Gender and age differences in symptoms and health-related quality of life in patients with atrial fibrillation referred for catheter ablation.

BACKGROUND: Primary indication for catheter ablation of atrial fibrillation (AF) is to reduce symptoms and improve health-related quality of life (HRQoL). There are data showing differences between the genders and between younger and older patients. To evaluate this, we studied a large Scandinavian cohort of patients referred for catheter ablation of AF. METHODS: Consecutive patients filled out the ASTA questionnaire, assessing symptoms, HRQoL, and perception of arrhythmia, prior to ablation. Patients were recruited from four Swedish and one Danish tertiary center. RESULTS: A total of 2493 patients (72% men) filled out the ASTA questionnaire. Women experienced eight of the nine ASTA scale symptoms more often than men. Patients <65 years reported four symptoms more often, only tiredness was more frequent in those ≥65 years (P = .007). Women and patients <65 years experienced more often palpitations and regarding close to fainting and this was more common among women, no age differences were seen. Women and men scored differently in 10 of the 13 HRQoL items. Only negative impact on sexual life was more common in men (P < .001). Older patients reported more negative influence in four of the HRQoL items and the younger in one; ability to concentrate. CONCLUSIONS: Women experienced a more pronounced symptom burden and were more negatively affected in all HRQoL concerns, except for the negative impact on sexual life, where men reported more influence of AF. Differences between age groups were less pronounced. Disease-specific patient-reported outcomes measures (PROMs) add important information where gender differences should be considered in the care.

The cost-effectiveness of radiofrequency catheter ablation as first-line treatment for paroxysmal atrial fibrillation: results from a MANTRA-PAF substudy.

AIM: The aim of this prospective substudy was to estimate the cost-effectiveness of treating paroxysmal atrial fibrillation (AF) with radiofrequency catheter ablation (RFA) compared with antiarrhythmic drugs (AADs) as first-line treatment. METHODS AND RESULTS: A decision-analytic Markov model, based on MANTRA-PAF (Medical Antiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation) study data, was developed to study long-term effects and costs of RFA compared with AADs as first-line treatment. Positive clinical effects were found in the overall population, a gain of an average 0.06 quality-adjusted life years (QALYs) to an incremental cost of €3033, resulting in an incremental cost-effectiveness ratio of €50 570/QALY. However, the result of the subgroup analyses showed that RFA was less costly and more effective in younger patients. This implied an incremental cost-effectiveness ratio of €3434/QALY in ≤50-year-old patients respectively €108 937/QALY in >50-year-old patients. CONCLUSION: Radiofrequency catheter ablation as first-line treatment is a cost-effective strategy for younger patients with paroxysmal AF. However, the cost-effectiveness of using RFA as first-line therapy in older patients is uncertain, and in most of these AADs should be attempted before RFA (MANTRA-PAF ClinicalTrials.gov number; NCT00133211).

Development and validation of a new Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA) with focus on symptom burden.

BACKGROUND: Arrhythmias can appear with a variety of symptoms, all from vague to pronounced and handicapping symptoms. Therefore, patient-reported outcomes (PROs) concerning symptom burden are important to assess and take into consideration in the care and treatment of patients with arrhythmias. The main purpose was to develop and validate a disease-specific questionnaire evaluating symptom burden in patients with different forms of arrhythmias. METHODS: A literature review was conducted and arrhythmia patients were interviewed. Identified symptoms were evaluated by an expert panel consisting of cardiologists and nurses working daily with arrhythmia patients. SF-36 and Symptoms Checklist (SCL) were used in the validation of the new questionnaire Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA). Homogeneity was evaluated with Spearman's correlations and Cronbach's alpha coefficient (α) was used to evaluate internal consistency. Construct validity was evaluated using item-total correlations and convergent and discriminant validity. For this, Spearman's correlations were calculated between the ASTA symptom scale, SCL and SF-36. Concurrent validity was validated by Spearman's correlations between the ASTA symptom scale and SCL. RESULTS: The correlations between the different items in the ASTA symptom scale showed generally sufficient homogeneity. Cronbach's coefficient was found to be satisfactory (α = 0.80; lower bound 95% CI for α = 0.76). Construct validity was supported by item-total correlations where all items in the symptom scale were sufficiently correlated (≥0.3). Convergent and discriminant validity was supported by the higher correlations to the arrhythmia-specific SCL compared to the generic SF-36. Concurrent validity was evaluated and there were sufficiently, but not extremely strong correlations found between the ASTA symptom scale and SCL. CONCLUSIONS: The nine items of the ASTA symptom scale were found to have good psychometric properties in patients with different forms of arrhythmias. Arrhythmia patients suffer from both frequent and disabling symptoms. The validated ASTA questionnaire can be an important contribution to PROs regarding symptom burden in arrhythmia patients.

Validation of the English version of the arrhythmia-specific questionnaire in tachycardia and arrhythmia (ASTA): a Rasch evaluation study.

BACKGROUND: Patient-reported outcome measures are important in person-centered care, providing valuable information about patients' experiences. Disease-specific questionnaires add important information about a certain disease in comparison to generic questionnaires. Questionnaires need to be validated in the targeted population to achieve reliable data. The purpose with the study was to use Rasch measurement theory to evaluate the English version of the ASTA questionnaire. METHODS: The Rasch model theory was used to evaluate global and item fit, targeting, response category functioning, local independency, unidimensionality, differential item functioning (DIF) for gender and age, and reliability. RESULTS: The study included 202 patients undergoing DC conversion or catheter ablation at the Centre for Heart Rhythm Disorders at the University of Adelaide, Australia. The mean age was 67 years and 30% were women. Most patients had atrial fibrillation (n = 179), others had atrial flutter or had a combination. One of nine items demonstrated unsatisfactory model fit in the ASTA Symptom scale and two of 13 in the ASTA Health-Related Quality of Life (HRQoL) scale. Unidimensionality was supported for both scales. The targeting was acceptable except for the lower end of the scales. Both scales showed reversed thresholds for the response categories "quite a lot" and "a lot" (eight of ASTA symptoms and 12 of ASTA HRQoL items). Some problems with local dependency were detected in both scales. The reliability (person separation index) was satisfactory: 0.75 for the ASTA symptom scale and 0.77 for the ASTA HRQoL scale. No DIF for gender and age were detected. CONCLUSIONS: The English version of the ASTA questionnaire demonstrated satisfactory measurement properties according to the Rasch model. However, it needs to be evaluated in patients with other arrhythmias. The response categories should be considered as well as DIF in further validation. The ASTA questionnaire can be used for assessments of symptoms and HRQoL between groups of different ages and genders in patients with arrhythmia.

Symptoms and health-related quality of life 5 years after catheter ablation of atrial fibrillation.

OBJECTIVES: To investigate the effect of catheter ablation (CA) on symptoms and health-related quality of life (HRQoL) after 5 years, and analyze predictors of recurrence of symptoms. BACKGROUND: The primary indication for CA of atrial fibrillation (AF) is to reduce symptoms and improve HRQoL where long-term follow-up are sparse. METHODS: In this observational, long-term, single-center study, patients were recruited from Linköping University Hospital, Sweden. They were aged ≥18 years and had been referred for CA from November 2011 until June 2019. Arrhythmia-specific symptoms and HRQoL were assessed by patient-reported outcome measures (PROMs) with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA). RESULTS: In the study were 1521 patients, 69% men, mean age 62 years. At baseline, 87% of the patients and at the 5-year follow-up 80% of those eligible filled out the ASTA questionnaire. At follow-up, 50% reported freedom from symptoms, 18% had >50% symptom reduction, 14% had a minor reduction, while 18% reported no effect or a worsening of symptoms. Factors predicting symptoms were female gender (hazard ratio [HR]: 1.8; 1.2-2.8), body mass index ≥ 35 (HR: 3.9; 1.6-9.8), and ischemic heart disease (IHD) (HR: 2.6; 1.2-5.9). After 5 years, breathlessness during activity, weakness/fatigue, and tiredness were still the most common symptoms; regarding HRQoL they were impaired physical ability and deteriorated life situation. CONCLUSIONS AND CLINICAL IMPLICATIONS: This clinical cohort of patients with AF evaluated through PROMs showed that CA had long-lasting effects on symptoms and HRQoL and that the use of PROMs in clinical routines was feasible. Factors predicting symptoms after CA were female gender, IHD, and obesity, an important reminder to encourage lifestyle management.

A Brazilian Portuguese translation, cultural adaptation and validation of the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA) health-related quality of life (HRQOL) scale.

INTRODUCTION: The health-related quality of life (HRQOL) of patients with tachyarrhythmia can be negatively influenced by the clinical manifestations. The evaluation of HRQOL with validated instruments can provide valuable information that will contribute to clinical decision-making and treatment. In Brazil, however, there is no available scale that evaluates HRQOL in different types of arrhythmia. The purpose of this study was to adapt the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia-HRQOL scale (ASTA-HRQOL scale) to the Brazilian culture, and to assess the psychometric properties of the adapted questionnaire. METHODS: The study used a methodological process of cultural adaptation based on international literature guidelines. The analyses were performed with 172 participants, 32 for cultural adaptation and 140 for psychometric validation. Calculation included analysis of reliability by Cronbach's α coefficient, construct validity with convergent validity using the WHOQOL-BREF questionnaire and by the Spearman correlation coefficient, Average Variance Extracted, and assessment of confirmatory factor analysis. RESULTS: The translation and adaptation processes showed a satisfactory degree of comprehension and applicability (93% reported them to be easy to understand). Confirmatory factor analysis indicated exclusion of one item from the mental scale, but after qualitative analysis the item was retained. The items presented adequate internal consistency (Cronbach's alpha coefficient = 0.88), and an inverse correlation of moderate magnitude with the physical domain (rho = -0.63) and with the mental domain (rho = -0.58) of the WHOQOL-BREF. CONCLUSIONS: The Brazilian Portuguese version of the ASTA-HRQOL scale, the ASTA-Br-HRQOL scale, can be a valuable tool for use in clinical practice and research.

ASK FOR IT: An Internet-based educational program for patients with atrial fibrillation - Results from a pilot study and design of the randomized, controlled, multicenter ASK FOR IT study.

Background: In the structured care of patients with atrial fibrillation (AF), education is compulsory. Patients search for information but sources of reliable information are sparse. ASK FOR IT, an internet- and guideline-based educational program, offers such information. Objective: To describe the development of ASK FOR IT, report on a pilot study, and present the design of a randomized controlled trial evaluating the benefits of ASK FOR IT in addition to standard care on symptoms, health-related quality of life (HRQoL), and health economy. Methods: ASK FOR IT was developed by healthcare providers, patients, and a psychologist. ASK FOR IT contains 6 parts: basic mechanisms, symptoms, treatment options, diagnostic possibilities, lifestyle management, and a mental support section. The following questionnaires were used: SF-36, EQ-5D, the disease-specific ASTA (symptoms and HRQoL), and HADS (depression and anxiety). Interviews regarding usability and understanding were conducted. Results: Pilot study: Fifteen patients (mean age 65 years), 4 women and 11 men, took part in the study. During follow-up, the patients improved regarding symptoms in ASTA (P = .038) and the HRQoL mental domain (P = .011), while no differences were seen in SF-36, EQ-5D, or HADS. Interviews indicated that the program was easy to use and the content easy to understand. Conclusion: The ASK FOR IT program functioned as intended. It was easy to use and the information was easy to understand. The significant reduction in symptoms and improvement in HRQoL (mental domain) after only 3 months are encouraging. In the main study, 200 patients will be randomized.

MediYoga as a part of a self-management programme among patients with paroxysmal atrial fibrillation - a randomised study.

BACKGROUND: Paroxysmal atrial fibrillation is associated with impaired health-related quality of life. Yoga has been suggested to improve health-related quality of life among patients with heart failure and hypertension. AIM: The aim of the study was to evaluate the effects of MediYoga, in respect of health-related quality of life, blood pressure, heart rate, as well as N-terminal pro b-type natriuretic peptide, among patients with symptomatic paroxysmal atrial fibrillation, compared with standard therapy or relaxation. METHODS: Patients with symptomatic paroxysmal atrial fibrillation, n=132, were stratified for gender and randomised to MediYoga, a relaxation group or a control group, 44 patients per group with a 12-week follow-up. Health-related quality of life, blood pressure, heart rate and N-terminal pro b-type natriuretic peptide were assessed. RESULTS: After 12 weeks, there were no differences in health-related quality of life between the groups. There were improvements in Short-Form Health Survey bodily pain, general health, social function, mental health and mental component summary scores within the MediYoga group (p=0.014, p=0.037, p=0.029, p=0.030, p=0.019, respectively). No change was seen in the relaxation and control groups. Systolic blood pressure decreased in the MediYoga group (134±18 to 127±13) compared with the control group (126±17 to 127±15, p=0.041); no difference compared with the relaxation group (131±17 to 125±12). Diastolic blood pressure decreased in the MediYoga group (79±9 to 74 ±9) compared with the control group (76±9 to 79±8, p=0.005); no difference compared with the relaxation group (76±9 to 77±8). There were no differences in heart rate and N-terminal pro b-type natriuretic peptide between the groups after 12 weeks. CONCLUSIONS: MediYoga improves health-related quality of life and decreases blood pressure in patients with paroxysmal atrial fibrillation. MediYoga may be used as a part of a self-management programme among patients with paroxysmal atrial fibrillation.

Translation and Validation of the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia (ASTA) to the Brazilian Context: An Instrument Focusing on Arrhythmia Symptoms.

INTRODUCTION: The wide variety of symptoms in patients with cardiac arrhythmias can affect daily living activities. The evaluation of symptoms with patient-reported outcome measures (PROMs), with validated instruments, can provide information that contributes to clinical decisions and treatment. In Brazil, however, there is no available scale that evaluates symptoms in different types of arrhythmias. PURPOSE: This study aimed to translate the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia symptom scale (ASTA-symptom scale) and then validate the questionnaire in terms of Brazilian culture. METHOD: The methodological process of cultural adaptation used was based on international literature guidelines consisting of forward translation, synthesis, back translation, review by an expert committee, and pretest. Psychometric analyses were conducted with 140 patients. These included measuring internal consistency (Cronbach's alpha), construct validity with item-total correlations, and convergent construct validity with correlations with the quality of life questionnaire for patients with atrial fibrillation-version 2 (QVFA-v2). Usability and understandability were evaluated through the usability evaluation of instruments. RESULTS: The translation and adaptation processes were performed by obtaining the Brazilian Portuguese version of the original Swedish instrument. This version presented the internal consistency of items, evaluated through Cronbach's α (0.79). Construct validity was demonstrated by item-total correlations for the nine items, all except one reached the level of >0.30 (0.24). Convergent validity showed a high correlation with QVFA-v2 (0.89). As for the evaluation of usability and understanding, after two small suggested changes, no additional alterations were necessary. CONCLUSION: The psychometric properties of the Brazilian version of ASTA-symptom scale evaluated in this study were satisfactory, and the scale was proved to be a valid and reliable tool to assess the symptom burden in patients with different forms of tachyarrhythmia. The ASTA-Br-symptom scale questionnaire can be an important addition to PROMs for patients with arrhythmias and could help healthcare professionals in decision-making.

Cardiac disease and stroke: Practical implications for personalised care in cardiac-stroke patients. A state of the art review supported by the Association of Cardiovascular Nursing and Allied Professions.

Cardiac and stroke conditions often coexist because of common risk factors. The occurrence of stroke may have significant consequences for patients with cardiac conditions and their caregivers and poses a major burden on their lives. Although both cardiac and stroke conditions are highly prevalent, primary stroke prevention in cardiac patients is crucial to avert disabling limitations or even mortality. In addition, specific interventions may be needed in the rehabilitation and follow-up of these patients. However, healthcare systems are often fragmented and are not integrated enough to provide specifically structured and individualised management for the cardiac-stroke patient. Cardiac rehabilitation or secondary prevention services are crucial from this perspective, although referral and attendance rates are often suboptimal. This state of the art review outlines the significance of primary stroke prevention in cardiac patients, highlights specific challenges that cardiac-stroke patients and their caregivers may experience, examines the availability of and need for structured, personalised care, and describes potential implications for consideration in daily practice.

Wolff-Parkinson-White syndrome and atrioventricular nodal re-entry tachycardia in a Swedish population: consequences on health-related quality of life.

BACKGROUND: Living with paroxysmal supraventricular tachycardia affects a patient's whole life situation, but few studies have addressed health-related quality of life (HRQOL) aspects in these patients. The aim was therefore to describe HRQOL in patients with atrioventricular nodal re-entry tachycardia (AVNRT) or Wolff-Parkinson-White (WPW) syndrome, referred for radiofrequency ablation (RF-ablation), compared to age- and gender-matched Swedish reference groups. METHODS: HRQOL was assessed with SF-36 and EuroQol (EQ-5D and EQ-VAS) and the patients were asked disease-specific questions. RESULTS: The 97 patients with AVNRT [53 +/- 16 years of age/65 women] and 79 patients with WPW [42 +/- 15 years of age/26 women] exhibited significantly lower HRQOL scores in SF-36 in the same seven of the eight scales: Physical functioning (PF), role-physical (RP), social functioning (SF), role-emotional (RE), general health (GH), vitality (VT), and mental health (MH) while there was no difference in bodily pain (BP) compared to their respective age- and gender matched Swedish reference group. HRQOL scores were lower for patients with AVNRT compared to WPW in the areas of PF (P < 0.001), BP (P < 0.05), and GH (P < 0.01) in SF-36, and the same was found in EQ-VAS (64.8 vs. 71.2, P < 0.05). Occurrence of episodes of tachycardia more often than once a month compared to less frequently than once a month was associated with significantly lower HRQOL in all eight scales in SF-36 (GH, RE, MH: P < 0.01 and PF, RP, BP, VT, SF: P < 0.001) and EQ-5D index (P < 0.001) and EQ-VAS (P < 0.05) Arrhythmia duration longer than one hour compared to patients with shorter duration of the tachycardia-affected GH in SF-36 negatively (P < 0.05). Patients who experienced symptoms not only during activity but also at rest scored lower in SF-36 GH (P < 0.01) and SF (P < 0.05). CONCLUSION: Measuring HRQOL in patients with WPW or AVNRT is an important way to evaluate and describe these patients' life situation. These conditions were found to have a pronounced negative impact on HRQOL. The frequency of arrhythmia occurrence is one important factor to consider when setting priorities for treatment with RF-ablation.

Patients' Experiences of Living with Atrial Fibrillation: A Mixed Methods Study.

INTRODUCTION: Awareness of epidemiological and clinical consequences of atrial fibrillation (AF) has increased, as have disease-related costs. Less attention has been paid to patient-related issues, such as understanding how symptoms, different therapies, and lifestyle adjustments affect daily life. We aimed to describe patients' experiences of living with AF. METHODS: The study design used a parallel convergent mixed methods approach. Patients with AF were included in the SMURF study and referred for catheter ablation. Patients completed questionnaires on symptoms, health-related quality of life, depression, anxiety, and perceived control and were interviewed. The datasets were analysed separately using inductive content analysis and descriptive statistics. Data were merged to obtain a final interpretation. RESULTS: Nineteen patients were interviewed and 18 completed questionnaires. Twelve of the patients were male, mean age 60 years (45-75 years). Inductive qualitative analysis revealed three categories: (i) symptoms and concerns limiting life, (ii) dimensions of worries, and (iii) strategies for management. The most common symptoms were tiredness, weakness/fatigue, and breathlessness during activities, and the most pronounced negative impacts on health-related quality of life (HRQOL) were physically related, shown in the ASTA questionnaire. The most negative SF-36 scores were found in role limitations due to physical health problems and vitality. HADS revealed five patients with some degree of anxiety and four with some degree of depression. Patients had lower scores on perceived control than perceived helplessness in CAS. Patients' perceived control was higher than their families', and families experienced more helplessness. CONCLUSIONS: The mixed methods design deepens our understanding of challenges faced by patients. Patients experienced a limited ability to perform activities of daily living due to AF which created different kinds of worries that encouraged the use of various strategies to manage their lives. Healthcare providers need to be aware that relationships between patients and their relatives can change, and therefore they need to be supported and integrated into the care system.

Echocardiographic and Biochemical Factors Predicting Arrhythmia Recurrence After Catheter Ablation of Atrial Fibrillation-An Observational Study.

Background: RFA is a well-established treatment for symptomatic patients with AF. However, the success rate of a single procedure is low. We aimed to investigate the association between the risk of recurrence of atrial fibrillation (AF) after a single radiofrequency ablation (RFA) procedure and cardiac neurohormonal function, left atrial (LA) mechanical function as well as proteins related to inflammation, fibrosis, and apoptosis. Methods and Results: We studied 189 patients undergoing RFA between January 2012 and April 2014, with a follow-up period of 12 months. A logistic regression analysis was performed to investigate the association between pre-ablation LA emptying fraction (LAEF), MR-proANP, Caspase-8 (CASP8), Neurotrophin-3 (NT3), and the risk for recurrence of AF after a single RFA procedure. 119 (63.0%) patients had a recurrence during a mean follow-up of 402 ± 73 days. An increased risk of recurrence was associated with: Elevated MR-proANP (fourth quartile vs. first quartile: HR, 2.80 (95% CI, 1.14-6.90]; P = 0.025); Low LAEF (fourth quartile vs. first quartile: hazard ratio [HR], 2.41 [95% CI, 1.01-5.79]; P = 0.045); Elevated CASP8 (fourth quartile vs. first quartile: HR 12.198 95% CI 2.216-67.129; P = 0.004); Elevated NT-3 (fourth quartile vs. first quartile: HR 7.485 95% CI 1.353-41.402; P = 0.021). In a receiver operating characteristic curve analysis, the combination of MR-proANP, CASP8, and NT3 produced an area under the curve of 0.819; CI 95% (0.710-0.928). Conclusions: Patients with better LA mechanical function and lower levels of atrial neurohormones as well as of proteins related to fibrosis and apoptosis, have a better outcome after an RFA procedure. Unique identifier: No. NCT01553045 (https://clinicaltrials.gov/ct2/show/NCT01553045?term=NCT01553045&rank=1).

Psychometric evaluation of the Polish version of the Arrhythmia­Specific Questionnaire in Tachycardia and Arrhythmia: a new tool for symptom and health­related quality of life assessment.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia resulting in hospitalization. The assessment of symptoms and health­related quality of life (HRQoL) can provide valuable information before, during, and after health care interventions for AF. AIMS: We aimed to perform a translation and cultural adaptation of the Arrhythmia­Specific Questionnaire in Tachycardia and Arrhythmia (ASTA), and to evaluate the reliability and validity of its Polish version. METHODS: The standard forward­backward translation procedure to translate the ASTA questionnaire into Polish was used. A total of 244 patients with AF at a mean (SD) age of 70.7 (10.7) years completed the questionnaire and were included in the study. Reliability was tested using internal consistency (Cronbach α) and validity with an item­total correlation, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA). RESULTS: The ASTA symptom scale had satisfactory psychometric properties (α = 0.718), and the corrected item­total correlation was sufficient for most items (0.361-0.506), except for cold sweats (0.156). The ASTA HRQoL scale showed good psychometric properties (α = 0.855). Initial CFA analyses showed that the 1- and 2­factor models had similar properties, with strong factor loadings and satisfactory goodness­of­fit values according to the comparative fit index (0.947 for the 1­factor model vs 0.988 for the 2­factor model). A comparison of the 1­and 2­factor models showed that the close fit for the root­mean­square error of approximation was better for the 2­factor model (0.387 vs 0.193). A 2­factor EFA model was produced, and for factor 1 (physical scale), the varimax low ranged between 0.470 and 0.804, and for factor 2 (the mental scale), it ranged between 0.597 and 0.873. CONCLUSIONS: The psychometric properties of the Polish version of the ASTA questionnaire were overall found to be satisfactory.

Predictors of improvement in arrhythmia-specific symptoms and health-related quality of life after catheter ablation of atrial fibrillation.

BACKGROUND: The primary goal of radiofrequency ablation (RFA) of atrial fibrillation (AF) is to improve symptoms and health-related quality of life (HRQoL). However, most studies have focused on predictors of AF recurrence rather than on predictors of improvement in symptoms and HRQoL. HYPOTHESIS: We sought to explore predictors of improvement in arrhythmia-specific symptoms and HRQoL after RFA of AF, and to evaluate the effects on symptoms, HRQoL, anxiety, and depression. METHODS: We studied 192 patients undergoing their first RFA of AF. The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), arrhythmia-specific questionnaire in tachycardia and arrhythmia (ASTA), and hospital anxiety and depression scale (HADS) questionnaires were filled out at baseline, at 4 months, and at a 1-year follow-up. RESULTS: All questionnaire scale scores improved significantly over time. In the ASTA symptom scale score, female gender and > 10 AF episodes the month before RFA were significant positive predictors of improvement, while diabetes and AF recurrence within 12 months after RFA were significant negative predictors (R2 = 0.18; P < 0.001). In the ASTA HRQoL scale score, the presence of heart failure and > 10 AF episodes the month before RFA were significant positive predictors of improvement, while diabetes, maximum left atrial volume and AF recurrence were significant negative predictors (R2 = 0.20; P < 0.001). CONCLUSION: Left atrial volume, gender, diabetes, heart failure, the frequency of AF attacks prior to RFA, and recurrence of AF after RFA were significant factors affecting improvement in symptoms and HRQoL after RFA of AF. Future studies are warranted to confirm these findings.

The association between alcohol consumption, cardiac biomarkers, left atrial size and re-ablation in patients with atrial fibrillation referred for catheter ablation.

BACKGROUND: Information on alcohol consumption in patients undergoing radiofrequency ablation (RFA) of atrial fibrillation (AF) is often limited by the reliance on self-reports. The aim of this study was to describe the long-term alcohol consumption, measured as ethyl glucuronide in hair (hEtG), in patients undergoing RFA due to AF, and to examine potential associations with cardiac biomarkers, left atrial size and re-ablation within one year after the initial RFA. METHODS: The amount of hEtG was measured in patients referred for RFA, and a cut-off of 7 pg/mg was used. N-terminal pro B-type natriuretic peptide (NT-proBNP) and the mid-regional fragment of pro atrial natriuretic peptide (MR-proANP) were examined and maximum left atrium volume index (LAVI) was measured. The number of re-ablations was examined up to one year after the initial RFA. Analyses were stratified by gender, and adjusted for age, systolic blood pressure, body mass index, presence of heart failure and heart rhythm for analyses regarding NT-proBNP, MR-proANP and LAVI and heart rhythm being replaced by type of AF for analyses regarding re-ablation. RESULTS: In total, 192 patients were included in the study. Median (25th- 75th percentile) NT-proBNP in men with hEtG ≥ 7 vs. < 7 pg/mg was 250 (96-695) vs. 130 (49-346) pg/ml (p = 0.010), and in women it was 230 (125-480) vs. 230 (125-910) pg/ml (p = 0.810). Median MR-proANP in men with hEtG ≥ 7 vs. < 7 pg/mg was 142 (100-224) vs. 117 (83-179) pmol/l (p = 0.120) and in women it was 139 (112-206) vs. 153 (93-249) pmol/l (p = 0.965). The median of maximum LAVI was 30.1 (26.7-33.9) vs. 25.8 (21.4-32.0) ml/m2 (p = 0.017) in men, and 25.0 (18.9-29.6) vs. 25.7 (21.7-34.6) ml/m2 (p = 0.438) in women, with hEtG ≥ 7 vs. < 7 pg/ml, respectively. Adjusted analyses showed similar results, except for MR-proANP turning out significant in men with hEtG ≥ 7 vs. < 7 pg/mg (p = 0.047). The odds ratio of having a re-ablation was 3.5 (95% CI 1.3-9.6, p = 0.017) in men with hEtG ≥ 7 vs. < 7 pg/mg, while there was no significant difference in women. CONCLUSIONS: In male patients with AF and hEtG ≥ 7 pg/mg, NT-proBNP and MR-proANP were higher, LA volumes larger, and there was a higher rate of re-ablations, as compared to men with hEtG < 7 pg/mg. This implies that men with an alcohol consumption corresponding to an hEtG-value ≥ 7, have a higher risk for LA remodelling that could potentially lead to a deterioration of the AF situation.

Factors Predicting Arrhythmia-Related Symptoms and Health-Related Quality of Life in Patients Referred for Radiofrequency Ablation of Atrial Fibrillation: An Observational Study (the SMURF Study).

OBJECTIVES: The purpose of this study was to correlate the arrhythmia-related symptoms and health-related quality of life (HRQoL) in patients with atrial fibrillation (AF) who are eligible for radiofrequency ablation (RFA) with a number of objective indicators. BACKGROUND: Although the clinical consequences of AF have been studied extensively, the variation in the symptoms of patients with AF and HRQoL remains under-researched. METHODS: We studied 192 patients eligible for RFA of AF referred to the University Hospital, Linköping, Sweden, between January 2012 and April 2014. The ASTA (Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia) symptom scale was used to assess arrhythmia-related symptoms in the patients. The ASTA HRQoL scale and the short-form 36 (SF-36) physical and mental components summaries (PCS and MCS) were used to express disease-specific and overall HRQoL of the patients, respectively. RESULTS: Anxiety, low-grade inflammation, and left atrial dilatation significantly predicted arrhythmia-related symptoms (R2 = 0.313; p < 0.001). Depression was the most important predictor of arrhythmia-specific HRQoL (standardized beta: 0 .406), and the produced model explained a significant proportion of the variation in arrhythmia-specific HRQoL (R2 = 0.513; p < 0.001). The most important predictor of PCS was obesity (body mass index >30 kg/m2) (standardized beta: -0.301), whereas the most important predictor of MCS was anxiety (standardized beta: -0.437). CONCLUSIONS: Anxiety, depression, and low-grade inflammation were the factors that predicted both arrhythmia-related symptoms and HRQoL in patients with AF. Obesity was the most significant predictor of patient general physical status. These factors need to be addressed in patients with AF to improve management of their disease. Intensive risk factor modification can be of great importance. (Reasons for Variations in Health Related Quality of Life and Symptom Burden in Patients With Atrial Fibrillation [SMURF]; NCT01553045).

The Swedish RAND-36 Health Survey - reliability and responsiveness assessed in patient populations using Svensson's method for paired ordinal data.

BACKGROUND: The Short Form 36-Item Survey is one of the most commonly used instruments for assessing health-related quality of life. Two identical versions of the original instrument are currently available: the public domain, license free RAND-36 and the commercial SF-36.RAND-36 is not available in Swedish. The purpose of this study was threefold: to translate and culturally adapt the RAND-36 into Swedish; to evaluate its reliability and responsiveness using Svensson's method for paired ordered categorical data; and to assess the usability of an electronic version of the questionnaire.The translation process included forward and backward translations and reconciliation. Test-retest reliability was examined during a period of two-weeks in 84 patients undergoing dialysis for chronic kidney disease. Responsiveness was examined in 97 patients before and 2 months after a cardiac rehabilitation program. Usability tests and cognitive debriefing of the electronic questionnaire were carried out with 18 patients. RESULTS: The Swedish translation of the RAND-36 was conceptually equivalent to the English version. Test-retest reliability was supported by non-significant relative position (RP) values among dialysis patients for all RAND-36 subscales (range - 0.02 to 0.10; all confidence intervals (CI) included zero). Responsiveness was demonstrated by significant improvements in RP values among cardiac rehabilitation patients for all subscales (range 0.22-0.36; lower limits of all CI > 0.1) except two subscales (General health, RP -0.02; CI -0.13 to 0.10; and Role functioning/emotional, RP 0.03; CI -0.09 to 0.16). In cardiac rehabilitation patients, sizable individual variation (RV > 0.2) was also shown for the Pain, Energy/fatigue and Social functioning subscales.The electronic version of RAND-36 was found easy and intuitive to use. CONCLUSIONS: Our results provide evidence supporting the reliability and responsiveness of the newly translated Swedish RAND-36 and the user-friendliness of the electronic version. Svensson's method for paired ordinal data was able to characterize not only the direction and size of differences among the patients' responses at different time points but also variations in response patterns within groups. The method is therefore, besides being suitable for ordinal data, also an important and novel tool for gaining insights into patients' response patterns to treatment or interventions, thus informing individualized care.