Education of Patients With Atrial Fibrillation and Evaluation of the Efficacy of a Mobile Virtual Patient Environment: Protocol for a Multicenter Pseudorandomized Controlled Trial

BACKGROUND

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a leading cause of mortality and morbidity. Patient knowledge about AF and its management is paramount but often limited. Patients need to be appropriately informed about treatment options, medicinal adherence, and potential consequences of nonadherence, while also understanding treatment goals and expectations from it. Mobile health apps have experienced an explosion both in their availability and acceptance as "soft interventions" for patient engagement and education; however, the prolific nature of such solutions revealed a gap in the evidence base regarding their efficacy and impact. Virtual patients (VPs), interactive computer simulations, have been used as learning activities in modern health care education. VPs demonstrably improved cognitive and behavioral skills; hence, they have been effectively implemented across undergraduate and postgraduate curricula. However, their application in patient education has been rather limited so far.

OBJECTIVE

This work aims to implement and evaluate the efficacy of a mobile-deployed VP regimen for the education and engagement of patients with AF on crucial topics regarding their condition. A mobile VP app is being developed with the goal of each VP being a simple scenario with a set goal and very specific messages and will be subsequently attempted and evaluated.

METHODS

A mobile VP player app is being developed so as to be used for the design of 3 educational scenarios for AF management. A pseudorandomized controlled trial for the efficacy of VPs is planned to be executed at 3 sites in Greece, Ukraine, and Kazakhstan for patients with AF. The Welch t test will be used to demonstrate the performance of patients' evaluation of the VP experience.

RESULTS

Our study is at the development stage. A preliminary study regarding the system's development and feasibility was initiated in December 2022. The results of our study are expected to be available in 2024 or when the needed sample size is achieved.

CONCLUSIONS

This study aims to evaluate and demonstrate the first significant evidence for the value of VP resources in outreach and training endeavors for empowering and patients with AF and fostering healthy habits among them.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45946.

Prognostic value of plasma neutrophil gelatinase-associated lipocalin for cardiovascular events in patients with chronic heart failure and atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

We aimed to assess the prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL), a marker of renal tubular damage, in patients with heart failure with or without atrial fibrillation (AF).

Methods

The study involved 113 (83.2% men) patients with mean age 60.0 [54.0-67.0] years with II-IV functional class (recommendations of the New York Heart Association) is due to ischemic heart disease. Serum levels of NGAL were quantified by ELISA. Echocardiography was performed according to the American Society of Echocardiography/European Association of Echocardiography recommendations. Receiver operating characteristic (ROC) curve analysis was used to determine the best NGAL cut-off to predict events. Cox proportional hazards models were used to investigate the prospective association between NGAL and events during follow-up. Outcome was cumulative incidence of the primary endpoint (cardiovascular death, myocardial infarction, stroke, HF hospitalization) at 36 months.

Results

Median plasma NGAL in patients with and without AF was 34 (25-46) ng/ml and 26 (18-44) ng/ml, p<0.01, respectively. The ROC curve showed an optimal admission NGAL level cut-off >25.5 ng/mL, with 70% sensitivity and 89% specificity. The area under the ROC curve (AUC) was (0.814; p<0.01). In patients with CHF and atrial fibrillation multivariable analysis shows, that NGAL independently associated with outcomes (HR 2.35, 95% CI 1.2-4.61; p<0.01).

Conclusions

Admission plasma NGAL >25.5 ng/ml appears a sensible tool for in-hospital AF prediction as well as an marker for adverse cardiovascular outcome during long-term follow-up period.

Soluble ST2 and renal function in ischemic heart failure with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Soluble ST2 (sST2) is a novel cardiac biomarker whose concentration rises in response to myocardial strain. The aim of this study was to analyse the relationship between soluble ST2 (sST2) level and renal function in heart failure (HF) patients with atrial fibrillation (AF).

Methods

The study involved 113 (83.2% men) patients with mean age 60.0 [54.0-67.0] years with II-IV functional class (recommendations of the New York Heart Association) is due to ischemic heart disease. Serum levels of N-terminal proBNP (NT-proBNP), sST2, TIMP-1 and Cystatine C (CysC) were quantified by ELISA of 33 patients with HF and AF and 80 patients with HF without AF. Echocardiography was performed according to the American Society of Echocardiography/European Association of Echocardiography recommendations. Estimated glomerular filtration rate (eGFR) was calculated by MDRD formula. Nonparametric Mann-Whitney U-test for independent data, Spearman’s rank correlation and multiple linear regression coefficients were calculated.

Results

Patients with HF and AF characterized significantly higher concentration of sST2 (1453.2 [1184.3-1945.7] vs 1279.7 [1110.9-1616.6] pg/ml, p = 0.05), as well as the marker of kidney dysfunction CysC (1375 [1111.7-1867.4] vs 1136.4 [955-1386.4] ng/ml, p = 0.02) and was significantly lower eGFR (67.7 [60.6-77.2] vs 79.3 [70.9-88.0] ml/min/1.73m2; p = 0.0002). sST2 correlated with TIMP-1 (r = 0.56; p = 0.004) E/e’ (r = 0.87; p = 0.002), as well as CysC with NT-proBNP (r = 0.56; p = 0.002), with age (r = 0.49; p = 0.009) in patients with HF and AF. At multivariate linear regression analysis, only TIMP-1 (β=0.63) and left atrial volume index (β=0.22) were independently associated with sST2 (R2 = 0.58; p = 0.002).

Conclusions

In patients with ischemic HF and atrial fibrillation elevation sST2, associated with high level cystatine C and correlated with TIMP-1, E/e’, markers which showed abnormal collagen homeostasis and significant diastolic dysfunction LV. Multivariate analysis shows, that sST2 independently associated with TIMP-1 and LAVi. Further studies are needed to clarify the prognostic role of marker renal function (CysC) and cardiovascular stress (sST2) in ischemic HF patients with atrial fibrillation.