My heart, my choice? how to improve the patient engagement in decision-making for catheter ablation of atrial fibrillation

This invited commentary refers to ‘Factors influencing patient engagement in decision-making for catheter ablation of atrial fibrillation: a cross-sectional survey’, by F. Dong et al., https://doi.org/10.1093/eurjcn/zvae141. In many areas of medicine, two or more paths may be useful to reach a given diagnosis or treat a specific condition, posing challenging dilemmas and forcing complicated decisions. Historically, these decisions have been performed following a paternalistic model, with clinicians making choices on behalf of patients. Over time, this has shifted to recognizing patients as active participants. Shared decision-making is a collaborative process in which patients and clinicians work together to weigh evidence, assess risks and benefits, discuss outcomes, and integrate patient preferences into decisions. This approach enhances care, treatment adherence, satisfaction, and communication, empowering patients and improving health outcomes.1 The advantages of patient active engagement extend beyond the shared decision-making. Active patient involvement has been demonstrated to positively contribute to the improvement of the healing process.2,3 Empowering patients to participate also enhances their confidence in their chosen treatment pathway, promoting a sense of control and collaboration. Taking time to explore patient concerns during longer consultations can significantly enhance their sense of control and satisfaction.4 However, challenges persist in achieving consistent implementation of shared decision-making. Atrial fibrillation (AF) is not an exception. Unfortunately, evidence of the current participation of patients in the management of their AF remains unequal. On the one hand, the true prevalence and impact of shared decision-making in the prescription of anticoagulant therapy is welldocumented.5 The same does not apply to rhythm management. Catheter ablation (CA) has evolved as a cornerstone in the therapeutic approach for AF,6 it carries some (yet low) risk. Despite being perceived as a safer approach, antiarrhythmic drugs are less effective than CA and their risk of adverse effects in the long term is non-negligible. Deciding on CA involves numerous variables, making informed patient participation critical. Research specific to patient involvement in CA decisions is still limited.7,8 In this issue of the European Journal of Cardiovascular Nursing, Dong et al.9 provide novel and relevant data. They describe the degree of engagement in a cohort of more than 800 Chinese patients undergoing CA for AF. By means of specific questionnaires, they found that only 20% of patients reported active participation in decisions regarding CA, with 40% reporting passive involvement and another 40% reporting collaborative participation. Several factors influenced patient participation in the decision to undergo CA. First, those patients with higher monthly incomes are more likely to get involved, possibly owing to their better access to educational resources, enhancing informed decision-making. Second, gender differences also contribute: women, often primary caregivers, may carefully consider the implications of CA, such as recovery time or temporary disability, motivating more active participation.10 Additionally, women with AF often experience more severe symptoms and a lower quality of life, increasing their willingness to seek relief through interventions like CA.11 Third, those patients with a shorter time from diagnosis are more likely to participate in shared decision-making. Indeed, patients experiencing more severe symptoms are more inclined to seek quick medical attention and pursue CA to restore normalcy. Unfortunately, all of the aforementioned predictors are non- (or hardly) modifiable and are therefore unlikely to serve as targets for action. So how can we improve patient involvement in the decision to undergo CA? Dong et al. also shed some light on potentially activable factors. Improving health literacy and knowledge of AF predicts patient engagement and seems attractive and desirable targets to foster patient involvement in their disease. Creating an environment conducive to patient engagement in decision-making is essential. It is imperative that healthcare providers receive training in these strategies with a comprehensive approach that considers the patient’s family, caregivers, and socioeconomic environment. Moreover, it is important to identify the barriers that keep off patient participation. Vulnerable populations may encounter difficulties due to restricted access to education resources. Identifying these factors and tailoring interventions is indispensable to bridge the gap. A baseline knowledge assessment helps healthcare providers tailor resources that align with patients’ understanding and cultural context, focusing on health literacy. Nurses may be key in educating patients and providing them with the necessary tools to achieve a good understanding of AF and subsequently encourage patient engagement.12,13 Key strategies include comprehensive educational materials, decision aids tools, and involving them in risk-benefit analysis.14,15 Patient-centred programmes such as expert patient initiatives, group sessions, and individualized education plans can further foster active participation.16 In today's digital age, we must see internet as potentially ally and not as the enemy. Dr. Google serves as a key source of health information, though its reliability can vary.17 Rather than dismissing online resources, providers should guide patients towards credible platforms.18 The European Society of Cardiology (ESC) recommends the patient information website (www.afibmatters.org) a multilingual website offering evidence-based information about AF. It is crucial to encourage patients to select information from reliable online sources in order to facilitate their empowerment. It is important to consider the limitations of the Dong et al. study when interpreting the results, particularly when extrapolating their findings to other populations. The broader healthcare system plays a critical role in shaping patient engagement. The Chinese healthcare context is assessed in their work. Differences in healthcare access, resource availability, and societal attitudes towards patient autonomy influence the success of shared decision-making. It is essential to examine whether these findings are replicated in completely different settings such as the European or American healthcare systems. Adapting these approaches to regional and cultural contexts is essential for achieving equitable and effective patient involvement.19 Importantly, only patients with AF already scheduled for CA were included in the current study. Those who declined CA in a previous appointment with their cardiologist, and who had quite likely participated in the decision, were not included. Understanding their decision-making preferences and levels of participation at a previous stage, before CA is scheduled, would offer a more comprehensive perspective on patient engagement across all AF treatment strategies. In conclusion, while patient engagement remains low in the shared decision-making to perform CA, addressing barriers to participation, including tailored education and information from reliable sources, is feasible and could facilitate shared decision-making and improve outcomes. Expert nurses may be key in this process. Alba Cano-Valls, MSc (conceptualization [lead], and writing—original draft [lead], and Eduard Guasch (supervision [supporting], and writing—review & editing [supporting]) None declared.