Cognitive impairment and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study.

BACKGROUND: Cognitive impairment is strongly associated with atrial fibrillation (AF). Rate and rhythm control are the two treatment strategies for AF and the effect of treatment strategy on risk of cognitive decline and frailty is not well established. We sought to determine how treatment strategy affects geriatric-centered outcomes. METHODS: The Systematic Assessment of Geriatric Elements-AF (SAGE-AF) was a prospective, observational, cohort study. Older adults with AF were prospectively enrolled between 2016 and 2018 and followed longitudinally for 2 years. In a non-randomized fashion, participants were grouped by rate or rhythm control treatment strategy based on clinical treatment at enrollment. Baseline characteristics were compared. Longitudinal binary mixed models were used to compare treatment strategy with respect to change in cognitive function and frailty status. Cognitive function and frailty status were assessed with the Montreal Cognitive Assessment Battery and Fried frailty phenotype tools. RESULTS: 972 participants (mean age = 75, SD = 6.8; 49% female, 87% non-Hispanic white) completed baseline examination and 2-year follow-up. 408 (42%) were treated with rate control and 564 (58%) with rhythm control. The patient characteristics of the two groups were different at baseline. Participants in the rate control group were older, more likely to have persistent AF, prior stroke, be treated with warfarin and have baseline cognitive impairment. After adjusting for baseline differences, participants treated with rate control were 1.5 times more likely to be cognitively impaired over 2 years (adjusted OR: 1.47, 95% CI:1.12, 1.98) and had a greater decline in cognitive function (adjusted estimate: -0.59 (0.23), p < 0.01) in comparison to rhythm control. Frailty did not vary between the treatment strategies. CONCLUSIONS: Among those who had 2-year follow-up in non-randomized observational cohort, the decision to rate control AF in older adults was associated with increased odds of decline in cognitive function but not frailty.

Acute Cardiomyopathy in a Prisoner on a Hunger Strike.

Chronic starvation and its associated metabolic derangements are known to have dangerous cardiovascular implications in the long term, but less is known about the cardiovascular consequences of acute starvation, such as in the context of a hunger strike. This case describes a patient who presented with signs and symptoms of acute coronary syndrome which began two weeks into a hunger strike and was ultimately found to have stress cardiomyopathy with complete resolution on subsequent imaging.

Technology engagement is associated with higher perceived physical well-being in stroke patients prescribed smartwatches for atrial fibrillation detection.

Background: Increasing ownership of smartphones among Americans provides an opportunity to use these technologies to manage medical conditions. We examine the influence of baseline smartwatch ownership on changes in self-reported anxiety, patient engagement, and health-related quality of life when prescribed smartwatch for AF detection. Method: We performed a post-hoc secondary analysis of the Pulsewatch study (NCT03761394), a clinical trial in which 120 participants were randomized to receive a smartwatch-smartphone app dyad and ECG patch monitor compared to an ECG patch monitor alone to establish the accuracy of the smartwatch-smartphone app dyad for detection of AF. At baseline, 14 days, and 44 days, participants completed the Generalized Anxiety Disorder-7 survey, the Health Survey SF-12, and the Consumer Health Activation Index. Mixed-effects linear regression models using repeated measures with anxiety, patient activation, physical and mental health status as outcomes were used to examine their association with smartwatch ownership at baseline. Results: Ninety-six participants, primarily White with high income and tertiary education, were randomized to receive a study smartwatch-smartphone dyad. Twenty-four (25%) participants previously owned a smartwatch. Compared to those who did not previously own a smartwatch, smartwatch owners reported significant greater increase in their self-reported physical health (ß = 5.07, P < 0.05), no differences in anxiety (ß = 0.92, P = 0.33), mental health (ß = -2.42, P = 0.16), or patient activation (ß = 1.86, P = 0.54). Conclusions: Participants who own a smartwatch at baseline reported a greater positive change in self-reported physical health, but not in anxiety, patient activation, or self-reported mental health over the study period.

Anxiety, patient activation, and quality of life among stroke survivors prescribed smartwatches for atrial fibrillation monitoring.

Background: The detection of atrial fibrillation (AF) in stroke survivors is critical to decreasing the risk of recurrent stroke. Smartwatches have emerged as a convenient and accurate means of AF diagnosis; however, the impact on critical patient-reported outcomes, including anxiety, engagement, and quality of life, remains ill defined. Objectives: To examine the association between smartwatch prescription for AF detection and the patient-reported outcomes of anxiety, patient activation, and self-reported health. Methods: We used data from the Pulsewatch trial, a 2-phase randomized controlled trial that included participants aged 50 years or older with a history of ischemic stroke. Participants were randomized to use either a proprietary smartphone-smartwatch app for 30 days of AF monitoring or no cardiac rhythm monitoring. Validated surveys were deployed before and after the 30-day study period to assess anxiety, patient activation, and self-rated physical and mental health. Logistic regression and generalized estimation equations were used to examine the association between smartwatch prescription for AF monitoring and changes in the patient-reported outcomes. Results: A total of 110 participants (mean age 64 years, 41% female, 91% non-Hispanic White) were studied. Seventy percent of intervention participants were novice smartwatch users, as opposed to 84% of controls, and there was no significant difference in baseline rates of anxiety, activation, or self-rated health between the 2 groups. The incidence of new AF among smartwatch users was 6%. Participants who were prescribed smartwatches did not have a statistically significant change in anxiety, activation, or self-reported health as compared to those who were not prescribed smartwatches. The results held even after removing participants who received an AF alert on the watch. Conclusion: The prescription of smartwatches to stroke survivors for AF monitoring does not adversely affect key patient-reported outcomes. Further research is needed to better inform the successful deployment of smartwatches in clinical practice.

False Atrial Fibrillation Alerts from Smartwatches are Associated with Decreased Perceived Physical Well-being and Confidence in Chronic Symptoms Management.

Wrist-based wearables have been FDA approved for AF detection. However, the health behavior impact of false AF alerts from wearables on older patients at high risk for AF are not known. In this work, we analyzed data from the Pulsewatch (NCT03761394) study, which randomized patients (≥50 years) with history of stroke or transient ischemic attack to wear a patch monitor and a smartwatch linked to a smartphone running the Pulsewatch application vs to only the cardiac patch monitor over 14 days. At baseline and 14 days, participants completed validated instruments to assess for anxiety, patient activation, perceived mental and physical health, chronic symptom management self-efficacy, and medicine adherence. We employed linear regression to examine associations between false AF alerts with change in patient-reported outcomes. Receipt of false AF alerts was related to a dose-dependent decline in self-perceived physical health and levels of disease self-management. We developed a novel convolutional denoising autoencoder (CDA) to remove motion and noise artifacts in photoplethysmography (PPG) segments to optimize AF detection, which substantially reduced the number of false alerts. A promising approach to avoid negative impact of false alerts is to employ artificial intelligence driven algorithms to improve accuracy.

Self-reported efficacy in patient-physician interaction in relation to anxiety, patient activation, and health-related quality of life among stroke survivors.

BACKGROUND: Early detection of AF is critical for stroke prevention. Several commercially available smartwatches are FDA cleared for AF detection. However, little is known about how patient-physician relationships affect patients' anxiety, activation, and health-related quality of life when prescribed smartwatch for AF detection. METHODS: Data were used from the Pulsewatch study (NCT03761394), which randomized adults (>50 years) with no contraindication to anticoagulation and a CHA2DS2-VASc risk score ≥2 to receive a smartwatch-smartphone app dyad for AF monitoring vs. conventional monitoring with an ECG patch (Cardea SoloTM) and monitored participants for up to 45 days. The Perceived Efficacy in Patient-Physician Interactions survey was used to assess patient confidence in physician interaction at baseline with scores ≥45 indicating high perceived efficacy in patient-provider interactions. Generalized Anxiety Disorder-7 Scale, Consumer Health Activation Index, and Short-Form Health Survey were utilized to examine anxiety, patient activation, and physical and mental health status, at baseline, 14, and 44 days, respectively. We used mixed-effects repeated measures linear regression models to assess changes in psychosocial outcomes among smartwatch users in relation to self-reported efficacy in physician interaction over the study period. RESULTS: A total of 93 participants (average age 64.1 ± 8.9 years; 43.0% female; 88.2% non-Hispanic white) were included in this analysis. At baseline, fifty-six (60%) participants reported high perceived efficacy in patient-physician interaction. In the fully adjusted models, high perceived efficacy (vs. low) at baseline was associated with greater patient activation and perceived mental health (ß 12.0, p-value <0.001; ß 3.39, p-value <0.05, respectively). High perceived self-efficacy was not associated with anxiety or physical health status (ß - 0.61, p-value 0.46; ß 0.64, p-value 0.77) among study participants. CONCLUSIONS: Higher self-efficacy in patient-physician interaction was associated with higher patient activation and mental health status among stroke survivors using smartwatches. Furthermore, we found no association between anxiety and smartwatch prescription for AF in participants with high self-efficacy in patient-physician interaction. Efforts to improve self-efficacy in patient-physician interaction may improve patient activation and self-rated health and subsequently may lead to better clinical outcomes.KEY MESSAGESHigher self-efficacy in patient-physician interaction was associated with higher patient activation and mental health status among stroke survivors using smartwatches.No association between anxiety and smartwatch prescription for AF in participants with high self-efficacy in patient-physician interaction.Efforts to improve self-efficacy in patient-physician interaction may improve patient activation and self-rated health and subsequently may lead to better clinical outcomes.

Usefulness of Self-Reported Physical Activity and Clinical Outcomes in Older Patients With Atrial Fibrillation.

Current guidelines encourage regular physical activity (PA) to gain cardiovascular health benefit. However, little is known about whether older adults with atrial fibrillation (AF) who engage in the guideline-recommended level of PA are less likely to experience clinically relevant outcomes. We did a retrospective study based on the data from Systemic Assessment of Geriatric Elements in AF (SAGE-AF) prospective cohort study. The study population consisted of older participants with AF (≥65 years) and a congestive heart failure, hypertension, age, diabetes, stroke vascular disease, age 65 to 75 and sex(CHA2DS2-VASc) score ≥2. PA was quantified by self-reported Minnesota Leisure Time PA questionnaire. Competing risk models were used to examine the association between PA level and clinical outcomes over 2 years while controlling for several potentially confounding variables. A total of 1,244 participants (average age 76 years; 51% men; 85% non-Hispanic White) were studied. A total of 50.5% of participants engaged in regular PA. Meeting the recommended level of PA was associated with lower mortality over 2 years (adjusted hazard ratio 0.60, 95% confidence interval 0.38 to 0.95) but was not associated with rates of stroke or major bleeding. In conclusion, older adults with AF who engaged in guideline-recommended PA are more likely to survive in the long term. Healthcare providers should promote and encourage engagement in PA and tailor interventions to address barriers of engagement.

Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study.

BACKGROUND: Atrial fibrillation (AF) treatment includes anticoagulation for high stroke risk individuals and either rate or rhythm control strategies. We aimed to investigate the impact of age, geriatric factors, and medical comorbidities on choice of rhythm versus rate control strategy in older adults. METHODS: Patients with AF aged ≥65 years with CHA2 DS2 VASc score ≥2 and eligible for anticoagulation were recruited for the Systematic Assessment of Geriatric Elements-AF (SAGE-AF) prospective cohort study. An interview that included measures of HRQoL, cognitive function, vision, hearing, and frailty was performed. The association between these elements and AF treatment strategy was examined by multivariable logistic regression models. RESULTS: One thousand two hundred forty-four participants (mean age 76 years; 49% female; 85% non-Hispanic white) were enrolled. Rate and rhythm control were used in 534 and 710 participants, respectively. Compared to participants <75 years, those ≥75 were more likely to be treated with a rate control strategy (age 75-84 adjusted odds ratio [aOR] 1.37 [95% CI 0.99, 1.88]; age 85+ aOR = 2.05, 95% CI 1.30, 3.21). Those treated with a rate control strategy were more likely to have cognitive impairment (aOR = 1.50, 95% CI 1.13, 1.99), and peripheral vascular disease (PVD) (aOR = 1.82, 95% CI 1.22, 2.72) but less likely to have visual impairment (aOR 0.73 [0.55, 0.98]), congestive heart failure (CHF; aOR 0.68 [0.49, 0.94]) or receive anticoagulation (aOR 0.53, 95% CI 0.36, 0.78). CONCLUSION: Older age, cognitive impairment, and PVD were associated with use of rate control strategy. Visual impairment, CHF, and anticoagulation use were associated with a rhythm control strategy. There was no difference in HRQoL between the rate and rhythm control groups. This study suggests that certain geriatric elements may be associated with AF treatment strategies. Further study is needed to evaluate how these decisions affect outcomes.

Usability of a smartwatch for atrial fibrillation detection in older adults after stroke.

Background: Smartwatches can be used for atrial fibrillation (AF) detection, but little is known about how older adults at risk for AF perceive their usability. Methods: We employed a mixed-methods study design using data from the ongoing Pulsewatch study, a randomized clinical trial (NCT03761394) examining the accuracy of a smartwatch-smartphone app dyad (Samsung/Android) compared to usual care with a patch monitor (Cardea SOLO™ ECG System) for detection of AF among older stroke survivors. To be eligible to participate in Pulsewatch, participants needed to be at least 50 years of age, have had an ischemic stroke, and have no major contraindications to anticoagulation therapy should AF be detected. After 14 days of use, usability was measured by the System Usability Scale (SUS) and investigator-generated questions. Qualitative interviews were conducted, transcribed, and coded via thematic analysis. Results: Ninety participants in the Pulsewatch trial were randomized to use a smartwatch-smartphone app dyad for 14 days (average age: 65 years, 41% female, 87% White), and 46% found it to be highly usable (SUS ≥68). In quantitative surveys, participants who used an assistive device (eg, wheelchair) and those with history of anxiety or depression were more likely to report anxiety associated with watch use. In qualitative interviews, study participants reported wanting a streamlined system that was more focused on rhythm monitoring and a smartwatch with a longer battery life. In-person training and support greatly improved their experience, and participants overwhelmingly preferred use of a smartwatch over traditional cardiac monitoring owing to its comfort, appearance, and convenience. Conclusion: Older adults at high risk for AF who were randomized to use a smartwatch-app dyad for AF monitoring over 14 days found it to be usable for AF detection and preferred their use to the use of a patch monitor. However, participants reported that a simpler device interface and longer smartwatch battery life would increase the system's usability.

Online health information seeking, low atrial fibrillation-related quality of life, and high perceived efficacy in patient-physician interactions in older adults with atrial fibrillation.

Background: Little is known about online health information-seeking behavior among older adults with atrial fibrillation (AF) and its association with self-reported outcomes. Objective: To examine patient characteristics associated with online health information seeking and the association between information seeking and low AF-related quality of life and high perceived efficacy in patient-physician interaction. Methods: We used data from the SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study, which includes older participants aged ≥65 years with AF and a CHA2DS2-VASc risk score ≥2. To assess online health information seeking, participants who reported using the Internet were asked at baseline if they used the Internet to search for advice or information about their health in the past 4 weeks (not at all vs at least once). Atrial Fibrillation Effect on Quality of Life and Perceived Efficacy in Patient-Physician Interactions questionnaires were used to examine AF-related quality of life (QOL) and patient-reported confidence in physicians. Logistic regression models were used to examine demographic and clinical factors associated with online health information seeking and associations between information seeking and low AF-related QOL (AFEQT <80) and high perceived efficacy for patient-physician interactions (PEPPI ≥45). Results: A total of 874 online participants (mean age 74.5 years, 51% male, 91% non-Hispanic White) were studied. Approximately 60% of participants sought health information online. Participants aged 74 years or older and those on anticoagulation were less likely, while those with a college degree were more likely, to seek online health information after adjusting for potential confounders. Participants who sought health information online, compared to those who did not, were significantly more likely to have a low AF-related QOL, but less likely to self-report confidence in patient-physician interaction (aOR = 1.56, 95% CI: 1.15-2.13; aOR = 0.68, 95% CI: 0.49-0.93, respectively). Conclusion: Clinicians should consider barriers to patient-physician interaction in older adults who seek health information online, encourage shared decision-making, and provide patients with a list of online resources for AF in addition to disease education plans to help patients manage their health.

Secondary Precipitants of Atrial Fibrillation and Anticoagulation Therapy.

Background Atrial fibrillation (AF) commonly occurs in the setting of acute conditions. We aimed to identify the acute conditions associated with secondary AF (AF precipitants) including pneumonia/sepsis, pneumothorax, respiratory failure, myocarditis, pericarditis, alcohol intoxication, thyrotoxicosis, cardiothoracic surgery, other surgery in patients with newly diagnosed AF and determine their association with subsequent oral anticoagulant use. Methods and Results We assembled a cohort of patients in the UMass Memorial Healthcare system with a new diagnosis of AF with and without AF precipitants. We used combinations of International Classification of Diseases, Tenth Revision (ICD-10) codes, Current Procedural Terminology codes, laboratory values, imaging reports, and physician notes including discharge summary texts to identify AF precipitants. We then manually reviewed the individual charts to validate presence of AF precipitants. The study sample consisted of 185 patients with and 172 patients without AF precipitants. Pneumonia/sepsis, myocardial infarction, respiratory failure, and cardiothoracic surgery were the most common precipitants identified. In multivariable analyses adjusting for age, sex, patient comorbidities, left atrial enlargement, left ventricular ejection fraction, and antiplatelet use, patients with AF precipitants were less likely to receive subsequent anticoagulation therapy at 30 days after the initial AF diagnosis (odds ratio, 0.31; 95% CI, 0.19-0.52). The association was persistent after excluding men with CHA2DS2-VASc score <2 and women with CHA2DS2-VASc score <3. Conclusions Our study highlights lower usage of oral anticoagulant in secondary AF in contemporary clinical practice.

Incident frailty and cognitive impairment by heart failure status in older patients with atrial fibrillation: the SAGE-AF study.

BACKGROUND: Atrial fibrillation (AF) and heart failure (HF) frequently co-occur in older individuals. Among patients with AF, HF increases risks for stroke and death, but the associations between HF and incident cognition and physical impairment remain unknown. We aimed to examine the cross-sectional and prospective associations between HF, cognition, and frailty among older patients with AF. METHODS: The SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study enrolled 1244 patients with AF (mean age 76 years, 48% women) from five practices in Massachusetts and Georgia. HF at baseline was identified from electronic health records using ICD-9/10 codes. At baseline and 1-year, frailty was assessed by Cardiovascular Health Survey score and cognition was assessed by the Montreal Cognitive Assessment. RESULTS: Patients with prevalent HF (n = 463, 37.2%) were older, less likely to be non-Hispanic white, had less education, and had greater cardiovascular comorbidity burden and higher CHA2DS2VASC and HAS-BLED scores than patients without HF (all P's < 0.01). In multivariable adjusted regression models, HF (present vs. absent) was associated with both prevalent frailty (adjusted odds ratio [aOR]: 2.38, 95% confidence interval [CI]: 1.64-3.46) and incident frailty at 1 year (aOR: 2.48, 95% CI: 1.37-4.51). HF was also independently associated with baseline cognitive impairment (aOR: 1.60, 95% CI: 1.22-2.11), but not with developing cognitive impairment at 1 year (aOR 1.04, 95%CI: 0.64-1.70). CONCLUSIONS: Among ambulatory older patients with AF, the co-existence of HF identifies individuals with physical and cognitive impairments who are at higher short-term risk for becoming frail. Preventive strategies to this vulnerable subgroup merit consideration.

Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation.

BACKGROUND: Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS: Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either "excellent/very good", "good", and "fair/poor". Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS: Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], ≥ 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS: Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF.

Self-reported risk of stroke and factors associated with underestimation of stroke risk among older adults with atrial fibrillation: the SAGE-AF study.

BACKGROUND: Though engaging patients with atrial fibrillation (AF) in understanding their stroke risk is encouraged by guidelines, little is known regarding AF patients' perceived stroke risk or its relationship with oral anticoagulation (OAC) use. We aim to identify factors associated with underestimation of stroke risk among older patients with AF and relate this to OAC use. METHODS: Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study, which included older patients (> 65 years) with non-valvular AF and a CHA2DS2-VASc score of ≥ 2. Participants reported their perceived risk of having a stroke without OAC. We compared the perceived risk to CHA2DS2-VASc predicted stroke risk and classified participants as "over" or "under" estimators, and identified factors associated with underestimation of risk using multiple logistic regression. RESULTS: The average CHA2DS2-VASc score of 915 participants (average age: 75 years, 47% female, 86% white) was 4.3 ± 1.6, 43% of participants had discordant predicted and self-reported stroke risks. Among the 376 participants at highest risk (CHA2DS2-VASc score ≥ 5), 46% of participants underestimated their risk. Older participants (≥ 85 years) were more likely and OAC treated patients less likely to underestimate their risk of developing a future stroke than respective comparison groups. CONCLUSIONS: A significant proportion of study participants misperceived their stroke risk, mostly by overestimating. Almost half of participants at high risk of stroke underestimated their risk, with older patients more likely to do so. Patients on OAC were less likely to underestimate their risk, suggesting that successful efforts to educate patients about their stroke risk may influence treatment choices.

Impact of comorbid conditions on disease-specific quality of life in older men and women with atrial fibrillation.

BACKGROUND: Older persons with atrial fibrillation (AF) experience significant impairment in quality of life (QoL), which may be partly attributable to their comorbid diseases. A greater understanding of the impact of comorbidities on QoL could optimize patient-centered care among older persons with AF. OBJECTIVE: To assess impairment in disease-specific QoL due to comorbid conditions in older adults with AF. METHODS: Patients aged ≥ 65 years diagnosed with AF were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. At 1 year of follow-up, the Quality of Life Disease Impact Scale-for Multiple Chronic Conditions was used to provide standardized assessment of patient self-reported impairment in QoL attributable to 34 comorbid conditions grouped in 10 clusters. RESULTS: The mean age of study participants (n = 1097) was 75 years and 48% were women. Overall, cardiometabolic, musculoskeletal, and pulmonary conditions were the most prevalent comorbidity clusters. A high proportion of participants (82%) reported that musculoskeletal conditions exerted the greatest impact on their QoL. Men were more likely than women to report that osteoarthritis and stroke severely impacted their QoL. Patients aged < 75 years were more likely to report that obesity, hip/knee joint problems, and fibromyalgia extremely impacted their QoL than older participants. CONCLUSIONS: Among older persons with AF, while cardiometabolic diseases were highly prevalent, musculoskeletal conditions exerted the greatest impact on patients' disease-specific QoL. Understanding the extent of impairment in QoL due to underlying comorbidities provides an opportunity to develop interventions targeted at diseases that may cause significant impairment in QoL.