; p = 0.0004). Only 25.9% of the VKA patients and 49.3% of the NOAC users knew what to do if they missed a dose of the anticoagulant. The knowledge of arrhythmia and anticoagulation is better regarding the safety issues among subjects on NOACs compared with those on VKAs. Irrespective of the type of oral anticoagulation therapy, education of AF patients should be improved.

Evaluating the potential for pharmacists to prescribe oral anticoagulants for atrial fibrillation.

Oral anticoagulant therapy (OAC) to prevent atrial fibrillation (AF)-related strokes remains poorly used. Alternate strategies, such as community pharmacist prescribing of OAC, should be explored. Approximately 400 pharmacists, half with additional prescribing authority (APA), randomly selected from the Alberta College of Pharmacists, were invited to participate in an online survey over a 6-week period. The survey consisted of demographics, case scenarios assessing appropriateness of OAC (based on the 2014 Canadian Cardiovascular Society AF guidelines) and perceived barriers to prescribing. Regression analysis was performed to determine predictors of knowledge. A total of 35% (139/397) of pharmacists responded to the survey, and 57% of these had APA. Depending on the case scenario, 55% to 92% of pharmacists correctly identified patients eligible for stroke prevention therapy, but only about a half selected the appropriate antithrombotic agent; there was no difference in the knowledge according to APA status. In multivariable analysis, predictors significantly associated with guideline-concordant prescribing were having the pharmacist interact as part of an interprofessional team (p = 0.04) and direct OAC (DOAC) self-efficacy (confidence in ability to extend, adapt, initiate or alter prescriptions; p = 0.02). Barriers to prescribing OAC for APA pharmacists included a lack of AF and DOAC knowledge and preference for consulting the physician first, but these same pharmacists also identified difficulty in contacting the physician as a major barrier. Community pharmacists can identify patients who would benefit from stroke prevention therapy in AF. However, physician collaboration and further training on AF and guidelines for prescribing OAC are needed.

'It's like a frog leaping about in your chest': Illness and treatment perceptions in persistent atrial fibrillation.

Persistent atrial fibrillation (AF) is an abnormal heart rhythm associated with low quality of life (QoL) and significant health-related costs. The purpose of the study was to examine patients' illness and treatment beliefs and ways of coping with AF symptoms, to provide insight into promoting better QoL and treatment-specific management. Beliefs were explored across three procedural treatment groups using a qualitative cross-sectional design. Thirty semi-structured interviews were carried out with patients undertaking cardioversion (n=10), catheter ablation (n=11) and atrioventricular node ablation (n=9). Interviews were transcribed and analysed using inductive thematic analysis with elements of grounded theory. An overarching theme of a vicious cycle was evident, which related to perceived lack of knowledge and understanding of AF, attempts to control symptoms and negative emotional reactions to failed control attempts. This vicious cycle related to three subordinate themes: (1) unpredictability and uncertainty of AF and symptoms; (2) coping with symptoms through (a) avoidance (b) all-or-nothing- (c) slowing down behaviours; and (3) concerns and expectations about treatment. Patients outlined a need to gain control of unpredictable symptoms by monitoring and varying activity levels. These behaviours were often appraised as ineffective at controlling symptoms, leading to heightened uncertainty and increased activity avoidance. Treatment concerns escalated with increasing number and invasiveness of procedures. Improving AF patients' perceived understanding of their illness and treatment and promoting more effective symptom-management strategies may alleviate psychological distress and improve QoL. Themes elaborated on the common-sense model whereby patients' beliefs about illness and treatment interact with coping behaviours. Statement of contribution What is already known about this subject? Quality of life (QoL) is disproportionately low in people with persistent atrial fibrillation (psAF). The common-sense model suggests illness perceptions and coping predict QoL in chronic illnesses. No previous studies have examined the idiosyncratic beliefs and coping behaviours of psAF patients. What does this study add? A vicious cycle of perceived lack of understanding of AF, attempts to control AF and distress at failed attempts at control, was a key theme. PsAF patients reported continued avoidance/all-or-nothing behaviours despite symptomatic relief post-procedure, and disengagement from enjoyable activities. PsAF patients reported procedure-specific concerns/expectations, which could be targeted in future interventions aimed at reducing distress.

Association between subjective risk perception and objective risk estimation in patients with atrial fibrillation: a cross-sectional study

ObjectiveOral anticoagulation (OAC) is state-of-the-art therapy for atrial fibrillation (AF), the most common arrhythmia worldwide. However, little is known about the perception of patients with AF and how it correlates...

Abstract TP294: Effect of Educational Level on Atrial Fibrillation Patients’ Knowledge and Perceptions About Oral Anticoagulation Therapy: Results From an International Study

Introduction: Previous research has demonstrated that patients with atrial fibrillation (AF) have limited knowledge of AF, stroke and oral anticoagulant (OAC) treatment. This analysis assessed the effect of educational level on stroke knowledge, AF perception, concern about stroke, OAC treatment preferences and adherence. Methods: This was a cross-sectional, prospective survey of 936 adult patients (mean (SD) age 54.3 (16.6) yrs; 37.2% female) with AF on OACs in the USA, Canada, Germany, France and Japan. Three groups were included: AF with recent stroke (≤ 6 m); new onset AF (≤ 6 [ ≤ 12 m in Japan]) without recent stroke; established AF (7-24m [1-3yrs in Japan]) without recent stroke. Open-ended questions determined stroke knowledge, assessed according to a predefined scoring system. Patients were grouped according to educational level: no school-leaving certificate (low), high school diploma, community college and university/technical college. Results: Stroke knowledge was similar in all patients regardless of educational level. A greater proportion of patients with college education were ‘always’ or ‘often concerned’ about stroke, whereas a greater proportion of those with low levels of education were ‘never concerned’ about stroke (or didn’t know). Educational level had no effect on self-reported OAC adherence or patient preference to be involved in OAC treatment decisions. Patients with no school leaving certificate perceived taking medication (all drugs) as a ‘major burden’ (25.9%), while significantly more patients with college/university education did not view taking medication as burdensome (38.5% and 50.4% versus 37.0%, respectively; Table). Conclusions: Education influenced patients’ perceptions of the seriousness of AF, frequency of concern about stroke and perceived burden of medication. Educational attainment did not affect level of stroke knowledge, OAC adherence and desire to be involved in OAC treatment decisions.

Self-monitoring for atrial fibrillation recurrence in the discharge period post-cardiac surgery using an iPhone electrocardiogram

Postoperative atrial fibrillation (POAF) occurs in 25-40% of patients following cardiac surgery, and is associated with a significant increased risk of stroke and mortality. Routine surveillance is not performed post-discharge; however, recurrence of POAF can occur in up to 30% of patients discharged in sinus rhythm. This study aimed to determine the feasibility of patients self-monitoring with an iPhone handheld electrocardiogram (iECG) to identify recurrence of POAF in the post-discharge period following cardiac surgery. Patients with POAF following cardiac surgery were eligible for participation if they had no prior history of atrial fibrillation (AF) and were discharged home in stable sinus rhythm. Participants were provided with an iECG and asked to record a 30-s iECG, four times per day for 4 weeks post-discharge. iECGs were automatically transmitted to a secure server, and reviewed for the presence of AF by the research team and a validated algorithm. All participants also received brief education on AF. Forty-two participants completed the intervention (mean age 69 ± 9 years, 80% male). Self-monitoring for POAF recurrence using an iECG was feasible and acceptable, and participants felt empowered. Self-monitoring identified 24% (95% confidence interval, 12-39%) with an AF recurrence within 17 days of hospital discharge. These participants were significantly younger than those without AF recurrence (64 ± 7 vs 70 ± 10 years; P = 0.025), and had a significantly lower CHA2DS2-VASc score (2.3 ± 1.2 vs 3.7 ± 2.3; P = 0.007). However, 80% were at high enough stroke risk to warrant consideration of anticoagulation, i.e. CHA2DS2-VASc score ≥2. Only 30% of recurrences were associated with palpitations. Participation also improved AF knowledge from 6.4 ± 1.8 to 7.3 ± 1.8 (P = 0.02), of a total score of 10. Providing patients with an iECG is a non-invasive, inexpensive, convenient and feasible way to monitor for AF recurrence in post-cardiac surgery patients. It also provides a mechanism to provide knowledge about the condition and also potentially reduce anxiety. The success of patients using this technology also has implications for extending the use of iECG self-monitoring to other patient groups such as those undergoing antiarrhythmic interventions for AF.

Your Father and Grandfather's Atrial Fibrillation: A Review of the Genetics of the Most Common Pathologic Cardiac Dysrhythmia.

Atrial fibrillation (AF) remains the most common pathologic dysrhythmia in humans with a prevalence of 1-2% of the total population and as high as 10% of the elderly. AF is an independent risk marker for cardiovascular mortality and morbidity, and given the increasing age of the population, represents an increasing burden of disease. Although age and hypertension are known risk factors for development of AF, the study of families with early onset AF revealed mutations in genes coding for ion channels and other proteins involved in electrotonic coupling as likely culprits for the pathology in select cases. Recent investigations using Genome-Wide Association Studies have revealed several single nucleotide polymorphisms (SNPs) that appear to be associated with AF and have highlighted new genes in the proximity of the SNPs that may potentially contribute to the development of the dysrhythmia. Here we review the genetics of AF and discuss how application of GWAS and next generation sequencing have advanced our knowledge of AF and further investigations may yield novel therapeutic targets for the disease.

Improved Resource Utilization With Similar Efficacy During Early Adoption of Cryoballoon Pulmonary Vein Isolation as Compared to Radiofrequency Ablation for Paroxysmal Atrial Fibrillation.

Cryoballoon pulmonary vein isolation (PVI) is an alternative to radiofrequency (RF) PVI for the treatment of paroxysmal atrial fibrillation (AF). Treatment effect, complication rates, and hospital length of stay are not well established with early use of cryoballoon PVI as compared to more experienced performance of RF PVI. We reviewed the early experience of cryoballoon PVIs for paroxysmal AF performed by 3 operators at our institution compared to their most recent RF PVIs. All repeat procedures were excluded. Patients were assessed for recurrence of AF at 6 months after the procedure, including a 3-month blanking period. Complications, procedure time, and hospital length of stay were recorded. Consecutive patients presenting to the ER with ECG-documented AF at an urban teaching hospital were treated according to a guideline-based care protocol, including a patient toolkit at ER discharge, and systematic referral to a rapid access AF clinic. Consenting patients received questionnaires on AF knowledge, patient satisfaction, and the AFEQT questionnaire at first visit and three-month follow-up. Final analysis included 50 cryoballoon PVIs and 50 RF PVIs. There was no significant difference in baseline characteristics or percentage of patients wearing a home monitor (80% for cryoballoon vs 80% for RF). Symptomatic improvement was experienced by 96% of cryoballoon PVI as compared to 86% of RF PVI patients (p=0.08). Freedom from AF at 6 months was similar between the two groups (70% for cryoballoon and 70% for RF, p=1). Complications were seen in 6% of cryoballoon procedures as compared to 10% of RF procedures (p=0.46). Hospital length of stay was significantly shorter in the cryoballoon group (1.6 vs 3.4 nights, p=0.003). At the time of its adoption, cryoballoon PVI is associated with shorter procedure times and hospital length of stay as compared to RF PVI in experienced operators while maintaining similar efficacy outcomes and complication rates.

Best practice for atrial fibrillation patient education.

Patients' beliefs about their health (and illness), medications and healthcare they receive are important determinants of whether or not they accept recommended treatments; influence their coping responses in relation to their illness; make them adhere to recommended therapy and ultimately affect health outcomes. Incorporation of patients' preferences for therapy should now be considered an integral part of the decision-making process. This gradual shift in health-care practice from paternalistic to shared-decision making, whereby there is a two-way exchange of information between the patient and healthcare provider and both are involved in the treatment decision, requires a reasonable level of understanding and knowledge of the condition and its treatment by the patient. However, patients with atrial fibrillation (AF) often have poor knowledge about their condition and the benefits and risks of AF and AF treatments. Physicians and other healthcare providers may have doubts over a patient's ability to adhere to certain treatment regimens, particularly oral anticoagulation, due in part to the lack of patient knowledge, and this may be an important determinant of whether such treatments are even considered as therapeutic options. Further, patients often hold misconceptions about AF and treatment options, which may act as barriers to their acceptance of the condition and adherence to therapy. This review will summarise the literature on the knowledge of patients about AF and its management, how patients' values and preferences can impact on their treatment choices, the ideal components of patient education, the impact of educational interventions on patients' knowledge and perceptions of AF, and where appropriate highlight specific issues facing lone AF patients.

CAN GENDER INFLUENCE SYSTEM OF CARE, PATIENT SATISFACTION AND QUALITY OF LIFE FOR PATIENTS REFERRED TO THE ATRIAL FIBRILLATION CLINIC?

Few studies have examined gender-related differences in common arrhythmias such as atrial fibrillation (AF) and atrial flutter (AFL). Prior studies indicate that women have a worse quality of life (QOL) and less improvement with treatment compared to men. We examined gender in relation to clinical characteristics and QOL in patients receiving a standardized follow-up program after an Emergency Room (ER) visit with AF/AFL. Consecutive patients presenting to the ER with ECG documented AF or AFL at an urban teaching hospital were treated according to a care protocol, including a patient toolkit at ER discharge and systematic referral to a rapid access AF Clinic. The toolkit included educational pamphlets on AF, stroke and stroke prevention, treatment options, and letters to family doctors. Consenting patients received questionnaires on AF knowledge, satisfaction, and disease specific quality of life (AFEQT - QOL) at first visit and at a three month follow-up. One hundred and twenty eight patients seen in the AF Clinic participated in the AFTER3 study. Fifty nine percent of the patients were male. The mean age was 67.7±13.0 years and 60.8±12.6 for females and males (p=0.0032), respectively. Newly documented AF was reported in 80% of women and 65% of men (p=0.07). Eighty five percent of males and females received a toolkit in the ER. Patients were seen an average of 14.6 days following ER visit, with no difference between men and women. Ninety eight percent of females and 78% males (p=0.0036) brought the toolkit to their AF Clinic appointment. Fifty eight percent of males and 38% of females searched for more information about AF elsewhere (p=0.0473). Over 80% were aware of their diagnosis, while slightly more females (87%) than males (79%) knew that AF increased their risk of stroke. Eight five percent of males and 78% of females were “Very Satisfied” with the care they received in the AF Clinic at 3 month follow-up. Over 90% of males and females indicated that they had a General Practitioner, while only 31% of females and 45% of males had a Cardiologist. Baseline patient characteristics and QOL outcomes are shown in Table 1. In comparison to males, females with AF/AFL were older and had a higher stroke risk. A systematic program of patient education, follow-up and protocol driven care in the AF Clinic led to high patient satisfaction and significant improvement in QOL for both genders.

A Censis survey on atrial fibrillation awareness in the general population and among general practitioners and affected patients in Italy

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, particularly in the elderly. AF is considered an independent predictor of mortality and risk factor for stroke. AF-related stroke is usually severe and associated with a high rate of mortality and disability. Despite its prevalence, AF is a poorly known disease and it is underestimated by the general population. The aim of the Censis survey was to analyze the levels of AF knowledge and information in the Italian population and the level of AF risk awareness by general practitioners and AF patients. The survey included structured interviews with a sample of 1000 Italian citizens aged ≥18 years, 300 general practitioners, and 1200 AF patients. The analysis confirmed low levels of knowledge of AF. In particular, the results showed that only one third of Italians know AF that is however perceived as a severe disease. In this subgroup, the risk of stroke associated with AF is known by 65%, but it is also widespread the wrong concept that AF is associated with an increased risk of myocardial infarction. The lack of knowledge of AF and its complications by the Italian population is due to educational gaps of general practitioners. In particular, only 50% of the Italian general practitioners perceive the thromboembolic risk of paroxysmal AF as comparable to that of permanent AF. In addition, there is an underuse of the scores for thromboembolic and hemorrhagic risk stratification recommended by current guidelines and a frequent use of antiplatelet therapy rather than oral anticoagulant therapy. There is also a low level of knowledge and awareness of the disease among AF patients. However, the majority of AF patients are aware of the importance of antithrombotic prophylaxis for stroke prevention. This study demonstrates limited knowledge and awareness of AF in the general population and also among general practitioners and affected patients.

The effect of a nurse-led integrated chronic care approach on quality of life in patients with atrial fibrillation

Quality of life (QoL) is often impaired in patients with atrial fibrillation (AF). A novel nurse-led integrated chronic care approach demonstrated superiority compared with usual care in terms of cardiovascular hospitalization and mortality. Consequently, we hypothesized that this approach may also improve QoL and AF-related knowledge, which in turn may positively correlate with QoL. In this randomized controlled trial, 712 patients were randomly assigned to nurse-led care vs. usual care. Nurse-led care consisted of guidelines-based, software supported care, supervised by cardiologists. Usual care was provided by cardiologists in the regular outpatient setting. Quality of life was assessed by means of the Medical Outcomes Study 36-Item Short-Form Survey (SF-36). The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression scores. The AF knowledge scale was used to gain an insight into the patients' AF knowledge levels. Baseline QoL scores were relatively high in both groups, with median scores ranging from 55 to 100. Quality of life significantly improved over time in both groups with no significant differences between the two groups. Atrial fibrillation-related knowledge improved over time and was significantly higher at follow-up in the intervention group, compared with the usual care group (8.23 ± 2.16 vs. 7.66 ± 2.09; P < 0.05). Quality of life was correlated with gender (rs: -5.819 to -2.960), anxiety (rs: -0.746 to -0.277), depression (rs: -0.596 to -0.395), and knowledge (rs: 0.145-0.245), expressed in Spearman's rank correlation coefficient (rs). Quality of life including anxiety and depression improved over time, regardless of the treatment group. The AF-related knowledge level was better in the nurse-led care group at follow-up. Trial registration information: Clinicaltrials.gov identifier number: NCT00753259.

Stroke Prevention in Atrial Fibrillation in Older Adults: Existing Knowledge Gaps and Areas for Innovation: A Summary of an American Federation for Aging Research Seminar

Atrial fibrillation (AF) is a common and morbid cardiac arrhythmia that increases in prevalence with advancing age. The risk of ischemic stroke, a primary and disabling hazard of AF, also increases with advancing age. The aging of the population is anticipated to contribute to a rising burden of AF-related morbidity and economic costs, given the close association between the arrhythmia and aging. Recent biological, diagnostic, and therapeutic developments raise hope that AF-related stroke can be largely prevented, yet despite advances in stroke prevention for individuals with AF, numerous scientific and clinical knowledge gaps remain, particularly as these developments are applied to older adults. Given the public health importance of AF-related stroke in elderly adults, a group of clinician-investigators convened on April 5, 2012, to identify promising areas for investigation that may ultimately reduce stroke-related morbidity. This article summarizes the meeting discussion and emphasizes innovative topic areas that may ultimately facilitate the application of novel preventive, diagnostic, and therapeutic insights into the management of older adults with AF. The opinions of those that participated in the meeting limit this report, which may not represent all of the questions that other experts in this field might raise.

The atrial fibrillation knowledge scale: Development, validation and results

Patients' understanding of the nature and consequences of atrial fibrillation (AF) and appropriate therapy, is essential to optimize AF management. Currently, no valid instrument exists to measure knowledge in AF patients with a combined focus on disease, symptom recognition and therapy. Since there is a need for a specific instrument to detect gaps in the knowledge of AF patients, we developed and assessed the AF knowledge scale. The scale was developed based on a standard questionnaire in AF and existing knowledge scales in heart failure. Content validity was evaluated by a panel of 24 cardiology nurses, and 2 cardiologists. Face validity was assessed by judgment of 8 randomly selected AF patients, and construct validity was determined by performing an exploratory factor analysis with varimax rotation, based on 529 patients who completed the AF knowledge scale after one year follow-up. Internal consistency was calculated by means of Cronbach's α. Finally the scale was tested for sensitivity, in terms of ability to distinguish patients' knowledge levels. The scale consists of 11 items concerning AF in general, symptom recognition, and treatment. Content-, face- and construct validity appeared to be acceptable. Cronbach's α was .58. The scale was able to differentiate between knowledge levels in patients with newly detected AF and after one year follow up. The instrument is valid and able to distinguish knowledge levels in AF patients. Furthermore, it can be successfully used in an outpatient care setting as an important tool in the tailoring of patient education (Clinicaltrials.gov identifier: NCT00753259).

Barriers to Warfarin Use for Stroke Prevention in Patients With Atrial Fibrillation in Hong Kong

Oral anticoagulation medications such as warfarin reduce the risk of stroke in atrial fibrillation (AF) but have been underutilized. This study aimed to investigate physicians' perceptions of stroke prevention management and patients' knowledge of AF and warfarin therapy in Hong Kong (HK). Both physician and patient's knowledge on warfarin use were the barriers for stroke prevention in patients with atrial fibrillation in Hong Kong. This prospective survey-based study was conducted between February 2011 and April 2011 to assess physicians' perceptions of stroke prevention management, patients' knowledge of AF, and patients' knowledge of warfarin therapy. The results were scored and compared with those in foreign countries. Sixty-two physicians and 114 warfarin users were recruited in the study. The average score of HK physicians in the knowledge of stroke prevention therapy in AF patients was lower than that of Australian (AUS) family physicians (HK 2.48 vs AUS 4.02 out of 7). The mean scores of AF patients in Hong Kong regarding the knowledge of AF were lower than that of United Kingdom (UK) (HK 1.16 vs UK 2.24 out of 4) (P < 0.001) and that of Finland (FIN) (HK 2.77 vs FIN 5.94 out of 8) (P < 0.001), respectively. The mean score of AF patients in Hong Kong regarding the knowledge of warfarin therapy was lower than that of AF patients in the United States (US) (HK 2.39 vs US 3.92). The barriers of warfarin use for AF patients in Hong Kong were related to both physicians and patients. Many Hong Kong physicians did not comply with international recommendations of stroke prevention in AF patients, and AF patients had a low knowledge level about the disease and warfarin therapy.

Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: Effects of an educational intervention programme: The West Birmingham Atrial Fibrillation Project

Objective Previous research has demonstrated that patients with atrial fibrillation (AF) possess very little knowledge of their disease, the consequences of AF and the benefits/risks of anti-coagulant therapy. The aim of this pilot study was to examine patient's knowledge and perceptions of AF and their anticoagulant treatment before and after a brief educational intervention. Materials and methods Ninety-three patients (47 male; mean (S.D.) age 67.3 (11.6) years) completed the baseline interview to assess their knowledge and perceptions of AF. All patients were given an information booklet which explained what AF was, associated symptoms, the possible causes and consequences of AF, treatment options and their benefits/risks, what the INR is and what factors may effect it. The booklet was explained to each patient by the researcher and given to the patient to take away for reference. Thirty-three (35.5%) patients (12 men; mean (S.D.) age 68.0 (13.6) years) completed the follow-up assessment to re-assess their knowledge and perceptions of AF. Results Only 49% of patients could name their cardiac condition at baseline, although the majority were aware that AF was an arrhythmia (80% baseline vs. 91% follow-up). Only about half the patients perceived AF as a serious condition or were aware that AF predisposes to thromboembolism at baseline. Following the educational intervention there was a non-significant increase in patient knowledge of the risks associated with AF. Of those who completed both questionnaires, 52% were aware that anticoagulants prevented blood clots, which increased to 70% post-intervention. However, few patients were aware of the benefit of stroke prevention associated with anticoagulants at baseline (21%) or after the educational intervention (27%). The intervention had little effect on increasing awareness of the bleeding risks associated with anticoagulants, although three in five people appeared to appreciate these risks. However, the educational intervention significantly improved patient's knowledge of the target INR range and factors that may affect INR levels ( p = 0.001 and p = 0.014, respectively) for those who completed both questionnaires. Conclusions Most patients with AF possess very limited knowledge about their cardiac condition, its consequences, and how anticoagulant treatment can benefit them. This pilot study has demonstrated that a brief educational intervention with an information booklet can help to somewhat improve their knowledge about anticoagulation therapy for AF.

Ethnic differences in patient perceptions of atrial fibrillation and anticoagulation therapy: the West Birmingham Atrial Fibrillation Project.

We hypothesized that different ethnic groups would have different levels of knowledge and perceptions of atrial fibrillation (AF) and of their antithrombotic therapy. To investigate this further, we conducted a cross-sectional survey of patients with documented chronic AF who were attending the anticoagulation clinic in our city center teaching hospital, serving a multiethnic population. We surveyed 119 patients (77 male; mean age 69+/-9 years [mean+/-SD]); of these, 39 were Indo-Asian (33%), 27 Afro-Caribbean (23%), and 53 white (44%). Only 63% of patients in the overall study cohort were aware of their cardiac condition, with Indo-Asians and Afro-Caribbeans significantly less aware of AF compared with the white patients (P<0.001). When questioned about the perception of the severity of the underlying condition, the majority (61%) felt that AF was "not serious." A large proportion were unaware that AF predisposed to thrombosis and stroke; among the ethnic groups, Indo-Asians appeared to be the least aware of the stroke and thromboembolic associations of AF. Only 52% in the whole cohort were aware of the reason(s) for commencing their warfarin, whereas the remainder began warfarin therapy simply because their "doctor told them to." Most patients in the whole cohort were aware of warfarin being used to prevent blood clots (65%) or stroke (66%), but Indo-Asians and Afro-Caribbeans were less so. Only 45% of the study cohort believed that there was some risk associated with warfarin therapy in the form of either "bleeding" or "poisoning." Only a minority of Indo-Asians and Afro-Caribbeans with AF felt that their doctor had given them enough information about their warfarin therapy, and many from these ethnic groups felt that they were careless about taking their warfarin. In conclusion, many patients with AF possess very limited knowledge of AF as well as its consequences and therapy. In particular, our study has highlighted significant differences between different ethnic groups in terms of their knowledge of the risks, actions, and benefits of warfarin as well as of AF itself.