Higher symptom burden correlates with decreased quality of life but not risk of death in AF patients

An analysis of a large, nationwide registry of patients with atrial fibrillation has delivered some counterintuitive results that could signal a needed change in healthcare utilization for such patients.

After a median of 1.8 years of follow-up, patients with worse symptoms reported a lower quality of life, as would be expected. However, highly symptomatic patients did not have a higher risk of death, stroke or myocardial infarction despite a higher risk of hospitalization and healthcare resource utilization. 

Lead researcher James V. Freeman, MD, MPH, MS, of the Yale University School of Medicine in New Haven, Conn., and colleagues published their findings online in Circulation: Cardiovascular Quality and Outcomes on June 9.

“I would say probably the most surprising or novel and interesting finding is that on average, the patients that are most highly symptomatic in our study tended to be younger and healthier,” Freeman told Cardiovascular Business. “That’s something that’s very unique to atrial fibrillation. In general, the more symptomatic people are sicker, but that’s not true in atrial fibrillation.”

The researchers examined the ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) registry, which is ongoing and includes data on more than 10,000 patients with atrial fibrillation. Of those patients, 2,006 voluntarily completed this substudy that evaluated their quality of life. Janssen Scientific Affairs funded the study.

Freeman, a steering committee member of ORBIT-AF, said younger patients did not have increased rates of death, stroke or bleeding. However, they had an increased risk of hospitalization.       

“That’s a very interesting, important finding because these people were not getting hospitalized because they were having strokes,” Freeman said. “They were getting hospitalized because they’re highly symptomatic. What that means is that if we can target these rhythms and we can target trying to minimize symptoms in these highly symptomatic people, we have an opportunity to really impact healthcare utilization.”

Of the 10,087 patients with atrial fibrillation between June 2010 and August 2011, 61.8 percent were symptomatic, and 16.5 percent had severe or disabling symptoms. The most common patient-reported symptoms were palpitations (32.7 percent of patients), dyspnea with exertion (27.6 percent), fatigue (26.4 percent) and lightheadedness or dizziness (20.6 percent).

“Those findings were largely confirmatory of previous studies,” said Freeman, who is a cardiac electrophysiologist and arrhythmia specialist. “The most common symptoms were pretty consistent with what had been previously shown.”

Physicians evaluated atrial fibrillation symptoms using the European Heart Rhythm Association (EHRA) symptom classification scoring system that ranged from 1 (asymptomatic) to 4 (disabling). The EHRA system had not been validated in large community populations, according to Freeman, who added that there is no standard symptom burden scoring system for atrial fibrillation.

Patients reported their symptoms and quality of life by completing the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire. There was a correlation between the EHRA and AFEQT scores, which Freeman said supported the use of both measures in clinical practice.

“Sometimes people have symptoms, but it doesn’t adversely impact their quality of life,” Freeman said. “In this case, we demonstrated that if people are symptomatic with atrial fibrillation, it really has an impact on the quality of life. There’s a clear correlation between the two. The more symptomatic they are, the worse their quality of life. That’s an important finding.”

The researchers plan on performing more analyses of the ORBIT-AF registry. They also are examining the ORBIT-AF II registry, which began enrolling patients in February 2013 to assess the association between antithrombotic agents and outcomes.

“A more aggressive approach to atrial fibrillation rhythm control and symptom management is really warranted,” Freeman said. “I think the implication there is that treating people more aggressively in an outpatient setting perhaps more frequently and then considering more advanced therapies for people that are highly symptomatic such as antiarrhythmic medications or the consideration of oblation are things that we may see taken away from this study in clinical practice.”