EDITORIAL: Modern Atrial Fibrillation Care: Becoming a Pro at
Using Pros
Being a pro in the future of cardiac electrophysiology may increasingly
involve expertise in understanding and addressing patient reported
outcomes (PROs). The field of cardiac electrophysiology has made
stunning progress over the last few decades with technological
innovation in procedures and devices to identify, manage, and treat
arhythmic disorders. The introduction and clinical utilization of PROs
extends a health outcome assessment process that may begin to resemble a
“dashboard” with a variety of indicators of treatment process and
outcomes. The time for routine measurement and integration of PROs in
atrial fibrillation (AF) has arrived. However, it is challenging to go
beyond measuring PROs alone and toward delivering pathways of care to
systematically address patient outcomes and behaviors.
In this issue of JCE , Zenger and colleagues1report on the implementation of the Toronto AF symptom severity scale in
all outpatients at the University of Utah spanning 1,338 patients. The
authors reported on rates of AF symptoms and compared this symptom
report with AF burden and healthcare utilization over the subsequent six
months of care. Their results in multivariate models show that AF
symptoms were reported at higher rates by patients who were female, of
younger age (<65 age), had a history of pulmonary disease, and
reported depression. Similarly, younger patients, women and those with
pulmonary disease or heart failure reported increased healthcare
utilization. Increased symptom scores were also associated with more
aggressive rhythm control strategies such as AF ablation,
anti-arrhythmic drug (AAD) therapy, and cardioversion. While these
results are not surprising, they represent innovation because seeking
and valuing patient reports completes the circle of stakeholders.
Quantitative patient reports can be more readily addressed if they are
sampled! PROs have been employed in cardiology, but their utility has
mostly been relegated to clinical research trials and not acted upon in
clinical settings.
PROs provide a new perspective to the clinical encounter that may not be
consistent with the time-honored metrics, such as device confirmed
atrial burden. Measuring AF symptoms is a reasonable variable as a
lead-off to initiate PROs, but they represent only a subset of the
potential value that PROs could bring. For example, in ORBIT-AF, 61.8%
of AF patients reported symptomatic experience, while 39.2% were not
aware of any symptoms from AF. Moreover, 16.5% of the symptomatic
patients reported that the symptoms were disabling.2This suggests that AF symptom experience is highly individualistic,
ranging from asymptomatic with no impact on quality of life to highly
symptomatic and disabling. The patient perception of AF symptoms spans
processes beyond the physiological and extend to the psychological and
behavioral realm. Nonetheless, AF symptoms are an important place to
start because AF symptoms drive health care utilization. In short,
patients who are symptomatic are both motivated to seek care and to
undergo procedures for symptom relief. Attending providers are motivated
to intervene to reduce symptoms and suffering. Both seek to implicitly
or explicitly improve another important PRO, quality of life (QOL), and
prevent harm such as stroke. Indeed, symptom burden has been identified
as the driver of QOL decrements,3 yet recent evidence
exists that physician and patient correspondence on recognition of AF
symptoms may be poor.4 Guideline directed medical
therapy can address the medical treatment aspects but may not fully
acknowledge or address the patient perspectives on AF.