Ulla Walfridsson

The Impact of Supraventricular Tachycardias on Driving Ability in Patients Referred for Radiofrequency Catheter Ablation

Aim: The aim of the present study was to evaluate the occurrence of arrhythmia‐related symptoms in patients with supraventricular tachycardia (SVT) referred for radiofrequency catheter ablation (RF ablation) with special focus on driving ability.

Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation: results on health-related quality of life and symptom burden. The MANTRA-PAF trial

AIMS The Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation (MANTRA-PAF) trial assessed the long-term efficacy of an initial strategy of radiofrequency ablation (RFA) vs. antiarrhythmic drug therapy (AAD) as first-line treatment for patients with PAF. In this substudy, we evaluated the effect of these treatment modalities on the Health-Related Quality of Life (HRQoL) and symptom burden of patients at 12 and 24 months. METHODS AND RESULTS During the study period, 294 patients were enrolled in the MANTRA-PAF trial and randomized to receive AAD (N = 148) or RFA (N = 146). Two generic questionnaires were used to assess the HRQoL [Short Form-36 (SF-36) and EuroQol-five dimensions (EQ-5D)], and the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA) was used to evaluate the symptoms appearing during the trial. All comparisons were made on an intention-to-treat basis. Both randomization groups showed significant improvements in assessments with both SF-36 and EQ-5D, at 24 months. Patients randomized to RFA showed significantly greater improvement in four physically related scales of the SF-36. The three most frequently reported symptoms were breathlessness during activity, pronounced tiredness, and worry/anxiety. In both groups, there was a significant reduction in ASTA symptom index and in the severity of seven of the eight symptoms over time. CONCLUSION Both AAD and RFA as first-line treatment resulted in substantial improvement of HRQoL and symptom burden in patients with PAF. Patients randomized to RFA showed greater improvement in physical scales (SF-36) and the EQ-visual analogue scale. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00133211.

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 patients 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.

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.

BackgroundArrhythmias 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.MethodsA 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.ResultsThe 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.ConclusionsThe 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.

Symptom burden, Metabolic profile, Ultrasound findings, Rhythm, neurohormonal activation, haemodynamics and health-related quality of life in patients with atrial Fibrillation (SMURF) : a protocol for an observational study with a randomised interventional component

Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia, with an estimated prevalence of 1.5–2%. It is an independent risk factor for ischaemic stroke and is estimated to cause about 20–25% of all stroke cases. AF has a great impact on health-related quality of life (HRQoL); however, one unresolved issue related to AF is the wide variation in its symptoms. Methods and analysis The symptom burden, metabolic profile, ultrasound findings, rhythm, neurohormonal activation, haemodynamics and HRQoL in patients with AF (Symptom burden, Metabolic profile, Ultrasound findings, Rhythm, neurohormonal activation, haemodynamics and health-related quality of life in patients with atrial Fibrillation, SMURF) study is a prospective observational, cohort study, with a randomised interventional part. The aim of the study is to investigate, in patients with AF, the relationship between symptom burden and metabolic aspects, atrial function and different neurohormones, and the effect of radiofrequency ablation (RFA). The interventional part of the study will give an insight into the neurohormonal and intracardiac pressure changes directly after initiation of AF. Consecutive patients with symptomatic AF accepted for treatment with RFA for the first time at Linköping University Hospital are eligible for participation. The enrolment started in January 2012, and a total of 200 patients are to be included into the study, with 45 of them being enrolled into the interventional study with initiation of AF. The sample size of the interventional study is based on a small pilot study with 5 patients induced to AF while 2 served as controls. The results indicated that, in order to find a statistically significant difference, there was a need to include 28 patients; for safety reasons, 45 patients will be included. Ethics and dissemination The SMURF study is approved by the Regional Ethical Review Board at the Faculty of Health Sciences, Linköping, Sweden. The results will be presented through peer-review journals and conference presentation. Trial registration number NCT01553045; Pre-results.

E-health in patients with atrial fibrillation

The term E-health, or information and communication technology, has been introduced during the last decade and is currently an evolving topic. The term refers to technology that supports health care providers in the management of chronic diseases and continuing care. The World Health Organization defines E-health as ‘the transfer of health resources and health care by electronic means’.1 According to this definition, it is a method of using health resources more appropriately and efficiently. Significant examples in terms of home telemonitoring can be found in the management of patients with heart failure (HF); a positive impact on self-care and self-efficacy in patients with HF2 and their admission to hospital3 has been demonstrated. A recent summary of systematic reviews has shown improved clinical outcomes in patients with HF using homebased E-health technology.4 The technology investigated included video consultations, mobile telemonitoring, telemonitoring based on automated devices and web-based telemonitoring. E-health (device-based telemonitoring and mobile telemonitoring) proved to be effective in reducing the relative risk of HF-related admission to hospital (from a relative risk of 0.64 to 0.86) compared with usual care (absolute risk from 3.7 to 8.2%) and the relative risk of allcause mortality (from 0.60 to 0.85) and absolute risk from 1.4 to 6.5% compared with usual care.4 These results are strongly dependent on the type of technology and the patient population and hence care should be taken in generalizing these E-health effects.5 Despite these promising results however, the implementation of E-health tools in the care of patients with HF is low internationally.6 Atrial fibrillation (AF) is the most common cardiac arrhythmia and is considered a chronic disease requiring long-term management. In fact, AF is an emerging epidemic, with an estimated 33.5 million patients affected globally in 2010, and its prevalence is increasing.7,8 This is significantly increasing the burden on the health care system and E-health technology might contribute to reducing this burden. E-health technology is finding its way in the management of AF and includes information websites, such as www.afibmatters.org, and the use of smartphones to detect AF using an iPhone-based ECG.9 Remote monitoring of implantable cardioverter defibrillator devices is another example of the innovative use of E-health technology in arrhythmia management. These interventions have been demonstrated to be safe and effective, to contribute to reducing the utilization of care in terms of follow-up10,11 and have the potential to reduce health care costs.12 A recent European Heart Rhythm Association paper advocated the development of structured educational arrhythmia programmes to optimize treatment effects and improve the quality of life of patients with arrhythmia.13 The emerging AF population requires the redesign of AF care to a system in which educational, self-management telemedicine has an important role in supporting patients and care providers in the management of this chronic arrhythmia. E-health technology is seen as a tool for surveillance and a source of information, but it can also act as a vital tool to actively involve patients with AF in their own care. As AF affects the well-being of patients and might lead to pronounced limitations in their daily life, it is important to understand how the disease affects individual patients.14 The use of information and communication technology in these patients can serve as a trigger for self-care motivation and support to decrease or minimize these limitations, resulting in improved patient outcomes and quality of life. Given the fact that patients with AF often require a large number of drugs (e.g. oral anticoagulant drugs, rate and/or rhythm control, as well as co-medication for underlying diseases) and the challenge of embedding lifestyle changes and risk factor management into their daily life, the use of E-health in patients with atrial fibrillation

Structured care of patients with atrial fibrillation improves guideline adherence

Aims There are many reports of lack of guideline adherence in the treatment of patients with atrial fibrillation (AF), and AF affects health-related quality of life (HRQoL) negatively. The aim of this study was to investigate whether structured care compared to standard care of a general AF population could improve guideline adherence and HRQoL, and reduce symptoms,anxiety and depression. Methods In total, 176 patients were recruited to the intervention and 146 patients to the control group.The intervention consisted of a structured follow-up program, while patients serving as controls received standard care. The primary outcome was guideline adherence evaluated through: appropriate use of oral anticoagulants (OAC) and antiarrhythmics, whether echocardiogram and thyroid lab tests were performed, and patient-reported outcome measures (PROMs), assessed with the questionnaires SF-36, EQ-5D, HADS and ASTA at baseline and after one year. Results Guideline adherence was significantly better in the intervention group, 91% vs. 63% (p < 0.01), mainly due to appropriate OAC treatment 94% vs. 74% (p < 0.01). Symptoms assessed with ASTA were less frequent and the negative impact of AF was reduced in the intervention group after one year/ at follow-up. Five scales in SF-36, and the visual analogue scale for current health status in EQ-5D (EQ-VAS), improved significantly in both groups. Conclusion Structured care of patients with AF significantly improved guideline adherence and patients reported fewer symptoms and a reduced negative impact on disease-specific HRQoL compared to standard care at one year follow-up.