Special articleA novel, simple scale for assessing the symptom severity of atrial fibrillation at the bedside: The CCS-SAF ScaleUne échelle simple et nouvelle pour évaluer la gravité des symptômes de fibrillation auriculaire au chevet du patient : L’échelle de GFA de la SCC
Background
The severity of symptoms caused by atrial fibrillation (AF) is extremely variable. Quantifying the effect of AF on patient well-being is important but there is no simple, commonly accepted measure of the effect of AF on quality of life (QoL). Current QoL measures are cumbersome and impractical for clinical use.
Objective
To create a simple, concise and readily usable AF severity score to facilitate treatment decisions and physician communication.
Methods
The Canadian Cardiovascular Society (CCS) Severity of Atrial Fibrillation (SAF) Scale is analogous to the CCS Angina Functional Class. The CCS-SAF score is determined using three steps: documentation of possible AF-related symptoms (palpitations, dyspnea, dizziness/syncope, chest pain, weakness/fatigue); determination of symptom-rhythm correlation; and assessment of the effect of these symptoms on patient daily function and QoL. CCS-SAF scores range from 0 (asymptomatic) to 4 (severe impact of symptoms on QoL and activities of daily living). Patients are also categorized by type of AF (paroxysmal versus persistent/permanent). The CCS-SAF Scale will be validated using accepted measures of patient-perceived severity of symptoms and impairment of QoL and will require ‘field testing’ to ensure its applicability and reproducibility in the clinical setting.
Conclusions
This type of symptom severity scale, like the New York Heart Association Functional Class for heart failure symptoms and the CCS Functional Class for angina symptoms, trades precision and comprehensiveness for simplicity and ease of use at the bedside. A common language to quantify AF severity may help to improve patient care.
Historique
La gravité des symptômes causés par la fibrillation auriculaire (FA) est extrêmement variable. Il est important de quantifier l’effet de la FA sur le bien-être du patient, mais il n’existe pas de mesure couramment acceptée pour mesurer l’effet de la FA sur la qualité de vie (QV). Les mesures de QV actuelles sont encombrantes et peu pratiques pour un usage clinique.
Objectif
Créer une échelle de gravité de la FA à la fois simple, concise et commode pour faciliter les décisions de traitement et les communications entre médecins.
Méthodologie
L’échelle de gravité de la fibrillation auriculaire (GFA) de la Société canadienne de cardiologie (SCC) est analogue à l’échelle d’angine de la SCC. L’échelle de GFA de la SCC est déterminée au moyen de trois étapes : documentation des symptômes pouvant être reliés à la FA (palpitations, dyspnée, étourdissements ou syncope, douleurs thoraciques, faiblesse ou fatigue), détermination de la corrélation entre les symptômes et le rythme et évaluation de l’effet de ces symptômes sur la fonction quotidienne et la QV du patient. Les échelles de GFA de la SCC oscillent entre 0 (asymptomatique) et 4 (graves répercussions des symptômes sur la QV et les activités de la vie quotidienne). Les patients sont également classés selon le type de FA (paroxystique par rapport à persistante ou permanente). L’échelle de GFA de la SCC sera validée à l’aide de mesures acceptées de gravité des symptômes et d’atteinte à la QV perçues par le patient et exigera des « essais sur le terrain » pour en garantir l’applicabilité et la reproductibilité en milieu clinique.
Conclusions
Ce type d’échelle de gravité des symptômes, tel que la classe fonctionnelle des symptômes d’insuffisance cardiaque de la New York Heart Association et la classe fonctionnelle de symptômes d’angine de la SCC, troque la précision et la perspective d’ensemble contre la simplicité et la facilité d’usage au chevet du patient. Un langage commun pour quantifier la gravité de la FA pourrait contribuer à améliorer les soins aux patients.
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Cited by (76)
Association Between Atrial Fibrillation Symptoms and Clinical Outcomes: A Prospective Multicenter Registry Study
2024, American Journal of CardiologyThe presence of symptoms plays an important role in determining whether to focus on rhythm control or rate control when treating atrial fibrillation (AF). Previous comparative studies on the clinical outcomes of symptomatic and asymptomatic AF have yielded inconsistent results, and a link between AF symptoms and left atrial (LA) remodeling is not established. Patients selected from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, which is a prospective, multicenter study consisting of patients with non-valvular AF, were grouped into 2 groups: symptomatic and asymptomatic. The primary outcome was a composite of the following cardiovascular outcomes: all-cause death, ischemic stroke, transient ischemic attack, systemic embolism, myocardial infarction, and heart failure hospitalization. Of 10,210 patients with AF, 4,327 (42%) had symptomatic AF. The asymptomatic group had an older mean age, more men, and more patients with hypertension and diabetes mellitus than the symptomatic group. The asymptomatic group had a larger left atrium (LA) diameter (43.6 vs 42.2 mm, p <0.001) than the symptomatic group. During a median follow-up of 32.9 (29.5 to 36.4) months, the asymptomatic and symptomatic groups showed similar incidences of the primary outcome (1.44 vs 1.45 per 100 person-years; log-rank, p = 0.8). In conclusion, the absence of AF symptoms is associated with increased LA. However, symptomatic and asymptomatic patients with AF have a similar risk of cardiovascular outcomes. This suggests that beneficial treatment for AF may be considered regardless of whether patients have symptomatic or asymptomatic AF.
Oral anticoagulant adherence and switching in patients with atrial fibrillation: A prospective observational study
2022, Research in Social and Administrative PharmacyAdherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) is important in preventing stroke. The dominance of retrospective studies using administrative data has led to a lack of data on psychosocial determinants of adherence and prevented comparison of adherence between OAC drug classes. OAC switching is another aspect of adherence that is unexplored.
A prospective design was utilized to measure AF patients’ self-reported adherence and OAC switching, and to identify their clinical, demographic, and psychosocial determinants. Participants were recruited from specialized AF clinics in Canada and followed for up to 2 years. Data were collected via telephone every 3–4 months using a structured survey. Adherence was measured using the Morisky Medication Adherence scale (©MMAS-8).
The included participants (N = 306) were followed for a median follow up time of 14.1 months and had an average of 3.2(SD 1.4) study visits. The mean self-reported adherence on the ©MMAS-8 was 7.28(SD 0.71) for patients receiving care at specialized AF clinics. Older age, experiencing a bleed, and higher satisfaction with the burden of medications were significantly associated with higher adherence. Drug class did not have any significant impact on adherence. 7.8% of the cohort experienced a switch with most of them being from warfarin to DOAC. Taking warfarin as the index medication, experiencing a bleed and older age were significantly associated with higher odds of switching.
Patients with AF reported high adherence to their OAC therapy however being on DOAC may not translate to better adherence compared to VKA. Improving satisfaction with the burden of therapy is important in improving adherence.
Dyspnea in patients with atrial fibrillation: Mechanisms, assessment and an interdisciplinary and integrated care approach
2022, IJC Heart and VasculatureAtrial fibrillation (AF) is the most common sustained heart rhythm disorder and is often associated with symptoms that can significantly impact quality of life and daily functioning. Palpitations are the cardinal symptom of AF and many AF therapies are targeted towards relieving this symptom. However, up to two-third of patients also complain of dyspnea as a predominant self-reported symptom. In clinical practice it is often challenging to ascertain whether dyspnea represents an AF-related symptom or a symptom of concomitant cardiovascular and non-cardiovascular comorbidities, since common AF comorbidities such as heart failure and chronic obstructive pulmonary disease share similar symptoms. In addition, therapeutic approaches specifically targeting dyspnea have not been well validated. Thus, assessing and treating dyspnea can be difficult.
This review describes the latest knowledge on the burden and pathophysiology of dyspnea in AF patients. We discuss the role of heart rhythm control interventions as well as the management of AF risk factors and comorbidities with the goal to achieve maximal relief of dyspnea. Given the different and often complex mechanistic pathways leading to dyspnea, dyspneic AF patients will likely profit from an integrated multidisciplinary approach to tackle all factors and mechanisms involved. Therefore, we propose an interdisciplinary and integrated care pathway for the work-up of dyspnea in AF patients.
An IoT based ECG system to diagnose cardiac pathologies for healthcare applications in smart cities
2022, Measurement: Journal of the International Measurement ConfederationCitation Excerpt :The use of mobile solutions detecting occurring arrhythmias is suggested as the most practical solution to reduce the risk of morbidity and mortality. Specific exclusion criteria have allowed authors to refine the review process by identifying 9 papers over 858 records assessed for eligibility, [25–33]. So, our analysis has been focused on these manuscripts.
The present paper aims to describe the project and development of an ECG monitoring system which is able to diagnose specific cardiac pathologies by adapting the processing algorithm to the monitored patient. The system can work standalone by providing the final diagnosis to the patient by a LEDs set. In addition, an IoT based architecture allows the system to share data and diagnosis with a remote cardiologist in real-time or to store data in a FTP folder, as an Holter monitor, for post-processing and further analysis.
The system consists of two sections: the digital one, based on the National Instruments MyRIO, digitalises the signal and processes it in real-time to make a diagnosis on possible occurring cardiac pathologies (bradycardia, tachycardia, infarction, ischemia); the analog section, which performs the acquisition, amplification, and preliminary filtering of a 3-leads electrocardiographic signal. The processing algorithm has been developed in NI LabVIEW environment. The main contribution to the state of the art is due to two removable and updatable memory devices. A first memory has been used to store clinical and personal data of patient so to configure the computing algorithm and adapt it to the monitored patient. A second memory has been used to store accuracy and uncertainty specifications of the ECG system in order to improve the reliability of the final diagnosis.
The system aims to provide an electrocardiographic monitoring system for healthcare applications in the smart city context. The possibility to monitor constantly the patient health state at home is an important challenge of the next future smart cities. IoT and automation are the main aspects of the proposed system. Patients having chronic heart diseases need frequent hospitalizations to check their heart health. In this scenario, the proposed system is an Ambient Assisted Living solution developed to encourage the independent life of cardiac subjects by supporting his/her care and wellness during the daily life.
Satisfaction With Oral Anticoagulants Among Patients With Atrial Fibrillation: A Prospective Observational Study
2021, CJC OpenSatisfaction with treatment has been identified as an important contributing factor to adherence with oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). We aimed to evaluate the satisfaction level of patients with AF regarding OAC use over time, using validated patient-reported outcome instruments, and to identify associated patient characteristics.
Participants were recruited from specialized AF clinics in Canada. Eligible AF patients who were prescribed OACs were followed for up to 2 years. Participants were interviewed via telephone every 3-4 months using a structured survey. The Treatment Satisfaction Questionnaire for Medication (TSQM II) and the Anti-Clot Treatment Scale (ACTS) were used to measure satisfaction over time.
Among the 306 participants, satisfaction scores on the TSQM II and ACTS instruments were high. Unadjusted analyses showed significantly greater satisfaction with the burden of therapy with direct OACs (DOACs) compared to that with warfarin (small-magnitude effect) and greater satisfaction with the convenience of rivaroxaban, compared with that of all other OACs (moderate-magnitude effect). After adjustment for all other variables, vitamin K antagonist therapy was associated with greater global satisfaction than was DOAC treatment. Satisfaction with benefit and burden as measured by the ACTS scale, and global satisfaction on the TSQM II scale, tended to increase over time. Patient factors that were somewhat consistently associated with greater satisfaction were female sex and younger age.
Patients with AF were highly satisfied with their therapy, with few differences among OAC classes and individual OACs. Individual patients may or may not be more satisfied with DOAC than VKA therapy, and regardless of the OAC prescribed, the may require significant support to maintain therapy adherence.
La satisfaction à l’égard du traitement a été désignée comme un facteur important contribuant à l’adhésion au traitement par anticoagulants oraux (ACO) chez les patients atteints de fibrillation auriculaire (FA). Notre objectif était d’évaluer le degré de satisfaction des patients atteints de FA concernant l’utilisation des ACO au fil du temps, à l’aide d’instruments validés mesurant les résultats signalés par les patients, et de déterminer les caractéristiques connexes des patients.
Les participants ont été recrutés dans des cliniques spécialisées en FA au Canada. Les patients admissibles atteints de FA qui se sont fait prescrire des ACO ont été suivis pendant une période allant jusqu’à 2 ans. Les participants ont été interrogés par téléphone tous les 3 ou 4 mois à l’aide d’une enquête structurée. Le questionnaire Treatment Satisfaction Questionnaire for Medication – Version II (TSQM II) et l’échelle Anti-Clot Treatment Scale (ACTS) ont été utilisés pour mesurer la satisfaction au fil du temps.
Parmi les 306 participants, les taux de satisfaction indiqués par les instruments TSQM II et ACTS étaient élevés. Les analyses non corrigées ont montré une satisfaction liée au fardeau du traitement significativement plus élevée avec les ACO directs qu’avec la warfarine (effet de faible ampleur) et une plus grande satisfaction concernant la commodité du rivaroxaban par rapport à celle de tous les autres ACO (effet de moyenne ampleur). Après ajustement pour tenir compte de toutes les autres variables, le traitement par antivitamines K (AVK) était associé à une plus grande satisfaction globale que le traitement par ACO direct. La satisfaction à l’égard des avantages et du fardeau, mesurée par l’échelle ACTS, et la satisfaction globale sur l’échelle TSQM II, ont eu tendance à augmenter avec le temps. Les facteurs liés aux patients qui ont été associés de manière assez constante à une plus grande satisfaction étaient le sexe féminin et un âge plus jeune.
Les patients atteints de FA étaient très satisfaits de leur traitement, et peu de différences existaient entre les classes d’ACO et les ACO individuels. Chaque patient peut être ou non plus satisfait du traitement par ACO direct que par AVK et, quel que soit l’ACO prescrit, il peut avoir besoin d’un soutien important pour maintenir l’adhésion au traitement.
A virtual platform to deliver ambulatory care for patients with atrial fibrillation
2021, Cardiovascular Digital Health JournalThere are little data on the use of virtual care for patients with arrhythmia. We evaluated a virtual clinic platform, in conjunction with specialist care, for patients with symptomatic atrial fibrillation (AF).
This was a prospective, observational cohort study evaluating an online educational and treatment platform, with a randomized sub-study examining the use of an ambulatory single-lead electrocardiogram heart monitor (AHM). Follow-up was 6 months. The main outcome was patients’ platform use; success was defined as 90% of patients using the platform at least once, and 75% using it at least twice. The primary outcome in the AHM sub-study was Atrial Fibrillation Symptom Severity (AFSS) score. Other outcomes included patient satisfaction questionnaires, quality of life, emergency department visits, and hospitalizations for AF.
We enrolled 94 patients between July 2018 and May 2019; 83% of patients logged in at least once and 54.3% more than once. Patients who were older, were male, or had new-onset AF were more likely to log in to the platform. Satisfaction scores were high; 70%–94% of patients responded favorably. Quality-of-life scores improved at 3 and 6 months. In the AHM sub-study (n = 71), those who received an AHM had lower AFSS scores (least square mean difference -2.52, 95% CI -4.48 to -0.25, P = .03). There was no difference in emergency department visits or hospitalizations.
The online platform did not reach our feasibility target but was well received. Allocation of an AHM was associated with improved quality of life. Virtual AF care shows promise and should be evaluated in further research.