Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Optimization of a care pathway before atrial fibrillation ablation with the integration of translational research into routine clinical care

Funding Acknowledgements

Type of funding sources: None.

Background

The diagnostic work-up for atrial fibrillation (AF) catheter ablation is often complex and expensive. Improving the organization of this work-up may help to streamline patient journeys and to reduce administrative burden and costs. Additionally, reorganizing the existing work-up provides the opportunity to integrate (translational) research into routine clinical care, hereby contributing to improved patient selection and improved care for future patients.

Purpose

The aim of this project was to optimize a care pathway for patients considered for AF ablation, with the goals to improve the patient journey and simultaneously integrate research into the clinical process.

Methods

The Lean Six Sigma approach was used to map the pre-existing process, identify constraints in the process and formulate countermeasures. The impact of this pathway optimization was evaluated using four outcome measures: (1) efficient use of medical resources, defined as the percentage of patients receiving the pre-ablation work-up and eventually undergoing AF ablation, (2) number of hospital visits and consultations with a cardiologist, (3) pathway compliance, defined as the percentage of patients that completed the work-up with a maximum of 2 outpatient hospital visits, a maximum of 1 cardiologist consultation, laboratory results available, and a complete echocardiogram available, and (4) completeness of scientific data, defined as the availability of a predefined set of relevant variables (clinical indicators, medication, laboratory results and echocardiography derived data).

Results

Five root causes for constraints in the pre-existing work-up were identified and corresponding countermeasures were formulated (Figure 1). The impact of the countermeasures was studied for 33 patients before and 26 patients after pathway optimization. After optimization, efficient use of resources increased from 44% to 95% (p<0.01). The project resulted in fewer hospital visits per patient (3.2 ±1.2 versus 2.3 ±0.8, p=0.01) and fewer cardiologist consultations (1.8 ±0.7 versus 1.0 ±0.3, p<0.01). Pathway compliance increased significantly (3% versus 73%, p<0.01), an increase that was reflected in all separate components of overall pathway compliance (Figure 2, panel A). The percentage of available data for scientific research increased from 80% to 94% (p<0.01), resulting in a complete dataset in 73% of patients after, compared to only 15% of patients prior to the optimization project (p<0.01, Figure 2, panel B).

Conclusions

This optimization project resulted in a more efficient care pathway for patients considered for AF ablation. The structural integration of research into the care pathway may lay the foundations for further improvements of AF care in the future.

Virtual reality to improve patient information and reduce anxiety towards atrial fibrillation ablation in times of remote patient care (and after)

Funding Acknowledgements

Type of funding sources: None.

Background. Nowadays frequently deployed invasive catheter ablation therapy in patients with symptomatic atrial fibrillation (AF) is unfortunately associated with distress such as preoperative anxiety. Improving preoperative patient information may lower anxiety towards AF ablation procedures.

Purpose. To evaluate whether a lifelike 360˚ virtual reality (VR) patient information video decreases anxiety levels and improves patient preparation towards AF ablation as compared to standard preoperative patient information.

Methods. Consecutive patients planned for AF ablation were recruited from the outpatient AF clinic and were randomized into two groups: the control group and the intervention group (VR group). The control group received standard preoperative information through oral counselling and information leaflets, the VR group received the standard information as well as a short dedicated 360˚ VR video (via in-hospital VR headset and disposable cardboard VR glasses for home use). Online questionnaires (aimed at information provision, anxiety and procedural experience) were administered both pre- and post-ablation.

Results. A total of 103 patients (39.8% female, age 64 [58-71] years) were included in the analysis. The VR group (n = 58) reported to be clearly better informed about catheterization laboratory environment (78% vs. 73%) and the course of the procedure (82% vs. 78%), indicated fewer concerns about the procedure (47% vs. 55%) and were eager to learn even more (82% vs. 74%) as compared to controls (n = 45). However, there was no significant difference in the anxiety scores between the VR group and controls (10 [8-12] vs. 10 [8-14], p = 0.548). Home use of the video was satisfactory and resulted in discussion with relatives. Patient overall satisfaction was higher in VR group as compared to controls (84% vs. 81%).

Conclusions. This study shows that a dedicated 360˚ VR video reduces concerns but does not reduce anxiety scores. Though, it easily improves procedural knowledge, patient information and patient satisfaction. Especially in times of remote patient care, this new way of informing patients may be of added value.