Pamela J. McCabe

Psychological distress in patients diagnosed with atrial fibrillation: the state of the science.

Atrial fibrillation (AF) is a life-complicating illness adversely affecting morbidity, health-related quality of life (HRQOL), and healthcare use. Studies using HRQOL instruments suggest that patients diagnosed with AF experience more psychological distress than do healthy controls. Psychological distress in forms of anxiety and depression in patients with heart failure or coronary artery disease is related to increased mortality, morbidity, and consumption of healthcare. However, there is a critical lack of knowledge regarding the type and extent of psychological distress and its consequences in patients diagnosed with AF. This article will review the current state of scientific knowledge regarding psychological distress in patients with AF and offer suggestions for future studies. Medline, CINAHL, PscyhInfo, and Psychology and Behavioral Sciences Collection databases up to June 2009 were reviewed for key terms atrial fibrillation, psychological distress, affective distress, mood, emotional distress, psychological stress, negative affect, anxiety, depression, anger, and hostility. Ten studies using tested instruments to measure psychological distress were retained. The prevalence of psychological distress was not consistently reported. Combined findings revealed that psychological distress in the form of depression and/or anxiety uniquely contributed to greater AF symptom severity, diminished HRQOL, and recurrence of AF. Studies describing interventions to address psychological distress were not found. Lack of conceptual clarity and diversity of study purposes, designs, participants, and instruments limit the ability to draw coherent conclusions from findings. Nevertheless, findings suggest that psychological distress is present in a substantial portion of patients diagnosed with AF and its presence is related to adverse outcomes. Further study to identify the prevalence, characteristics, and consequences of psychological distress in patients diagnosed with AF is required to extend our knowledge and provide a foundation for development of interventions to address psychological distress in this rapidly increasing population.

Typical, atypical, and asymptomatic presentations of new-onset atrial fibrillation in the community: Characteristics and prognostic implications

BACKGROUND The prognostic significance of the clinical presentation of atrial fibrillation (AF) is poorly defined. OBJECTIVE The purpose of this study was to determine the frequency, associations, and prognostic impact of different clinical presentations of new-onset AF. METHODS One thousand patients with incident AF in Olmsted County, Minnesota, were randomly selected (2000-2010). Patients with AF that was complicated at presentation (heart failure [n = 71], thromboembolism [n = 24]), provoked (n = 346), or unable to determine symptoms (n = 83) were excluded. In the remaining patients, characteristics and prognosis associated with different types of symptoms were examined. RESULTS Among 476 patients, 193 had typical (palpitations), 122 had atypical (other non-palpitation symptoms), and 161 had asymptomatic AF presentation. Patients with typical presentation had lower CHA2DS2-VASc scores (mean 2.3 ± 2) compared to atypical and asymptomatic presentation (mean 3.2 ± 1.8 and 3.3 ± 1.9, respectively; P <.001). Fifty-nine cerebrovascular events and 149 deaths (n = 49 cardiovascular) were documented over median 5.6 and 6.0 years, respectively. Atypical and asymptomatic AF conferred higher risks of cerebrovascular events compared to typical AF after adjustment for CHA2DS2-VASc score and age (hazard ratio [HR] 3.51, 95% confidence interval [CI] 1.65-7.48, and HR 2.70, 95% CI 1.29-5.66, respectively), and associations remained statistically significant after further adjustments including comorbidities and warfarin use. Asymptomatic AF was associated with an increased risk of cardiovascular (HR 3.12, 95% CI 1.50-6.45) and all-cause mortality (HR 2.96, 95% CI 1.89-4.64) compared to typical AF after adjustment for CHA2DS2-VASc score and age. CONCLUSION The type of clinical presentation may have important implications for the prognosis of new-onset AF in the community.

Illness perceptions, coping strategies, and symptoms contribute to psychological distress in patients with recurrent symptomatic atrial fibrillation.

Background: Atrial fibrillation (AF) is a prevalent, life-complicating illness associated with psychological distress. Interventions to manage the psychological challenges of living with AF are needed. Evidence suggests that illness perceptions, coping strategies, and symptoms that contribute to psychological distress may be modified by psychoeducational interventions to reduce psychological distress. However, little is known about how illness perceptions, coping strategies, and symptoms contribute to psychological distress in patients with AF. Objective: The aim of this correlational study guided by Levethal’s Common Sense Model of Self-regulation was to identify the extent to which illness perceptions, coping strategies, symptom frequency, and symptom severity contributed to psychological distress in patients with recurrent symptomatic AF. The contribution of these factors was considered with respect to the effects of gender, age, type of AF, and time since AF diagnosis. Methods: Participants (n = 207; 56% male; 64.2 ± 12.3 years old) completed the Illness Perception Questionnaire–Revised, the COPE Inventory, the Symptom Checklist–Frequency and Severity, and the Profile of Mood States. Data were analyzed using Pearson correlation and hierarchical multiple regression. Results: Illness perceptions contributed most to psychological distress, followed by coping strategies and symptom frequency. Illness perceptions explained the largest portion of the total variance for the following: Tension-Anxiety, 44/56%; Depression-Dejection, 38/50%; Fatigue-Inertia, 43/53%; Confusion-Bewilderment, 41/49%; Vigor-Activity, 24/35%; and Total Mood Disturbance, 47/63%. Illness perceptions of AF as having serious consequences, a psychological cause, and perceived poor understanding of AF together contributed more (.47) to Total Mood Disturbance than did coping by focusing on emotion (.08) or symptom frequency (.06). Conclusions: Illness perceptions are important contributors to psychological distress in patients with AF. Assessment of patients’ illness perceptions may reveal those that increase the risk for psychological distress. Research is warranted to evaluate interventions to modify psychological cause and consequence beliefs and to promote understanding of AF.

What patients want and need to know about atrial fibrillation.

Clinicians in a variety of settings are called upon to care for patients diagnosed with atrial fibrillation (AF), a common chronic condition that affects up to 3 million people in the USA. Evidence-based guidelines provide clinicians with direction for treatment of AF, but recommended content for educating patients and counseling about self-management of AF is not included in published guidelines. When patients believe they have a good understanding of AF they report fewer symptoms, perceive greater control over AF, and attribute less emotional distress to AF. Thus, providing patients with information about AF and how to manage it is important for promoting positive outcomes. The purpose of this article is to offer evidence-based recommendations for content to include in self-management education and counseling for patients with AF. Approaches for educating and counseling patients related to AF pathophysiology, the nature of AF (its cause, consequences, and trajectory), treatments, action plans, and symptom management, and managing the psychosocial challenges of living with AF, are discussed.

Fatigue, dyspnea, and intermittent symptoms are associated with treatment-seeking delay for symptoms of atrial fibrillation before diagnosis

Background: Delay in seeking treatment for symptoms of atrial fibrillation (AF) at onset results in a missed opportunity for vital early treatment of AF which is important for reducing stroke, tachycardia induced heart failure, and treatment-resistant AF. Little is known about factors that contribute to treatment-seeking delay for symptoms of AF. Purpose: The purpose of this study was to identify factors associated with treatment-seeking delay for symptoms of AF before diagnosis. Methods: For this descriptive study, 150 participants with recently detected AF completed structured interviews to collect data about symptoms, symptom characteristics, symptom representation regarding cause, seriousness, controllability of symptoms, responses to symptoms before diagnosis, and time from symptom onset to treatment-seeking. Chi-square analysis was used to identify factors associated with delay (>1 week) versus no delay (⩽1 week) in treatment-seeking after symptom onset. Results: Participants were 51% female (n=76) with a mean age of 66.5 (standard deviation (SD)±11.1) years. A majority (70%, n=105) delayed treatment-seeking. Factors associated with delay included experiencing fatigue, dyspnea, intermittent symptoms, attributing symptoms to deconditioning, overwork, inadequate sleep, and perceiving symptoms as not very serious and amenable to self-management. Responses such as a wait and see approach, working through symptoms, reporting no fear of symptoms, or attempting to ignore symptoms were associated with delay. Conclusion: Experiencing fatigue, dyspnea and intermittent symptoms produced symptom representations and emotional and behavioral responses associated with treatment-seeking delay. There is a critical need to develop and test educational interventions to increase awareness of the spectrum and characteristics of AF symptoms and appropriate treatment-seeking behaviors.

Atrial Fibrillation Burden: Moving Beyond Atrial Fibrillation as a Binary Entity: A Scientific Statement From the American Heart Association

Our understanding of the risk factors and complications of atrial fibrillation (AF) is based mostly on studies that have evaluated AF in a binary fashion (present or absent) and have not investigated AF burden. This scientific statement discusses the published literature and knowledge gaps related to methods of defining and measuring AF burden, the relationship of AF burden to cardiovascular and neurological outcomes, and the effect of lifestyle and risk factor modification on AF burden. Many studies examine outcomes by AF burden classified by AF type (paroxysmal versus nonparoxysmal); however, quantitatively, AF burden can be defined by longest duration, number of AF episodes during a monitoring period, and the proportion of time an individual is in AF during a monitoring period (expressed as a percentage). Current guidelines make identical recommendations for anticoagulation regardless of AF pattern or burden; however, a review of recent evidence suggests that higher AF burden is associated with higher risk of stroke. It is unclear whether the risk increases continuously or whether a threshold exists; if a threshold exists, it has not been defined. Higher burden of AF is also associated with higher prevalence and incidence of heart failure and higher risk of mortality, but not necessarily lower quality of life. A structured and comprehensive risk factor management program targeting risk factors, weight loss, and maintenance of a healthy weight appears to be effective in reducing AF burden. Despite this growing understanding of AF burden, research is needed into validation of definitions and measures of AF burden, determination of the threshold of AF burden that results in an increased risk of stroke that warrants anticoagulation, and discovery of the mechanisms underlying the weak temporal correlations of AF and stroke. Moreover, developments in monitoring technologies will likely change the landscape of long-term AF monitoring and could allow better definition of the significance of changes in AF burden over time.

Symptom Representation and Treatment-Seeking Prior to Diagnosis of Atrial Fibrillation

Early treatment-seeking for symptoms of atrial fibrillation (AF) is critical to avert AF-related stroke and heart failure, but early treatment is hindered if symptoms are not accurately interpreted. The purpose of this research was to describe symptom representation and treatment-seeking responses prior to diagnosis of AF. For this descriptive study, 150 participants were surveyed to describe the type and temporality of symptoms, perceptions regarding the cause, seriousness, controllability of symptoms, and responses to symptoms prior to diagnosis. Participants’ mean age was 66.5 years, and 51% were female. Participants perceived symptoms as having nondisease-based causes, as not very serious, and as amenable to self-management. The majority took a wait and see response with 69% waiting more than 1 week after symptom onset to seek treatment. Lack of recognition of the seriousness of symptoms of AF and delayed treatment put patients at risk of poorer outcomes.

Depression among patients with acute coronary syndromes.

Members of theCouncil onCardiovascularandStrokeNursing (CVSN) continue to make outstanding contributions to cardiovascular science and clinical practice. Two of our distinguished members, Erika S. Froelicher and Lynn V. Doering, were instrumental in the publication of the scientific statement on the role of depression as a risk factor of poor prognosis among patients with acute coronary syndromes (ACS). Dr Froelicher has been a prominent figure in the crafting of other scientific statements addressing the assessment and treatment of depression. Despite the prevalence of major depression and depressive symptoms among the nearly 16 million American adults with coronary heart disease (CHD), depression has lacked formal recognition as a risk factor of adverse morbidity and mortality outcomes. Cardiovascular nurse practitioners and scientists have taken leadership roles not only in raising the awareness of depression as a risk of CHD but also in articulating the detrimental effects depression has for nonadherence to evidence-based medications and healthy behavior change. The scientific writing group reviewed 53 studies and 4 meta-analyses to determine the relationship between depression, largely measured by selfreport instruments, and adverse outcomes includingmortalityandnonfatal events,with thegoalofmaking recommendations about the role of depression as a risk factor among patients with ACS. More than half (17/32) of the studies determined that depression was a risk factor of all-cause mortality. The majority of studies (8/12) found that depression was significantly associated with increased cardiac mortality after ACS. Mortality and nonfatal events such as rehospitalization for a cardiac diagnosis were the focus of 22 studies involving 18 unique patient cohorts. Nearly all of these studies used selfreport depressive symptom instruments, most commonly, the Beck Depression InventoryYI.Most of these studies found that depression was a risk factor of combined outcomes of either all-cause mortality or cardiac mortality and nonfatal cardiac events. The writing committee addressed several important issues regarding the measurement of depressive symptoms. Although most of the studies measured depressive symptoms with theBeckdepression InventoryYI,others included the Center for Epidemiologic Studies Depression Scale and the Hospital Anxiety and Depression Scale, Depression Subscale. Methodological differences among studies were apparent because of the use of dichotomous cut points of continuous measures to specify depression criterion. This measurement issue has important interpretive implications both in terms of the loss of statistical power with dichotomous variables and of the potential misclassification inherent in using a particular cut point. The writing committee recommended that future studies should usewell-validatedquestionnairesalong with structured interviews to assess depression and usewell-validated cutoff scores and diagnostic criteria to define cases of depression. They also suggested that depression that occurs soon after an ACS may carry a higher risk than episodes of depression that began before ACS. Some of the potential mechanisms underlying the relationship between depression and CHD that require further clarification include metabolic syndrome, diabetes mellitus, obesity, neuroendocrine dysfunction, enhanced platelet activity, delay in seeking treatment, and high-risk health behaviors (smoking, inactivity, and nonadherence to preventive measures). The link between depression and adverse outcomes in patients

Feasibility and Acceptability of a Dignity Therapy/Life Plan Intervention for Patients With Advanced Cancer

PURPOSE/OBJECTIVES To determine the feasibility and acceptability of a dignity therapy/life plan intervention in the outpatient oncology setting.
. RESEARCH APPROACH Pilot descriptive study.
. SETTING Outpatient clinic in a tertiary oncology center. 
. PARTICIPANTS 18 patients within 12 months after diagnosis undergoing treatment for advanced pancreatic cancer or non-small cell lung cancer.
. METHODOLOGIC APPROACH Patients received dignity therapy, consisting of a focused life review/values clarification interview session and two subsequent sessions to produce a generativity document, which they can use later as they wish. Participants also wrote a life plan, in which they listed future hopes and dreams. Intervention feasibility and acceptability for patients and oncology clinician satisfaction were assessed.
. FINDINGS Among the 18 patients completing the intervention, almost all felt it was worthwhile, would do it again, had their expectations met or exceeded, would recommend it to others, and said the timing was just right.
. INTERPRETATION This psychosocial intervention was found to be feasible and acceptable to patients with cancer undergoing active treatment.
. IMPLICATIONS FOR NURSING Nurses may be in an ideal position to offer a dignity therapy/life plan intervention to patients with advanced cancer during treatment.

Feasibility Testing of the Alert for AFib Intervention.

Improving early detection and treatment of atrial fibrillation (AF) is critical because untreated AF is a major contributor to stroke and heart failure. We sought to generate knowledge about the feasibility of conducting a randomized controlled trial to test the effect of the Alert for AFib intervention on knowledge, attitudes, and beliefs about treatment-seeking for signs and symptoms of AF. Adults ≥65 years old (96% White) at risk for developing AF were randomized to receive the Alert for AFib intervention (n = 40) or an attention control session (n = 40). Feasibility goals for recruitment, participant retention, adherence, perceived satisfaction and burden, and intervention fidelity were met. From baseline to study completion, knowledge (p = .005) and attitudes (p < .001) about treatment-seeking improved more in the intervention group compared with the control group. Results support testing the effectiveness of the Alert for AFib intervention in a large trial.