Atrial Fibrillation Symptom Clusters

Background: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. The majority of adults with AF are symptomatic, and symptoms are major determinants of quality-of-life. We proposed a theoretical model of symptom perception that involves both symptom detection and symptom interpretation. In order to better understand AF symptom perception, the aim of this body of work was to identify AF-specific symptom clusters, characterize individuals within clusters based on sociodemographic and clinical variables, and determine whether symptom cluster membership was associated with healthcare utilization (AF-related emergency department visits and hospitalizations). Methods/Results: Data sets from the Standard versus Atrial Fibrillation spEcific managemenT strategY (SAFETY) Trial (n=355) and Vanderbilt Atrial Fibrillation Registry (VAFR, n=1,501) were used to conduct cross-sectional secondary data analyses of adults with clinically verified AF. Symptom clusters were identified using self-reported symptoms and two statistical approaches: hierarchical cluster analysis and latent class analysis. Regression analyses were performed with VAFR to determine associations with healthcare utilization. Three symptom clusters were found using cluster analysis and SAFETY participants, 2 symptom clusters using cluster analysis and VAFR participants, and 4 symptom clusters using latent class analysis and VAFR participants. Symptom cluster membership was associated with gender, age, AF type, BMI, heart failure, coronary artery disease, current use of anti-arrhythmic medication, and history of ablation. Although the clusters differed between studies, when the results from the different studies were compared the results were complimentary. The symptom clusters found with VAFR were associated with an increased rate of AF-related emergency department visits and hospitalizations, either when compared to all individuals without that specific cluster (hierarchical cluster analysis), or when compared to an Asymptomatic cluster of patients (latent class analysis). Conclusions: Clinically meaningful symptom clusters were identified that were associated with increased rates of healthcare utilization. Both modifiable and non-modifiable sociodemographic and clinical characteristics are associated with cluster membership

Mechanisms of Change in Self-Care in Adults with Heart Failure Receiving a Tailored, Motivational Interviewing Intervention

Self-care is challenging but we previously demonstrated that motivational interviewing (MI) was effective in improving heart failure (HF) self-care. OBJECTIVE: To identify the mechanisms of intervention effectiveness by elucidating the MI techniques used and the relationship between the techniques and changes in self-care. METHODS: Audiotaped sessions (first and subsequent sessions) from 8 participants were transcribed verbatim and coded to evaluate changes in self-care. Using a sequential mixed method design, quantitative and qualitative self-care data were triangulated; congruence was 97%. The MI techniques used and mechanisms of intervention effectiveness were identified from the qualitative data. RESULTS: Three MI techniques used were related to improved self-care: 1) reflection and reframing, 2) genuine empathy, affirmation, and humor, and 2) individualized problem solving. These techniques stimulated openness to goal setting, positive self-talk, perceived ability to overcome barriers, and change talk. The mechanisms by which the techniques achieved the desired outcomes were the development of discrepancy and self-efficacy, which are consistent with the principles of MI. CONCLUSION: This study contributes to clarifying the mechanism by which MI facilitates behavioral change. PRACTICE IMPLICATIONS: Using MI to discuss self-care can help to overcome barriers and engage HF patients in goal setting for behavior change

Incidence of Patent Foramen Ovale in Adults with Cryptogenic Stroke or Migraine Headache

The foramen ovale is a part of normal fetal anatomy that typically closes early in life. The foramen ovale remains patent in approximately a quarter of the population. Patent foramen ovale has an increased incidence among individuals with migraine headache and cryptogenic stroke. Percutaneous closure of patent foramen ovale (PFO) is a secondary prevention measure for individuals with PFO and migraine headache or cryptogenic stroke. Results from randomized controlled trials are awaited in order to determine the safety and efficacy of percutaneous PFO closure in the treatment of migraine headache and cryptogenic stroke in comparison to the currently recommended standards of medical care. This article provides the advanced practice nurse a review of PFO anatomy and diagnostics, a review of the current science regarding percutaneous PFO closure as a treatment for stroke and migraine headache, as well as implications for nursing practice. Nurse practitioners should be advocates for their patients by coordinating with neurologists and cardiologists to ensure patients receive the most appropriate care

Atrial fibrillation symptom clusters and associated clinical characteristics and outcomes: a cross-sectional secondary data analysis

Background: Symptom clusters among adults with atrial fibrillation have previously been identified but no study has examined the relationship between symptom clusters and outcomes. Aims: The purpose of this study was to identify atrial fibrillation-specific symptom clusters, characterize individuals with each cluster, and determine whether symptom cluster membership is associated with healthcare utilization. Methods: This was a cross-sectional secondary data analysis of 1501 adults from the Vanderbilt Atrial Fibrillation Registry with verified atrial fibrillation. Self-reported symptoms were measured with the University of Toronto Atrial Fibrillation Severity Scale. We used hierarchical cluster analysis (Ward’s method) to identify clusters and dendrograms, pseudo F, and pseudo T-squared to determine the ideal number of clusters. Next, we used regression analysis to examine the association between cluster membership and healthcare utilization. Results: Males predominated (67%) and the average age was 58.4 years. Two symptom clusters were identified, a Weary cluster (3.7%, n=56, fatigue at rest, shortness of breath at rest, chest pain, and dizziness) and an Exertional cluster (32.7%, n=491, shortness of breath with activity and exercise intolerance). Several sociodemographic and clinical characteristics varied by symptom cluster group membership, including age, gender, atrial fibrillation type, body mass index, comorbidity status, and treatment strategy. Women were more likely to experience either cluster (p<0.001). The Weary cluster was associated with nearly triple the rate of emergency department utilization (incident rate ratio [IRR] 2.8, p<0.001) and twice the rate of hospitalizations (IRR 1.9, p<0.001). Conclusion: We identified two symptom clusters. The Weary cluster was associated with a significantly increased rate of healthcare utilization

Atrial fibrillation symptom profiles associated with healthcare utilization: a latent class regression analysis

Background Symptoms drive healthcare use among adults with atrial fibrillation, but limited data are available regarding which symptoms are most problematic and which patients are most at‐risk. The purpose of this study was to: (1) identify clusters of patients with similar symptom profiles, (2) characterize the individuals within each cluster, and (3) determine whether specific symptom profiles are associated with healthcare utilization. Methods We conducted a cross‐sectional secondary data analysis of 1,501 adults from the Vanderbilt Atrial Fibrillation Registry. Participants were recruited from Vanderbilt cardiology clinics, emergency department, and in‐patient services. Subjects included in our analysis had clinically verified atrial fibrillation and a completed symptom survey. Symptom and healthcare utilization data were collected with the University of Toronto Atrial Fibrillation Severity Scale. Latent class regression analysis was used to identify symptom clusters, with clinical and demographic variables included as covariates. We used Poisson regression to examine the association between latent class membership and healthcare utilization. Results Participants were predominantly male (67%) with a mean age of 58.4 years (±11.9). Four latent classes were evident, including an Asymptomatic cluster (N = 487, 38%), Highly Symptomatic cluster (N = 142, 11%), With Activity cluster (N = 326, 25%), and Mild Diffuse cluster (N = 336, 26%). Highly Symptomatic membership was associated with the greatest rate of emergency department visits and hospitalizations (incident rate ratio 2.4, P < 0.001). Conclusions Clinically meaningful atrial fibrillation symptom profiles were identified that were associated with increased rates of emergency department visits and hospitalizations

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients’ daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable

A mixed methods study of symptom perception in patients with chronic heart failure

Background,br> Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF. Methods We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months. Results In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received. Conclusion Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention