Therapies on Quality of Life?
B. LÜDERITZ
Atrial fibrillation (AF) is a frequent and costly health care problem. In patients with AF, the restoration and maintenance of sinus rhythm is the primary therapeutic goal. The most frequent strategy for maintaining sinus rhythm after restoration is the use of anti-arrhythmic drugs. The efficacy of therapy in AF has been predominantly measured using objective criteria such as mortality and morbidity. In recent years, the importance of quality of life as an outcome measure has been recognised. However, few published studies have examined quality of life in patients with AF using properly validated tools. In addition, the specific impact of anti-arrhythmic treat- ment on quality of life in patients with AF has not been assessed. These issues are now being addressed in several ongoing studies. This article attempts to define quality of life, makes recommendations on how it might be assessed, and reviews our current knowledge regarding quality of life in patients with AF.
AF is the most frequently experienced cardiac arrhythmia, affecting an estimated 2.2 million people in the United States, and approximately 6 mil- lion in Europe. Approximately 1.2 million patients are suffering from parox- ysmal AF, and about 1 million from persistent AF. A rate of conversion from paroxysmal AF to persistent AF of 30% is anticipated [1]. The prevalence of AF increases with age [2], ranging from less than 1% at 50–59 years to near- ly 9% at 80–89 years [3]. In addition to palpitations, patients with AF have an increased risk of stroke and can develop decreased exercise tolerance and left ventricular dysfunction [4]. All of these problems may be reversed with restoration and maintenance of sinus rhythm. Thus, treatment of AF is
Department of Medicine – Cardiology, University of Bonn, Germany
warranted in the hope of eliminating symptoms, preventing complications, and possibly decreasing the excess mortality associated with this arrhythmia [5]. The primary intervention for maintaining sinus rhythm after restoration is use of anti-arrhythmic drugs. However, many of the existing drugs have only limited efficacy and are associated with considerable undesirable adverse effects. Current treatment is therefore suboptimal [6].
In patients with AF, the restoration and maintenance of sinus rhythm is the primary therapeutic goal. Once sinus rhythm is maintained, physiologi- cal rate control is restored and left ventricular ejection fraction, cardiac out- put, and exercise capacity are increased. This improved cardiovascular per- formance enhances the patient’s ability to perform the functions of normal daily life. Effective treatment of AF is based on these objective criteria, but subjective criteria such as quality of life are important. To address the quali- ty-of-life issues, rigorous yet practical approaches are needed to enable a comprehensive understanding of quality of life in patients with AF [7].
Different instruments can be used to measure various parameters reflecting quality of life. The most important items to be considered for endpoints and outcome events for the assessment of therapy for AF, as agreed by the European Society of Cardiology Atrial Fibrillation Endpoints Working Group in June 2000, are listed in Table 1 [8–13].
Table 1.Meaningful endpoints for quality of life evaluation in AF patients Frequency of episodes
Duration of episodes Hospitalisations Frequency of symptoms
Type of AF: ‘Paroxysmal, Persistent, Permanent’ or ‘Initial, Recurrent, Established’
respectively
AF and NYHA classification
General life satisfaction (general health and well being)
Cardiac symptom frequency / cardiac symptom severity (symptom burden) SF-36 category
Mental health / social functioning (emotional/social functioning) Physical role, vitality (physical functioning)
Somatisation
Gender men/women (SF-36) Outcome scores (follow-up) Silent AF vs symptomatic AF Age < 50 years, > 50 years
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Rhythm Control or Rate Control and Anticoagulation
The clinical categorisation relating to quality of life of patients who present with AF is a major determinant of the most appropriate strategy for rhythm management. For patients with recurrent AF that has not become perma- nent, the two available strategies are (1) rhythm control and anticoagulation and (2) rate control and anticoagulation. There is no clear evidence that one of these strategies is superior to the other [14]. Our knowledge about the efficacy and safety of various therapeutic strategies is insufficient, especially with respect to the direct comparison of re-establishment of sinus rhythm by drugs in comparison to rate control [14].
Ventricular Rate Control By AV Junction Ablation
Haemodynamic effects of complete atrioventricular (AV) junction ablation with subsequent regular ventricular pacing are exclusively due to rate con- trol and regularisation of ventricular contraction rather than to atrial con- tractile function and previous AV synchrony. Several studies have been pub- lished that underline the beneficial effects of complete AV junction ablation in patients with AF, fast ventricular response, and depressed left ventricular function (Table 2) [9, 15–21].
RFC Ablation
The frequency of hospital admissions and emergency room visits and the number of anti-arrhy thmic drugs taken decreased significantly after Comparison to other settings (Post Myocardial Infarction, Implantable Cardioverter/
Defibrillator
Congestive Heart Failure
Therapeutic interventions: radiofrequency catheter and atrioventricular node abla- tion
Medical therapy vs ablation AV junction ablation
Cardiac Output-change (rest, exercise) after cardioversion Effects of Maze operation
New technology for therapy (new leads, new algorithms, ATP, stabilisation features) Table 1,continue
radiofrequency catheter (RFC) ablation and pacemaker implantation.
Activity capacity improved significantly after ablation in patients with depressed left ventricular function. All improvements after ablation were maintained over 6 months follow-up. However, compared with patients with- out AF before ablation, patients who did have AF before ablation had less improvement in general quality of life, frequency of significant symptoms, and symptoms during attacks [22].
In summary, it has been shown that not only pharmaceutical but, even more, electrical treatment can enhance quality of life in patients with AF (Table 3) [23].
Table 2.Impact of complete atrioventricular (AV) junction ablation and pacemaker implantation on left ventricular haemodynamics, exercise capacity, and quality of life
Author No. Haemodynamics Exercise Quality
of patients capacity of life
Heinz et al. [15] 10 (10/0) + 0 –
Twidale et al. [16] 14 (7/7) + + –
Rodriguez et al. [17] 30 (3/2) + – –
Brignole et al. [18] 23 (23/0) + + +
Edner et al. [19] 29 (17/12) + + –
Fitzpatrick et al. [20] 90 (54/46) + + +
Natale et al. [21] 29 (17/12) + + +
Schumacher and Lüderitz [9] 45 (27/18) + + +
+ Significant improvement, 0 no significant improvement, – no data available
Table 3.Estimates by scorig points of health-related quality of life (SF-36 categories), medical therapy vs ablation therapy [16]. Higher score indicates higher quality of life SF-36 category Medical therapy Ablation therapy
Baseline Follow-up P value Baseline Follow-up P value Physical function 71 ± 26 81 ± 24 < 0.05 70 ± 25 83 ± 27 < 0.005 Physical role 54 ± 41 65 ± 38 < 0.05 47 ± 38 81 ± 31 < 0.001 Bodily pain 67 ± 17 63 ± 245 ns 72 ± 15 81 ± 20 < 0.05 General health 68 ± 19 69 ± 21 ns 65 ± 21 79 ± 21 < 0.001 Vitality 50 ± 16 55 ± 21 ns 51 ± 22 66 ± 22 < 0.005 Social function 68 ± 24 78 ± 26 < 0.01 72 ± 26 83 ± 29 < 0.001 Emotional role 74 ± 40 78 ± 36 ns 79 ± 37 94 ± 17 < 0.05 Mental health 69 ± 15 73 ± 19 < 0.05 68 ± 19 77 ± 18 < 0.01 ns Not significant
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