Atrial Fibrillation Severity Scale Research Articles

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 symptom clusters and associated clinical characteristics and outcomes: A cross-sectional secondary data analysis.

Symptom clusters among adults with atrial fibrillation have previously been identified but no study has examined the relationship between symptom clusters and outcomes. The purpose of this study was to identify atrial fibrillation-specific symptom clusters, characterize individuals with each cluster, and determine whether symptom cluster membership is associated with healthcare utilization. This was a cross-sectional secondary data analysis of 1501 adults from the Vanderbilt Atrial Fibrillation Registry with verified atrial fibrillation. Self-reported symptoms were measured with the University of Toronto Atrial Fibrillation Severity Scale. We used hierarchical cluster analysis (Ward's method) to identify clusters and dendrograms, pseudo F, and pseudo T-squared to determine the ideal number of clusters. Next, we used regression analysis to examine the association between cluster membership and healthcare utilization. Males predominated (67%) and the average age was 58.4 years. Two symptom clusters were identified, a Weary cluster (3.7%, n=56, fatigue at rest, shortness of breath at rest, chest pain, and dizziness) and an Exertional cluster (32.7%, n=491, shortness of breath with activity and exercise intolerance). Several sociodemographic and clinical characteristics varied by symptom cluster group membership, including age, gender, atrial fibrillation type, body mass index, comorbidity status, and treatment strategy. Women were more likely to experience either cluster ( p<0.001). The Weary cluster was associated with nearly triple the rate of emergency department utilization (incident rate ratio [IRR] 2.8, p<0.001) and twice the rate of hospitalizations (IRR 1.9, p<0.001). We identified two symptom clusters. The Weary cluster was associated with a significantly increased rate of healthcare utilization.

Atrial fibrillation symptom profiles associated with healthcare utilization: A latent class regression analysis.

Symptoms drive healthcare use among adults with atrial fibrillation, but limited data are available regarding which symptoms are most problematic and which patients are most at-risk. The purpose of this study was to: (1) identify clusters of patients with similar symptom profiles, (2) characterize the individuals within each cluster, and (3) determine whether specific symptom profiles are associated with healthcare utilization. We conducted a cross-sectional secondary data analysis of 1,501 adults from the Vanderbilt Atrial Fibrillation Registry. Participants were recruited from Vanderbilt cardiology clinics, emergency department, and in-patient services. Subjects included in our analysis had clinically verified atrial fibrillation and a completed symptom survey. Symptom and healthcare utilization data were collected with the University of Toronto Atrial Fibrillation Severity Scale. Latent class regression analysis was used to identify symptom clusters, with clinical and demographic variables included as covariates. We used Poisson regression to examine the association between latent class membership and healthcare utilization. Participants were predominantly male (67%) with a mean age of 58.4years (±11.9). Four latent classes were evident, including an Asymptomatic cluster (N=487, 38%), Highly Symptomatic cluster (N=142, 11%), With Activity cluster (N=326, 25%), and Mild Diffuse cluster (N=336, 26%). Highly Symptomatic membership was associated with the greatest rate of emergency department visits and hospitalizations (incident rate ratio 2.4, P<0.001). Clinically meaningful atrial fibrillation symptom profiles were identified that were associated with increased rates of emergency department visits and hospitalizations.

Relation of Body Mass Index to Symptom Burden in Patients withAtrial Fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and increased mortality. As body mass index (BMI) is increasingly recognized as an important risk factor for the development of AF, we tested the hypothesis that BMI modulates symptomatic AF burden. Cross-sectional data collected from 1,382 patients in the Vanderbilt AF Registry were analyzed. AF severity was assessed using the Toronto atrial fibrillation severity scale (AFSS). BMI was categorized according to World Health Organization guidelines and patients were grouped according to their present AF treatment regimen: no treatment (n = 185), rate control therapy with atrioventricular nodal blocking agents (n = 351), rhythm control with antiarrhythmic drugs (n = 636), and previous AF ablation (n = 210). Patients with BMI >35 kg/m2 had higher AFSS scores than those with BMI <30 kg/m2 in the rate control (43.57 vs 38.21: p = 0.0057), rhythm control (46.61 vs 41.08: p = 1.6 × 10-4), and ablation (44.01 vs 39.02: p = 0.047) groups. Inunivariate linear models, BMI was associated with an increase in the AFSS score in the rate control (0.27, 95% confidence interval [CI] 0.05 to 0.5, p = 0.02), rhythm control (0.38, 95% CI 0.21 to 0.56, p = 2.49 × 10-5), and ablation (0.38, 95% CI 0.03 to 0.73, p = 0.03) groups. The association remained significant in the rhythm control groups after adjusting for age, gender, race, and comorbidities (0.29, 95% CI 0.11 to 0.49, p = 0.002). In conclusion, increasing BMI was directly associated with patient reported measures of AF symptom severity, burden, and quality of life. This was most significant in patients treated with rhythm-control strategies.

Abstract 25: Accuracy of Patient Identification of Atrial Fibrillation in the Clinic Setting

Background: Atrial fibrillation (AF) related symptoms are commonly reported but often difficult to directly correlate with arrhythmia. Given that symptoms largely drive management, correct patient awareness of AF is critical to implementation of appropriate therapy. Objective: To determine accuracy of patient identification of their own atrial rhythm. Methods: All AF patients in our center undergo patient reported outcome assessment with the Toronto AF Severity Scale (AFSS) immediately prior to clinic visit. Using the validated questions from the AFSS, we assessed if patients were able to accurately determine their rhythm (AF or not) compared to an electrocardiogram (ECG) during the same clinic visit. Results: We identified 254 unique patients (Table 1) with interpretable ECG and AFSS data available from the same visit. Based on ECG, 81% (n=206) were not in AF. 20 of these 206 patients (9.7%) incorrectly identified themselves in AF (Figure 1). Patients who incorrectly thought they were in AF were significantly older (p&lt;0.05). Of the 48 (18.9%) that were in AF by ECG, 15 (31.2%) incorrectly identified themselves in sinus rhythm. There was no significant difference between sex, age or mean heart rate in patients in AF. Overall 14% (35 of 254) provided an assessment that was inconsistent with their ECG. Conclusion: Approximately one of ten patients incorrectly identified themselves as being in AF despite being in sinus rhythm. Without a standardized method to confirm if symptoms truly correlate with AF these patients may be at risk for unnecessary antiarrhythmic therapies. On the contrary, nearly a third of patients were unaware of AF which reemphasizes the incidence of asymptomatic AF.

Abstract 147: Impact of Risk Factor Modification in Improving Quality of Life and Arrhythmia Symptoms in Patients With Atrial Fibrillation

Objective: The desired goal of atrial fibrillation (AF) management is maintenance of sinus rhythm in order to improve quality of life (QoL) and arrhythmia symptoms (AS). Although obesity and obstructive sleep apnea (OSA) are known risk factors for development of AF, these remain inadequately treated. We report the impact of prospectively modifying these risk factors on QoL and AS in AF patients (pts). Methods: AF pts with obesity (body mass index (BMI) ≥30kg/m 2 ) and/or the need for OSA management (high-risk as per Berlin Questionnaire or untreated OSA) were voluntarily enrolled in a nurse-led risk factor modification (RFM) program at their arrhythmia clinic visit. RFM entailed patient education, lifestyle modification counseling, coordination of care with appropriate specialists, and longitudinal care management. Progress with weight loss (WL) and OSA treatment was monitored via monthly follow-up calls and/or downloads from continuous positive airway pressure (CPAP) units for up to 12 months. QoL and AS were determined with the SF-36 and AF Severity Scale (AFSS) respectively, and were assessed at baseline, 6 months, and 12 months. Student t-test and chi-square tests were used to compare continuous and dichotomous variables. Results: From 11/1/16 to 10/31/17, 252 pts (age 63±11 years; male=179; paroxysmal AF=126) were enrolled as follows: 189 for obesity and 93 for OSA. The mean WL was 2.7±3.8% from baseline and 78% (n=126 of 162 pts with available data) of enrolled obese patients achieved WL. Among 93 pts at risk for OSA, 70 completed sleep studies and 50 were identified with OSA. Majority of these patients (76%; n=38 of 50) started CPAP therapy and have remained full (57%; n=17 of 30 pts with available CPAP data) and partial (13%; n=4 of 30) users. Table shows that SF-36 and AFSS scores improved for most measures of QoL and AS from baseline to 6 months. Conclusion: Participation in a risk factor modification program targeting obesity and obstructive sleep apnea can improve quality of life and arrhythmia symptoms in patients with atrial fibrillation. The impact of this strategy on long-term maintenance of sinus rhythm remains to be determined.

PSYCHOLOGICAL FACTORS ASSOCIATED WITH SELF-REPORTED SYMPTOM BURDEN, QUALITY OF LIFE AND HEALTH CARE USAGE AMONG PAROXYSMAL ATRIAL FIBRILLATION PATIENTS

Atrial fibrillation (AF) is associated with distressing symptoms, impaired quality of life (QoL) and hospital readmissions. Anxiety sensitivity (AnxS), a cognitive trait, predisposes individuals to interpret autonomic changes as harmful. AnxS measured with the Anxiety Sensitivity Index (AnxSI), has been associated with AF symptoms independently of objective disease variables. The more recently developed AnxSI-R provides dimensional scores including fear of cardiovascular/somatic reactions. We report from an ongoing study, to: 1) describe clinician- and self-reported AF symptom burden, self-reported health care usage, QoL, anxiety and depression among AF patients at differing care stages; 2) determine whether AnxSI-R scores were associated with AF symptom burden, health-care usage and QoL, independently of age, sex and left atrial diameter from echocardiogram (echo-LAD). To date, 59 eligible consenting subjects (24 females; mean age=57.6 years) with paroxysmal AF, LVEF>55%, no documented stroke/TIA, recruited from an outpatient arrhythmia clinic between Sept/13-April/17, have been categorized as: 1) non-candidates for catheter ablation, n=20; 2) ablation candidates, n=19, mean anticipated time to ablation= 5.6 weeks; 3) ablation, n=20, mean post-ablation interval =20.1 weeks. Measurement included: Canadian Cardiovascular Society Severity of Atrial Fibrillation Scale (SAF; 0-5 mild-severe; clinician-completed); Atrial Fibrillation Severity Scale (AFSS: burden 0-5 low-high; health-care usage 0-6 low-high; well-being/QoL 1-10 low-high), Hospital Anxiety and Depression Scale (HADS; anxiety, depression each 0-21 mild-severe), and AnxSI-R (0-168 mild-severe), patient-completed. Echo-LAD was available for 23 subjects. Parametric and non-parametric statistics were used to analyze continuous and categorical variables, respectively. Stepwise multiple regression with covariates age, sex echo-LAD and the AnxSI-R cardiovascular/somatic score was used to predict subjective (AFSS) symptom burden, well-being and health-care usage. The ablation group had significantly lower CCS-SAF arrhythmia symptom ratings (table) compared to each of the other groups (p < .001). Mean subjective symptom burden (figure) was higher in the ablation candidates vs. each of the other groups (p < .001). Health-care usage was significantly lower among non-candidates compared to ablation (p < .049). None of mean well-being/QoL, anxiety or depression varied significantly between groups. From regression (n=23): AnxS cardiovascular/somatic score (R=.55, p=.006) predicted symptom burden; sex (R=.45, p=.031) predicted well-being; AnxS cardiovascular/somatic score (R=.44, p=.038) predicted health-care usage. AF symptom burden, highest in ablation candidates, may be affected by AnxS independently of objective disease severity. As symptom burden influences treatment decisions, psychological factors may warrant consideration. The AnxSI-R has potential for identifying high-AnxS patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract 13826: Atrial Fibrillation Symptom Clusters Increase Hospitalizations and Emergency Department Visits

Introduction: Symptoms are a predictor of hospitalizations in adults with atrial fibrillation (AF). Symptom clusters are groups of two or more symptoms that are related due to shared mechanisms or a shared impact on outcomes. The impact of AF specific symptom clusters on hospitalization and emergency department (ED) visits has not previously been examined. Hypothesis: We assessed the hypothesis that symptom clusters were associated with AF-related hospitalizations and ED visits. Methods: We examined pre-existing data for 1,501 adults in the Vanderbilt AF Registry, a clinical biorepository that prospectively enrolls both AF patients and their family members. Our sample consists of subjects with confirmed AF and a completed symptom survey (derived from the University of Toronto AF Severity Scale, Chronbach’s α for symptom burden is 0.94). Seven common AF symptoms were measured on a 5 point Likert scale. Our outcomes were self-reported number of AF-related hospitalizations and ED visits in the past 12 months. To identify symptom clusters we used hierarchical cluster analysis, Ward’s method, and Euclidean distance as the dissimilarity measure. The ideal number of clusters was determined with dendrograms, pseudo F, and pseudo T. We used Poisson regression to examine whether the identified clusters were associated with hospitalization and ED visit rates controlling for clinical characteristics. Results: Our sample was primarily male (67%) and Caucasian (96%) with a mean age of 58.4 (± 12.2) years. Two symptom clusters were identified, which we labeled the At Rest cluster (fatigue at rest, shortness of breath at rest, chest pain, and dizziness) and the With Activity cluster (shortness of breath with activity and exercise intolerance). Palpitations was the only symptom that did not cluster with other symptoms. Subjects who experienced all the symptoms in the At Rest cluster had an adjusted incident rate ratio for hospitalizations of 1.9 (p&lt;0.0001) and for ED visits of 2.8 (p&lt;0.0001). There was no statistically significant association between the With Activity cluster and either clinical outcome. Conclusion: We identified two AF-specific symptom clusters. Only the At Rest cluster was significantly associated with AF-related hospitalizations and ED visits.

A Randomised Controlled Trial on the Effect of Nurse-Led Educational Intervention at the Time of Catheter Ablation for Atrial Fibrillation on Quality of Life, Symptom Severity and Rehospitalisation.

Atrial Fibrillation (AF) is a common condition associated with impaired quality of life (QOL) and recurrent hospitalisation. Catheter ablation for AF is a well-established treatment for symptomatic patients despite medical therapy. We sought to examine the effect of point specific nurse-led education on QOL, AF symptomatology and readmission rate post AF ablation. Forty-one patients undergoing AF ablation were randomised to Nurse Intervention (NI) versus Control (C), n=22 vs. 19. Both groups were well matched with respect to age, sex and AF subtype. All patients completed SF36 and AF Symptom Checklist, Frequency and Severity Scale questionnaires at baseline and six months post ablation. The NI group underwent nurse education on admission, prior to discharge, and with telephone contact. Baseline SF-36 and AF Symptom Checklist, Frequency and Severity scores were similar. The NI group showed significant differences compared to Control with respect to higher QOL on the SF-36 score of Physical Functioning and Vitality at six months. There were significant improvements in seven components of the AF Symptom Checklist, Frequency and Severity at six months in the NI group with a trend in a further seven. There was no difference in AF related hospital readmissions at six months between C and NI groups (10.5% vs. 13.6%, p=ns). Nurse-led education at time of AF ablation is associated with improved QOL and reduced symptom frequency and severity compared to usual care.

Depression and Physical Inactivity as Confounding the Effect of Obesity on Atrial Fibrillation

Obesity is associated with an increased likelihood for the development of atrial fibrillation (AF) and with worsened AF symptom severity. However, other factors that are correlated with obesity may confound or mediate the relation of obesity with AF symptom severity. The purpose of this study was to determine if depression and physical inactivity may confound the association of obesity and AF symptom severity. Health status and demographic data were captured by questionnaire for 332 outpatients with documented AF. Weight/height was measured and body mass index (kg/m(2)) calculated. Recent depression symptom severity was assessed using the Patient Health Questionnaire-9 questionnaire. Physical activity during the last month was assessed by questionnaire. AF symptom severity was assessed using the University of Toronto AF Severity scale. Multivariate linear regression was used to evaluate which factors were associated with AF symptom severity. Obesity in patients with AF is associated with increased depression severity. In bivariate analysis, increasing body mass index (p= 0.001), lower levels of physical activity (p<0.001), and more severe depression (p <0.001) were associated with worsened AF symptom severity. In multivariate analysis, only physical activity and depression persisted as significant predictors of AF symptom severity. In conclusion, although obesity likely contributes to the substrate predisposing to the development of AF, other factors may contribute to or mediate the worsened AF symptoms associated with obesity. Depression symptoms and physical inactivity, factors closely correlated with obesity, may exacerbate symptoms in patients with AF.

Flecainide-metoprolol combination reduces atrial fibrillation clinical recurrences and improves tolerability at 1-year follow-up in persistent symptomatic atrial fibrillation.

Atrial fibrillation (AF) affects ∼2% of the total population. In order to prevent AF recurrences, many anti-arrhythmic drugs are currently available, but most of them are burdened by serious side effects and suboptimal efficacy. The aim of the present study was to test efficacy and safety of a combination of flecainide and metoprolol in preventing AF clinical recurrences. This study is a monocentric, prospective, randomized, open-blinded trial on 173 patients with a recent episode of paroxysmal or persistent AF. Patients were randomized into group A (flecainide + metoprolol; n = 80), group B (flecainide only; n = 72), or group C (metoprolol only; n = 21). Main exclusion criteria were recent acute coronary syndrome, heart failure New York Heart Association class III-IV, left ventricular ejection fraction <0.40, atrioventricular conduction disorders, and severe bradycardia. Primary endpoint was symptomatic recurrence over 1-year follow-up. Secondary endpoint was quality of life (QoL) over 1-year follow-up, as assessed by the SF-36 and Atrial Fibrillation Severity Scale questionnaires. Combination therapy with flecainide and metoprolol significantly reduced recurrences at 1-year follow-up when compared with flecainide alone in the whole population (66.7 vs. 46.8%; P < 0.001) and in patients with persistent AF (71.1 vs. 43.6%; P = 0.025) while adding beta-blocker therapy to paroxysmal AF showed no benefit over IC anti-arrhythmic drug-only. Patients randomized to combination therapy experienced a significant improvement of QoL when compared with those assigned to a flecainide-only regimen irrespective of AF type. Flecainide-metoprolol combination therapy improves effectiveness of rhythm control in persistent symptomatic AF and increases tolerability, with a concomitant reduction of side effects and a better compliance.

Abstract 15799: Body Mass Index Modulates Symptomatic Atrial Fibrillation Burden

Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and increased mortality. Approximately fifty percent of patients have AF-related symptoms and require rhythm control therapy with antiarrhythmic drugs (AADs) or cathether ablation. Obesity is increasingly recognized as an important risk factor for the development of AF. Hypothesis: We assessed the hypothesis that body mass index (BMI) modulates AF symptom severity. Methods: Cross-sectional data was collected from 1429 patients in the Vanderbilt AF Registry. AF burden was assessed using the Toronto Atrial Fibrillation Severity Scale (AFSS), a validated survey tool measuring the frequency, duration and severity of AF episodes. BMI was categorized according to WHO guidelines, with BMIs of 18.5 kg/m 2 -25 kg/m 2 considered normal, 25 kg/m 2 -30 kg/m 2 overweight, 30 kg/m 2 -35 kg/m 2 obese and &gt;35 kg/m 2 morbidly obese. Patients were grouped according to their current AF treatment regimen; no treatment (n=195), rate control with AV-nodal blocking agents (n=388), rhythm control with AADs (n=678) and prior AF ablation (n=220). Results: Morbidly obese patients had higher AFSS scores than normal and overweight patients in the rate control (43.57 vs 38.21: P=0.0057), AAD (46.61 vs. 41.08: P=0.00016) and ablation (44.01 vs. 39.02: P=0.047) groups. In univariate linear models, BMI was associated with an increase in the AFSS score in the rate control (0.27, 95% CI 0.05-0.5, P=0.0181), AAD (0.38, 95% CI 0.21-0.56, P=2.49 x 10 -5 ) and ablation (0.38, 95% CI 0.03-0.73, P=0.033) groups. The association remained significant in the AAD group after adjusting for age, gender, race, and comorbidities (0.29, 95% CI 0.11-0.49, P=0.0024). Conclusion: In conclusion, our results showed that obesity and increasing BMI were associated with a significant increase in patient-reported measures of AF symptom severity and frequency of AF episodes. The association was most significant in patients on rhythm control therapy with AADs. Further research is needed to determine whether this finding is due to an overlap between subjective obesity-related and AF-related symptoms, or whether obesity may modulate response to rhythm control therapies.

Impact of CARDIOrespiratory FITness on Arrhythmia Recurrence in Obese Individuals With Atrial Fibrillation: The CARDIO-FIT Study

BackgroundObesity begets atrial fibrillation (AF). Although cardiorespiratory fitness is protective against incident AF in obese individuals, its effect on AF recurrence or the benefit of cardiorespiratory fitness gain is unknown. ObjectivesThis study sought to evaluate the role of cardiorespiratory fitness and the incremental benefit of cardiorespiratory fitness improvement on rhythm control in obese individuals with AF. MethodsOf 1,415 consecutive patients with AF, 825 had a body mass index ≥27 kg/m2 and were offered risk factor management and participation in a tailored exercise program. After exclusions, 308 patients were included in the analysis. Patients underwent exercise stress testing to determine peak metabolic equivalents (METs). To determine a dose response, cardiorespiratory fitness was categorized as: low (<85%), adequate (86% to 100%), and high (>100%). Impact of cardiorespiratory fitness gain was ascertained by the objective gain in fitness at final follow-up (≥2 METs vs. <2 METs). AF rhythm control was determined using 7-day Holter monitoring and AF severity scale questionnaire. ResultsThere were no differences in baseline characteristics or follow-up duration between the groups defined by cardiorespiratory fitness. Arrhythmia-free survival with and without rhythm control strategies was greatest in patients with high cardiorespiratory fitness compared to adequate or low cardiorespiratory fitness (p < 0.001 for both). AF burden and symptom severity decreased significantly in the group with cardiorespiratory fitness gain ≥2 METs as compared to <2 METs group (p < 0.001 for all). Arrhythmia-free survival with and without rhythm control strategies was greatest in those with METs gain ≥2 compared to those with METs gain <2 in cardiorespiratory fitness (p < 0.001 for both). ConclusionsCardiorespiratory fitness predicts arrhythmia recurrence in obese individuals with symptomatic AF. Improvement in cardiorespiratory fitness augments the beneficial effects of weight loss. (Evaluating the Impact of a Weight Loss on the Burden of Atrial Fibrillation [AF] in Obese Patients; ACTRN12614001123639)

Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study (LEGACY)

BackgroundObesity and atrial fibrillation (AF) frequently coexist. Weight loss reduces the burden of AF, but whether this is sustained, has a dose effect, or is influenced by weight fluctuation is unknown. ObjectivesThis study sought to evaluate the long-term impact of weight loss and weight fluctuation on rhythm control in obese individuals with AF. MethodsOf 1,415 consecutive patients with AF, 825 had a body mass index ≥27 kg/m2 and were offered weight management. After screening for exclusion criteria, 355 were included in this analysis. Weight loss was categorized as group 1 (≥10%), group 2 (3% to 9%), and group 3 (<3%). Weight trend and/or fluctuation was determined by yearly follow-up. We determined the impact on the AF severity scale and 7-day ambulatory monitoring. ResultsThere were no differences in baseline characteristics or follow-up among the groups. AF burden and symptom severity decreased more in group 1 compared with groups 2 and 3 (p < 0.001 for all). Arrhythmia-free survival with and without rhythm control strategies was greatest in group 1 compared with groups 2 and 3 (p < 0.001 for both). In multivariate analyses, weight loss and weight fluctuation were independent predictors of outcomes (p < 0.001 for both). Weight loss ≥10% resulted in a 6-fold (95% confidence interval: 3.4 to 10.3; p < 0.001) greater probability of arrhythmia-free survival compared with the other 2 groups. Weight fluctuation >5% partially offset this benefit, with a 2-fold (95% confidence interval: 1.0 to 4.3; p = 0.02) increased risk of arrhythmia recurrence. ConclusionsLong-term sustained weight loss is associated with significant reduction of AF burden and maintenance of sinus rhythm. (Long-Term Effect of Goal directed weight management on Atrial Fibrillation Cohort: A 5 Year follow-up study [LEGACY Study]; ACTRN12614001123639)

Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation: The ARREST-AF Cohort Study

BackgroundThe long-term outcome of atrial fibrillation (AF) ablation demonstrates attrition. This outcome may be due to failure to attenuate the progressive substrate promoted by cardiovascular risk factors. ObjectivesThe goal of this study was to evaluate the impact of risk factor and weight management on AF ablation outcomes. MethodsOf 281 consecutive patients undergoing AF ablation, 149 with a body mass index ≥27 kg/m2 and ≥1 cardiac risk factor were offered risk factor management (RFM) according to American Heart Association/American College of Cardiology guidelines. After AF ablation, all 61 patients who opted for RFM and 88 control subjects were assessed every 3 to 6 months by clinic review and 7-day Holter monitoring. Changes in the Atrial Fibrillation Severity Scale scores were determined. ResultsThere were no differences in baseline characteristics, number of procedures, or follow-up duration between the groups (p = NS). RFM resulted in greater reductions in weight (p = 0.002) and blood pressure (p = 0.006), and better glycemic control (p = 0.001) and lipid profiles (p = 0.01). At follow-up, AF frequency, duration, symptoms, and symptom severity decreased more in the RFM group compared with the control group (all p < 0.001). Single-procedure drug-unassisted arrhythmia-free survival was greater in RFM patients compared with control subjects (p < 0.001). Multiple-procedure arrhythmia-free survival was markedly better in RFM patients compared with control subjects (p < 0.001), with 16% and 42.4%, respectively, using antiarrhythmic drugs (p = 0.004). On multivariate analysis, type of AF (p < 0.001) and RFM (hazard ratio 4.8 [95% confidence interval: 2.04 to 11.4]; p < 0.001) were independent predictors of arrhythmia-free survival. ConclusionsAggressive RFM improved the long-term success of AF ablation. This study underscores the importance of therapy directed at the primary promoters of the AF substrate to facilitate rhythm control strategies.

Health-related quality of life in patients with atrial fibrillation treated with rhythm control versus rate control: insights from a prospective international registry (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation: RECORD-AF).

Improving health-related quality of life (HRQoL) is an important treatment goal in the management of patients with atrial fibrillation (AF). Uncertainty exists as to whether patients' HRQoL differ when treated with medical rhythm control or rate control. We compared HRQoL between patients treated with rhythm control or rate control in a large observational registry of patients with recent-onset AF. In the Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation (RECORD-AF), 2439 patients with recent onset (<1 year) AF completed an AF-specific HRQoL questionnaire, the University of Toronto Atrial Fibrillation Severity Scale. HRQoL was assessed by the AF symptom severity score (0-35, with higher scores reflecting more severe AF-related symptoms) at baseline and 1 year. The minimal clinically important difference was defined as a change of ≥3 points. The primary analysis was based on a propensity score-adjusted longitudinal regression analysis which compared the change in AF symptom severity scores between the 2 groups. Over an average follow-up of 1 year, the AF symptom severity scores improved in both groups (rhythm control: -2.82 point [95% confidence interval, -3.22 to -2.41]; rate control: -2.11 point [95% confidence interval, -2.54 to -1.67]; P<0.01 for both groups). The magnitude of improvement was higher in the rhythm control group than the rate control group (unadjusted difference: -0.75 point; 95% confidence interval, -1.31 to -0.19; P=0.01; propensity score-adjusted difference: -0.71 point; 95% confidence interval, -1.31 to -0.11; P=0.02). In this observational cohort of recent-onset AF patients, treatment with medical rhythm- or rate control over 1 year was associated with an improvement in HRQoL. The magnitude of HRQoL improvement was minimally higher in patients treated with rhythm control than rate control. However, the overall degree of improvement was not large, and its clinical significance was uncertain.

Symptom severity is associated with cardiovascular outcome in patients with permanent atrial fibrillation in the RACE II study.

Symptoms and symptom burden have a central place in diagnosis and management of atrial fibrillation (AF). The aim of the present study is to investigate whether severity of AF symptoms impacts prognosis in permanent AF. We studied the relation between AF symptom severity [quantified with the Toronto AF Severity Scale (AFSS)] and cardiovascular outcome in patients included in the RACE II study. The primary endpoint was a composite of cardiovascular morbidity and mortality. Secondary outcome was cardiovascular hospitalizations. Of 614 permanent AF patients in RACE II, AFSS questionnaires were available in 558 patients (91%). Mean age was 68 ± 8 years. One hundred and seventy-four patients (31%) reported a low score (score 0-3; lowest tertile), 190 patients (34%) reported a moderate score (score 4-9; middle tertile), and 194 (35%) reported a high score (score 10-35; highest tertile). Patients with the most severe symptoms were more often women, had higher N-terminal prohormone of brain natriuretic peptide concentrations, and had more previous heart failure hospitalizations. Median follow-up was 3.0 (interquartile range 2.3-3.0) years. The primary endpoint occurred most frequently in the highest tertile of the AFSS [16 (9%), 19 (10%), 36 (19%), respectively, P = 0.01], being mainly driven by heart failure hospitalizations [4 (2%), 1 (1%), 16 (8%), respectively, P < 0.001]. After multivariable adjustment, higher AFSS scores were associated with the primary endpoint [hazard ratio 1.38 (1.15-1.66), P = 0.001], as well as with cardiovascular hospitalizations [hazard ratio 1.33 (1.14-1.54), P < 0.001]. In permanent AF, after multivariable adjustment, symptom severity is associated with cardiovascular outcome.

Effectiveness of Atrial Fibrillation Monitor Characteristics to Predict Severity of Symptoms of Atrial Fibrillation

The goal of treatment for atrial fibrillation (AF) is often to control symptoms. It remains unclear whether targets for treatment such as AF rate or AF burden are correlated with AF symptom severity. Two hundred eighty-six patients completed a questionnaire of their general health and well-being, including a detailed AF symptom assessment immediately followed by a 7-day continuous monitor. AF characteristics assessed from the monitor included AF burden, AF rate, sinus rhythm rate, frequency and severity of pauses, and premature atrial contraction or premature ventricular contraction burden. Characteristics were analyzed separately for patients with paroxysmal or persistent AF. Symptom severity was assessed using the University of Toronto Atrial Fibrillation Severity Scale. Monitor characteristics were compared with AF symptom severity. The mean age of the cohort was 61.8 years and the majority of subjects were male (65.4%). Co-morbidities included hypertension (64.5%), sleep apnea (38.4%), congestive heart failure (19.6%), and diabetes (16.4%). In those with persistent or paroxysmal AF, there were no significant predictors of AF symptom severity. Specifically, heart rate in AF or sinus rhythm, AF burden, or premature atrial contraction or premature ventricular contraction burden was not predictive of AF symptom severity. After adjusting for potential cofounders (including age, gender, and co-morbidities), these findings persisted. In conclusion, there is no value in using AF monitor characteristics to predict symptoms in patients with AF.

EP News: Clinical

Abed and colleagues (JAMA. 2013 Nov 20; 310 (19):2050-60; PMID: 24240932) evaluated the effect of weight reduction on atrial fibrillation (AF) burden and cardiac structure in a randomized controlled trial. Obese patients with symptomatic AF (150) were randomized to weight management (intervention) or general lifestyle advice (control). The primary outcomes were AF Severity Scale scores, symptom burden, and symptom severity. Secondary outcomes were AF episodes and AF duration, left atrial area, and septal thickness. The intervention group showed a significantly greater reduction in weight (14.3 and 3.6 kg, respectively; P < .001) and in AF symptom burden scores (11.8 and 2.6 points, P < .001), symptom severity scores (8.4 and 1.7 points, P < .001), and cumulative AF duration (692-minute decline and 419-minute increase, P = .002). There was a reduction in septal thickness in the intervention and control groups (1.1 and 0.6 mm, P = .02) and left atrial area (3.5 and 1.9 cm2, P = .02). The authors conclude weight reduction with intensive risk factor management reduces AF symptom burden and severity and in beneficial cardiac remodeling.

The validity and reliability of the Turkish version of the University of Toronto Atrial Fibrillation Severity Scale.

There are various instruments to assess quality of life (QoL) in patients with atrial fibrillation (AF). The aim of this study is to determine the reliability and validity of the Turkish version of the University of Toronto Atrial Fibrillation Severity Scale (AFSS). The AFSS and Short Form-36 (SF-36) were completed by 130 patients with documented AF. The Canadian Cardiovascular Society Severity in Atrial Fibrillation (SAF) scale and European Heart Rhythm Association (EHRA) scale were also utilized by the attending physicians. To assess test-retest reliability, the AFSS was readministered to 47 clinically stable patients at a 1-month follow-up visit. Internal consistency reliability, test-retest reproducibility, and construct validity were evaluated. The mean age of the patients was 63.1 + 10.9 years and 58.5% of patients were male. The outcome scores of the Turkish version of the AFSS showed good correlations with theoretically related SF-36 domains. Additionally, AFSS outcome scores showed a linear correlation with the SAF and EHRA scores. Cronbach's alpha values for internal consistency were consistent and similar with the English language version of the AFSS. Intraclass correlation coefficients for reproducibility exceeded 0.80 for every item. Convergent-divergent and known-groups validity and reliability were established for the Turkish version of the University of Toronto AFSS.