Patients with Paroxysmal Atrial Fibrillation (AF), even in the absence of significant concomitant cardiac disease, show signs of depression, sleeping disorders and low physical activity, concludes a German study. The study found that electrophysiologists rate the quality of life of patients with Paroxysmal AF significantly better than the patients themselves do, with discordance greatest for mental health.
Since little difference has been found for hard outcomes (such as survival or stroke) when comparing rate and rhythm control strategies for AF patients, quality of life is considered an important factor for selecting treatment strategies. “The reality is that treatment decisions for AF patients are largely based upon the physicians’ estimation of their health related quality of life and symptom burden,” says Professor Karl Ladwig, from the Helmholtz Centre, Munich, Germany. This, he adds, makes communication between physicians and patients an essential part of informed decision making.
In the current study, Ladwig and colleagues set out to assess the degree of congruence between patient and physician assessment of patients’ subjective health status, which, the authors reason, provides a good indicator of patient-physician communication and shared understanding. Data for the analysis was taken for patients enrolled in the Angiotensin II Antagonist in Paroxysmal Atrial Fibrillation (ANTIPAF)trial, a study conducted by the German Competence NETwork on Atrial Fibrillation (AFNET) looking to see whether angiotensin II receptor blockers reduced the incidence of paroxysmal AF . The analysis, say the authors, is the first to specifically look at discordance in AF patients.
Between February 2004 and September 2008, 334 patients (41% female and 59% male) with paroxysmal AF, without significant concomitant heart disease, and their physicians from 43 participating centres were asked to rate the patients’ health related quality of life (HRQoL). Patients filled in the SF-12 self rating scale in the clinic or home; while physicians completed the SF8 scale after patients had left the clinic. The physicians were given no insight into patient answer sheets.
Intra-Class Correlations (ICC) were used to assess the consistency or conformity of the measures made by multiple observers, and Bland Altman graphs plotted the strength of concordance for each patient against average ratings for both physicians and patients.
Results showed that physicians rated their patients health related quality higher than patients, both for the mental component score (P<0.0001) and physical component score (p=0.001). Both the ICCs and Bland-Altman graphs showed unsatisfactory concordance. In the regression analyses, depression was significantly associated with discord in the mental component score (ß=-0.94; p<0.001) and the physical component score (ß=-4.13; p<0.002). Furthermore, sleeping disorders were associated with discord in the mental component score (ß=-4.13; p<0.002) and physical activity with discord in the physical component score (ß=-1.47; p=0.006).
“When one considers the importance placed on quality of life in the AF literature these levels of discordance between physicians and patients are surprisingly large,” says Ladwig. “They underline the need for physician training to recognize depression in patients and for the introduction of systematic screening for depression in all AF clinics.”
Shared understanding between patients and physicians, he adds, should be considered of major importance since it has implications for adherence to medications and ultimate prognosis. Future studies, he says, should explore whether interventions such as physician training and screening for depression, improve both quality of life and underlying disease in patients with AF.