A substudy from the ANTIPAF (Angiotensin II-antagonist in paroxysmal atrial fibrillation) trial has found that quality of life was overrated or underrated by physicians in 55% of patients with paroxysmal atrial fibrillation. Depression was the major contributor to a higher likelihood of overrating despite it being related to symptom burden, progression of disease, mortality and treatment adherence. The study is currently in press in the American Heart Journal.
Christof Kolb, Deutsches Herz-Zentrum, Munich Germany, presented the results of the substudy, on behalf of the study authors, at the European Heart Rhythm Association (EHRA) Europace Congress (23–26 June, Athens, Greece). Kolb told delegates that treatment decisions in atrial fibrillation are often based upon the physicians’ estimation of the patients’ quality of life and symptom burden. He added: “How well do electrophysiologists estimate the degree of quality-of-life impairment of their patients with paroxysmal atrial fibrillation?”
In an interview with Cardiac Rhythm News, Karl-Heinz Ladwig, Helmholtz Zentrum, Munich, Germany, commented that, to date, there has been no research into the quality of communication between physicians and atrial fibrillation patients; therefore the aim of this study was to assess the degree of congruence between patients’ and physicians’ assessments of quality of life in paroxysmal atrial fibrillation patients, as an indicator of patient-physician good communication and shared understanding. Ladwig said: “We chose this quality-of-life index not to design a quality-of-life paper but to take the quality-of-life issue as an example to illustrate the importance of the communication between the patient and the physician.”
In the substudy, 334 patients with paroxysmal atrial fibrillation (138 women and 196 men) without severe concomitant heart diseases and their physicians were asked in a prospective blinded manner to rate the patients’ health-related quality of life. The SF-12 was used for patients’ selfratings, and doctors rated how they believed patients would answer the SF-8. Paired t-tests were used to assess if patients’ ratings differed significantly from physicians’ rating; also Intra-Class Correlations (ICC) and Bland-Altman graphs were used to assess concordance.
The substudy found, according to Kolb, that, on average, physicians rated their patients’ health related quality of life higher than patients did, both for the mental component score and the physical component score. Fifty five per cent of patients were overrated or underrated by physicians by a clinically relevant amount and “depressed mood was the major contributor to a higher likelihood of overrating by physicians.”
Physical inactivity had the greatest bivariate effect on the physical component score discordance and major depressive disorder on the mental component score discordance. In the regression analyses, depression was significantly associated with discord in the mental component score (β= -0.94; p<0.001) and the physical component score (β= -0.37; p<0.002). Also, sleeping disorder was associated with discord in the mental component score (β= -4.13; p<0.002) and physical activity with discord in the physical component score (β= -1.47; p=0.006). Ladwig commented: “We found that patients with depressed mood also reported higher burden in atrial fibrillation symptoms. This leads us to think that it may be better for the physician to put more emphasis on this mental health issue [depression] because this might be the force of the symptom burden in the atrial fibrillation patients studied-much more than the actual heart disease condition. The mental condition could trigger symptoms even further; therefore there should be a treatment for depression that could help to diminish the symptoms.”
“Discordances could be due to patients’ inability to articulate their subjective health state, or unwillingness to confide relevant information to their physician,” said Kolb. In the study it was also noted that physicians may understand certain groups better, or have bias with regards to certain patients.
The results of this study, according to Ladwig, indicate the need for action, such as physician training to recognise depressed patients or systematic screening for depression in atrial fibrillation clinics. “Electrophysiologists should get training in this area as part of their formal education in order to acknowledge the mental health component of this cardiac condition,” Ladwig said.