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Dr. Pamela J. McCabe
Improving quality of life is a primary goal in the treatment of atrial fibrillation and is a key outcome to consider in evaluating approaches to care. Previous research has focused on pharmaceutical and procedural treatments to improve quality of life. However, cognitive and behavioral interventions are emerging as important approaches to improve quality of life for patients living with atrial fibrillation. The purpose of this article is to summarise current evidence-based therapies and to examine emerging cognitive and behavioral strategies to improve quality of life in patients living with atrial fibrillation.
Since the first study in 1988 by Kay et al.1 describing the effect of atrio-ventricular node ablation on quality of life, studies that focus on patient-centered factors and treatments that influence quality of life in patients with atrial fibrillation (AF) have grown substantially. Findings from these studies expand knowledge beyond metrics of mortality, morbidity, and rehospitalisation to provide insight into the patients’ perspective of the value of the treatment. The purpose of this article is to summarise current knowledge about interventions to improve quality of life in patients with AF.
Quality of life or health-related quality of life (HRQOL), for purposes of this paper, is considered a multidimensional phenomenon that is subjective in nature and dynamic. Improving HRQOL is a major goal of treatment for AF. Dimensions of quality of life considered in AF research generally include physical functioning, mental functioning, emotional wellbeing, and social functioning as well as a measure of global quality of life. Although there are a variety of instruments to measure HRQOL, the Medical Outcome Studies Short–Form 36 (SF-36) or the EuroQual 5-D have been commonly used in studies of patients with AF. Based on numerous research reports using the above instruments or others, there is general agreement that, for a portion of patients with AF, overall HRQOL is reduced compared to the general population. Although the greatest impairment in HRQOL is in the physical functioning dimensions, all dimensions are affected to some degree.2 Because the effect of AF on HRQOL differs among individuals, investigators have sought to identify factors that contribute to diminished HRQOL. The frequency and severity of symptoms, functional loss, female gender, presence of comorbidities such as heart failure,2 and psychological distress3 have been identified as contributors to reduced HRQOL. Identification of such factors provides insight that can help clinicians target those most at risk for poor outcomes of therapy and factors to consider when designing research and interpreting findings. With knowledge of the factors that contribute to poorer HRQOL, scientists have begun to investigate interventions to address those contributors. The following is a summary of investigations that have examined the how HRQOL can be improved by interventions to improve functional performance and reduce symptoms and psychological distress in patients with AF.
Contribution of symptoms to HRQOL was confirmed in the ORBIT-AF community practice study, where 62% of patients reported symptoms and symptom severity was related to poorer quality of life as measured by the new Atrial Fibrillation Effect on Quality of Life Questionnaire. Those without symptoms did not report an impaired HRQOL.4 Early treatment for AF focused on pharmacological treatment to reduce symptoms. Investigators explored whether rate control therapy or rhythm control therapy was most effective for symptom control. Results of the well- known multi-center AFFIRM study did not show any a significant difference in symptoms between the patients receiving rate control vs rhythm control drugs.5 Likewise, a more recent study, the RECORD-AF study, revealed that neither rate control nor rhythm control therapy by drugs improved the symptom severity score by three or more points.6
Because of the limitations of drug therapy to improve symptoms, ablation therapy may be offered. The major indication for ablation therapy is symptom control and improvement in HRQOL. The majority of studies have focused on ablation in patients with paroxysmal AF (PAF). There is evidence that ablation as a second line therapy improves symptoms to a greater degree than antiarrhythmic drugs in patients with PAF.7 However, findings regarding the benefit of ablation as a first line therapy compared to antiarrhythmic therapy are limited. Findings from the 2-year MANTRA-AF study revealed improvement in symptoms after ablation as first line therapy, but there was no significant difference in improvement of symptoms between patients with PAF treated with antiarrhythmic drugs and those treated with ablation.6 Further randomised controlled trials are needed to determine the benefit of ablation versus antiarrhythmic drugs for symptom management in patients with persistent AF.
Functional limitations are a strong contributor to poor HRQOL in patients with AF. There is increased interest in investigating exercise training to improve functional capacity. This is an emerging science that is limited by small samples. However, studies have shown that patients participating in training programmes demonstrate improved exercise capacity,8,9 increased 6 minute walk distance,9 improved tolerance for activities of daily living,10 and report reduced dyspnea and fatigue8,10 compared to patients who do not participate.
Programmes that address management of risk factors for AF such as obesity, physical inactivity, obstructive sleep apnea, diabetes, hypertension, hyperlipidemia, and tobacco use have recently been investigated for their benefit in symptom management.11,12 Investigators reported that a long term structured programme that included face to face goal setting sessions, education, and referral for nutrition and exercise recommendations significantly improved symptoms compared to a control group.11 Findings from these studies highlight the importance of including risk factor management as an essential component of the treatment plan to improve HRQOL.
There is evidence of an association between psychological distress in the form of depression and/or anxiety in HRQOL in patients with AF.3 Psychological distress is associated with increased symptom severity, but the direction of the relationship is not clear. Does preexisting psychological distress influence symptom appraisal, or do symptoms increase psychological distress? Understanding the contribution of psychological distress to symptoms is important to guide interventions to manage symptoms, but the science to guide practice is underdeveloped. A few reports have shown that ablation therapy results in decreased anxiety and depression,13 but little is known pertaining to cognitive and behavioral interventions to improve psychological wellbeing of patients with AF. In a pre-post single group trial, yoga reduced symptoms of AF, depression and anxiety in patients with PAF,14 but more data from randomised controlled trials are needed to guide practice. Studies that employ mindfulness, relaxation therapy, and cognitive therapy are in progress.
In summary, HRQOL is impaired in a substantial portion of patients who have AF. Those who experience symptoms, diminished functional status, and psychological distress are most at risk for reduced HRQOL. Pharmacological and nonpharmacological therapies directed at AF rate or rhythm control have all been shown to improve HRQOL through improved symptom management, thus there are a variety of treatment options that allow for individualized treatment plans. There is emerging evidence that risk factor management programmes play an important role in improving HRQOL. Although the benefit of cognitive-behavioral and integrative therapies for improving HRQOL in patients with other cardiac conditions has been documented, few investigators have studied their use in patients with AF. More evidence is needed to determine if such therapies will benefit patients with AF.
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