Always fibrillating: is your patient handling their atrial fibrillation?

Since Maurits Wijffels and colleagues first popularized the expression: ‘Atrial Fibrillation (AF) Begets Atrial Fibrillation’ in their 1995 study on goats, we have become very cognisant of the chronic nature of AF. The AF epidemic is a significant healthcare burden, both in the acute setting and in primary care, and patients require regular assessment and monitoring. For those with newly diagnosed AF, clinicians often attempt electrical or pharmacological cardioversion. If this fails, management consists of assessing the risk of stroke and accordingly prescribing anticoagulants (if indicated) and controlling the rate using various pharmacological drugs. The debate on whether rate control is superior to rhythm control is now largely redundant and the emphasis is on reducing stroke risk and minimizing the risk of bleeding from anticoagulation therapy.1 This is not an easy task in elderly people often with multiple co-morbidities, polypharmacy and in the presence of cognitive or sensory impairment.2,3 The shift in assessment and treatment has led to several studies examining the efficacy of the anti-arrhythmic drugs and more recently examining the benefits of AF ablation in paroxysmal AF.4 However, the treatment options for those with chronic AF are limited. Examining the literature, it is apparent that the focus has been primarily on the cellular and physiological changes associated with AF and the adverse clinical outcomes (especially stroke and bleeding). Indeed, a large chasm exists in our knowledge of patients’ perspectives on living and coping with their AF. Ekblad et al. have explored patients’ well-being on their preventing and handling of AF.5 The authors have shown through a critical incident technique that we are not addressing the concerns and needs of patients in AF. As well as the anticipated anxiety and worry associated with AF symptoms, the authors demonstrate a clear impact on patients’ daily activities and, quite worryingly, how some people limit their diet, daily activities and socializing because of their AF. The rationale for these self-imposed limitations is due to a fear that their daily activities can induce/increase AF symptoms. Admittedly, the negative impact of AF on patients’ physical quality of life and the anxiety and distress around their symptoms would probably be identified by cardiac-trained healthcare professionals; but it appears overall that we may be under-estimating the impact of long-term AF on the individual. The authors have highlighted a shortfall in our provision of information to patients and have drawn our attention to misconceptions patients have about factors that could induce palpitations or the severity of AF symptoms. It is interesting that patients still believe that simple daily activities can influence their symptoms, suggesting that nurses need to individualize education especially on how patients manage their symptoms. However, without being too critical of our care, those with arrhythmias often have difficulty retaining information due to the emotional distress they experience.6 Some may argue that patients’ anxieties are normal in AF, but, crucially, these are not newly diagnosed AF patients as the mean time from diagnosis to interview in Ekblad et al.’s study was 9 years. This supports the view that many of the patients’ perceived problems remain over time, and we are failing to adequately identify and address their psychological and behavioural needs in their handling of AF symptoms. The implications of providing better education and information to both patients and their relatives/carers are apparent.7 We need to tailor education to the individual and their particular circumstances. Given the need for on-going or intermittent education, learning needs could be delivered by several methods including telephone calls, text alerts or emails, mobile phone applications or, for technological savvy patients, use of social media. Through using these readily available resources, there is the possibility of improving not only the patient’s physical quality of life but also that of their families. Some of the potential outcomes of a successful programme are 1) the patient no longer worries about inducing AF through various activities; 2) there is a reduction in their anxiety, and, most importantly, 3) a reduced need for hospitalization and healthcare visits. Given rising healthcare costs and AF being a condition affecting low- to middle-income countries, use of electronic resources is an ideal solution.8 Hopefully these findings will inspire others to explore their patients’ handling of AF and to assist with the development of effective means in improving their well-being and ultimately better self-care.9 AF may beget AF but always fibrillating should not equate to ‘not living’.