Issues in cardiovascular nursingPatient experiences with atrial fibrillation and treatment with implantable atrial defibrillation therapy
Introduction
Advances in medical technology occur at a rapid pace, offering cardiovascular patients new and innovative therapies to treat or ameliorate illness. Innovative therapies, however, may also create new challenges for patients such as recovery from a surgical procedure, side effects from medications, new symptoms, or physical and psychological adjustment to an implanted device. Many therapies also require patients' active involvement in administration and monitoring. For the most part, patients and their families must make decisions about risks, benefits, and investment of resources (e.g., time, money, and assistance from others) when making decisions about acceptable therapy. The level of discomfort or distress from illness may have a powerful effect on patient decisions about treatment; thus it is important to understand patients' perspectives of their experiences with illness and treatment.
Atrial fibrillation (AF) is a dysrhythmia that affects approximately 2.2 million persons in the United States, with incidence increasing with older age.1, 2 Because AF is a chaotic cardiac rhythm, it affects cardiac output and the normal movement of blood through the cardiac chambers; causes left ventricular dysfunction; and fosters the development of thrombi and potential emboli in the fibrillating atria. Risk for stroke is increased in patients with AF (annual rate 5-7%)1, and is a leading cause of morbidity and mortality in US adults over 65 years of age. AF also contributes to heart failure progression as well as increased mortality in patients with left ventricular systolic dysfunction.3 Intermittent or paroxysmal AF is characterized by repeated episodes of AF that may either self-terminate or require repeated treatment such as external cardioversion to terminate. Restoration of normal sinus rhythm improves quality of life (QOL) and prevents worsening of heart failure.3, 4, 5
Medications, the Maze surgical procedure, and radiofrequency ablation are therapies that have been used to prevent or decrease episodes of AF and maintain sinus rhythm.6, 7, 8, 9 Patients with AF may experience distressing symptoms such as dyspnea, palpitations, dizziness, weakness, and anxiety, or the episodes may be asymptomatic.10, 11 One of the few studies that evaluated QOL in patients with AF found that AF patients had either similar or worse QOL across all subscales of a commonly used health status measure, Short Form 36 (SF-36), than 2 patient groups, even though the percutaneous transluminal coronary angioplasty patients were older and had worse left ventricular function.4 In addition, the AF patients had worse mental health scores and similar emotional and social role scores as patients with congestive heart failure, and either more or equivalent impairment on subscales as post-myocardial infarction patients.4 Thus AF, particularly if refractory to medication and other therapies, substantially impairs health status and QOL. To date, AF symptoms, frequency of paroxysmal events, and autonomic function have been associated with QOL in patients.12, 13 In addition to adversely affecting QOL, AF negatively affects patients' perceived illness intrusiveness, an important concept in acceptance of device technology. An AF patient cohort reported illness intrusiveness scores similar in magnitude to hemodialysis patients (35 vs 35), and significantly greater than an age-adjusted healthy cohort.5 This suggests that patients perceive AF as significantly debilitating both physically and psychologically.
A recent innovation in the treatment of patients with recurrent, symptomatic, and drug-refractory atrial fibrillation is the implantable atrial defibrillator.14 Early versions of the implantable atrial defibrillator had pacing and atrial defibrillation capabilities, and more recent models have added a ventricular defibrillation component. Implantable cardioverter defibrillator (ICD) with atrial therapies (ICD-AT) therapy is market approved for the AF Only indication (ie, no ventricular arrhythmias). The ICD-AT can be programmed to several operation modes including automatic, patient-activated, and pacing only. In the automatic mode, the device is programmed to monitor the cardiac rhythm for the presence of atrial fibrillation and to deliver therapy (1-27 joules) at a specific time. The patient-activated mode allows the patient to activate the device, once AF has been verified, at a particular time of their choosing with a pacemaker magnet. With either mode, patients experience the shock-like sensations of the therapy. As with any new device, patient acceptance of the technology is an important evaluation. Since AF is not life threatening, it is hypothesized that ICD-AT acceptance for an AF Only indication is related to the patient's perceived QOL improvement. This is in contrast to patients with ventricular arrhythmias who accept ICD therapy because it is life saving. Thus, the purpose of this qualitative study was to describe: 1) patients' experiences living with symptomatic drug-refractory atrial fibrillation and 2) patient acceptance of treatment and variables that associate with poor and good ICD-AT acceptance.
Section snippets
Methods
The study used a descriptive qualitative approach to examine the experiences and perceptions of subjects participating in a larger quantitative study involving assessment of patient acceptance and tolerance of the Medtronic Jewel AF7250 ICD-AT.15 This was a cross-sectional study design sampling patients that received the Jewel AF device for an AF Only indication (no documented ventricular arrhythmia indication) and were participating in the 7250 Jewel AF AF Only clinical study. Investigators
Context of the qualitative results
Eleven ICD-AT patients (8 men and 3 women, range 35-80 years of age) participated in the semi-structured interviews. All were married, and all had experienced AF that was unresponsive to treatment from 1 to 20 years (See Table 1). Participants had been living with the Jewel AF device from 6 months to 2 years. All participants had tried multiple medications in an effort to maintain sinus rhythm, and all had experienced repeated external cardioversions (once a month or more before the Jewel AF
Discussion
The ICD-AT is perceived as a useful therapy for patients with medication-refractory intermittent atrial fibrillation. In these stories, patient strength, endurance, willingness to try new therapies and incorporate them into their lifestyle routines, and ability to adapt to the technology are obvious. For some patients for whom therapy had been ineffective, associated with unpleasant or intolerable side effects, and sometimes painful and inconvenient, the ICD-AT seemed to be the only option for
Acknowledgements
The authors would like to acknowledge the contributions of Kathryn Wood, RN, PhD, for her ideas in the design of this study and Amy Valderama, RN, MSN, for her assistance in preparation of the manuscript.
References (26)
- et al.
Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunctiona retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction
J Am Coll Cardiol
(1998) - et al.
The impairment of health-related quality of life in patients with intermittent atrial fibrillationimplications for the assessment of investigational therapy
J Am Coll Cardiol.
(2000) - et al.
Quality of life improves with treatment in the Canadian Trial of Atrial Fibrillation
Am Heart J
(2002) - et al.
Quality of life and outcomes after radiofrequency His-bundle catheter ablation and permanent pacemaker implantationimpact of treatment in paroxysmal and established atrial fibrillation
Am Heart J
(1996) - et al.
Self-administration with UniJect of the once-a-month injectable contraceptive Cyclofem
Contraception
(1997) - et al.
The causes of patient dropout from penile self-injection therapy for impotence
J Urol
(1999) - et al.
Role of gender and personality on quality-of-life impairment in intermittent atrial fibrillation
Am J Cardiol
(2000) - et al.
Factors associated with outcomes three months after internal cardioverter defibrillator
Heart Lung
(1999) - et al.
Clinical trends in atrial fibrillation at the turn of the millennium
J Intern Med
(2001) - et al.
Exercise tolerance and quality of life in elderly patients with chronic atrial fibrillation
J Cardiovasc Pharmacol Ther.
(2001)
Algorithms useful in the treatment of atrial fibrillation
Curr Opin Cardiol
Effects of the maze operation on health-related quality of life in patients with atrial fibrillation
Circulation
Symptomatic improvement after radiofrequency catheter ablation for typical atrial flutter
Heart
Cited by (39)
Using the ‘Think Aloud’ Technique to Explore Quality of Life Issues During Standard Quality-of-Life Questionnaires in Patients With Atrial Fibrillation
2017, Heart Lung and CirculationCitation Excerpt :Their experiences were more likely to reflect anticipatory fear and anxiety, as described by McCabe et al. [19,20], often because of the unpredictable nature of AF symptoms and their heightened awareness of AF symptoms. Many people with AF adjust their lives due to emotional distress and physical limitation caused by AF symptoms, in particular they often modify job load and strenuous activities [18]. It is also widely acknowledged that the more symptoms experienced the more severe the loss of physical function or independence, and diminishment of HRQoL [8].
Shock-related anxiety and sexual function in adults with congenital heart disease and implantable cardioverter-defibrillators
2013, Heart RhythmCitation Excerpt :In turn, their psychological status has a significant impact on their health-care status. Specific at-risk groups of ICD recipients have been identified and include female patients, those under 50 years of age, and patients with a history of shock.24 This is particularly relevant to the adult population with CHD and ICDs who experience high shock rates and have the median age 35.5 years.
The daily experience of the patient with an implantable cardioverter defibrillator
2010, Enfermeria ClinicaExploring the experiences of individuals with an insertable cardiac monitor: Making the decision for device insertion
2020, Heart and LungCitation Excerpt :In this study, individual symptom experiences varied among the participants related to their etiology. However, symptoms reported in our study, such as rapid heart rate and fear, were consistent with previous studies in those with known AF.6,20,21 How the symptom was perceived by the participants affected the timing of the decision.
Patients' experiences across the trajectory of atrial fibrillation: A qualitative systematic review
2022, Health Expectations