Health-related quality of life, psychological distress, and symptom burden in an Asian population of outpatients with atrial fibrillation

Abstract

Background

Atrial fibrillation (AF) is the most common arrhythmia and has debilitating effects on patients' health-related quality of life (HRQoL) and psychological statuses.

Aim

To investigate the HRQoL, psychological distress, and symptom burden, and to identify the significant influencing factors of HRQoL among outpatients with AF in Singapore.

Methods

We conducted a cross-sectional descriptive correlational study of a sample of 116 outpatients with AF. Data were collected using 12-item Short Form Health Survey, Atrial Fibrillation Effect on Quality of Life scale, Patient Health Questionnaire-9 (PHQ-9), and University of Toronto Atrial Fibrillation Symptom Severity (AFSS) scale.

Results

Symptom burden and psychological distress significantly influenced the AF-specific HRQoL while symptom burden, unemployment and comorbidity of heart failure were significantly associated with poorer general physical health. Psychological distress was the only significant factor influencing the mental health.

Conclusion

Optimal symptom management is crucial for better HRQoL in patients with atrial fibrillation.

Introduction

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting nearly 33.5 million people worldwide.¹ AF-related mortality and morbidity rates have been on the rise over the past two decades.¹ In Singapore, the latest data revealed a prevalence of 1.5% in 2008, representing a 10% increase of AF over a three-year period.² Symptoms of AF such as palpitations, dyspnea, and fatigue can be disruptive and debilitating to normal daily life.³ Aside from experiencing the true symptomatic episodes, patients with AF are often found backing away from activities they used to enjoy as a form of self-protection against symptom triggers. On top of that, they carry the constant fear of suffering an unanticipated symptomatic attack or complication such as a stroke, which inevitably subjects them to a considerable amount of physical and psychological distress, which can easily impair their health-related quality of life (HRQoL).³

HRQoL is a multifaceted construct encompassing physiological, social, emotional and psychological domains of an individual's wellbeing.⁴ HRQoL takes into account the individual's subjective perception of their own health status in addition to standard objective assessments.4, 5 This concept complements the focus of patient-centric care in contemporary medicine well, and it has increasingly gained attention from its use as a treatment outcome in the recent decades and has thus been used to assess treatment effectiveness in cardiovascular clinical research.6, 7 A secondary analysis of the highly recognized Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study revealed that HRQoL is a predictor of hospitalization and mortality, hence, indicating its importance as an outcome measure for this population.⁸

Current literature has identified some factors associated with the HRQoL in patients with AF. Lower HRQoL have been consistently shown to be associated with female gender,9, 10 low social economic status,⁹ personality traits,¹¹ greater number of comorbidities,¹² the presence of psychological distress9, 13 as well as experiencing greater extents of symptom burden.10, 12 However, there seems to be conflicting evidence on the effects of age9, 10, 12 and length of diagnosis10, 12, 14 on HRQoL in this patient population. Moreover, these studies were mainly conducted in the Western population, suggesting that these associations may not hold true in an Asian country.

With the growing prevalence and detrimental effects of AF, there is definitely a need for a stronger emphasis on the study of this condition. HRQoL serves as a holistic outcome measure to direct clinical practice as it considers the multidimensional impacts of AF.¹⁵ Findings that correlate and predict HRQoL are important in guiding future interventions to lighten the disease impact on the sick individual. Two independent concepts – psychological distress and symptom burden – have been found to correlate with HRQoL in previous studies.9, 16 Despite the extensive library of literature available on this topic, majority studied the Western population, with minimal information available on the Asian scene. More specifically, the study of HRQoL on the Singaporean population was lacking. Therefore, this study aimed to investigate the HRQoL, psychological distress, and symptom burden among Singaporean outpatients with AF, and to identify the significant influencing factors of HRQoL among this patient population. The research questions of this study include: (1) what are the HRQoL, psychological distress and symptom burden among outpatients with AF in Singapore? (2) Are there any correlations between the HRQoL, psychological distress and symptom burden among this patient population? (3) What are significant factors influencing the HRQoL among this patient population?