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Quality of life in patients with atrial fibrillation

An intervention

Taheri, Leila PhD(c); Poorgholami, Farzad MSc; Zare, Azam PhD; Jahromi, Marzieh Kargar MSc

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doi: 10.1097/01.CCN.0000694088.53640.53
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Changes in disease patterns that have led to a decrease in infectious diseases and an increase in life expectancy in patients with chronic diseases have refocused the public's attention on new health concepts in recent decades.1 Scholars have stated that the focus of healthcare in the present century is improving quality of life and health for patients.2

In recent years, interest in evaluating and improving the quality of life of patients with chronic diseases has grown. The results of clinical trials have shown that quality of life can be considered an indicator of healthcare, providing more information about the health status of patients.3 In general, reducing the attenuation and disability ratio in patients with atrial fibrillation (AF) has been the focus of treatment. Few studies have been conducted on the impact of the disease and its treatments on health-related quality of life.4

AF is a type of supraventricular dysrhythmia and the most common cardiac dysrhythmia. The dysrhythmia affects more than 1% of adults, and prevalence increases with age; it occurs in 9% of people over age 80.5,6 By 2050, the rate of AF is predicted to be 2.5 times higher than present.7 AF can cause adverse reactions such as hemodynamic instability, venous thromboembolism, increased postoperative stroke, and increased hospitalization or recovery time.8,9

Although not generally a life-threatening disorder, AF causes gradual disruption of patients' quality of life.10 AF causes signs and symptoms including palpitations, shortness of breath, and fatigue. Therefore, the quality of life in patients with AF is reduced compared with healthy individuals.11 Studies also indicate an increased incidence of hospital readmissions in these patients, often described as an AF epidemic.12 According to epidemiologic studies, at least one-third of people who experience postoperative AF have some psychological disorder, which contributes to heart failure, decreased quality of life, and increased hospital length of stays.2,13,14

Although epidemiology, clinical implications, and therapeutic costs of AF have been the subject of studies, little attention has been paid to patient-related issues, such as quality of life.15 Evaluating the health-related quality of life of these patients is important because active intervention by patients in medical decision-making often focuses on identifying and selecting treatment options. Unfortunately, patients' daily activities are addressed less often.16 Evaluation of health-related quality of life as part of the clinical management of patients with AF allows healthcare providers to pay more attention to patients' understanding of the disease and their pathway to manage the disorder. The use of special tools for health-related quality of life helps to better assess the impact of the disorder on the patient's daily activities. In addition, specific aspects of the disorder can be identified.17

Health-related quality-of-life assessment in patients with AF has been performed with nonspecific disease questionnaires. Completing health-related quality-of-life questionnaires and using appropriate measurement tools allow clinicians to standardize the impact of AF on patients' quality of life.18 In a review of recent publications, at least 34 different quality-of-life instruments have been identified to measure health-related quality of life in patients with AF. Most of these studies used cardiac questionnaires, but only a few were specifically designed for patients with AF. The most commonly used disease-specific questionnaire is a dysrhythmia checklist that measures the frequency and severity of symptoms.19

In this study, the authors evaluated health-related quality of life in patients with AF in Iran for the first time using a specific questionnaire pertaining to quality of life in patients with AF with the goal of discovering the mean score for quality of life in such patients.

Methods and materials

Study design. This descriptive cross-sectional study used randomized sampling to evaluate the quality of life of patients with AF using a specific questionnaire.

Sample size. According to the statistical consultant's opinion and based on the study by Thrall and colleagues, the sample size for this study was 210 with a standard deviation of 0.18 from baseline AF quality-of-life score and a 3-month follow-up with a significance level of 0.05, power of 0.80, and 15% probability of attrition.20 Because the sample size of a study may decrease for reasons such as exacerbation of disease, lack of cooperation during study, or death, this sample size was selected according to the consultant's opinion based on previous studies.

Study setting and sample. The study was conducted from January to April 2018 in the coronary care units (CCUs) of Al Zahra Heart Hospital in Shiraz, Iran. The patients with AF who were admitted to the CCU participated voluntarily in the study. The inclusion criteria were: a written informed-consent form, the ability to read and write in Persian, at least 20 years of age, physician diagnosis of AF, other acute or chronic illness, and AF duration of at least 6 months. Exclusion criteria included: unwillingness to participate in the study, surgery to treat AF, and any type of illness interfering with the results of the study in accordance with medical criteria. Based on the inclusion and exclusion criteria, 210 patients were selected randomly to participate in the study.

Variable N (%)
Gender Female 150(72.6%)
Male 58(27.4%)
Occupation Self-employed 161(78.2%)
Civil servant 19(8.2%)
Retired 28(13.5%)
Education High school diploma 170(82.7%)
Diploma (pre-university program) 27(12.0%)
Associate's degree 3(1.4%)
Bachelor's degree 8(3.8%)
Marital status Single 2(1.9%)
Married 134(64.3%)
Divorced 2(1.0%)
Widow/widower 70(32.9%)
History of valvular heart disease No 115(57.6%)
Yes 93(42.4%)
History of thyroid disease No 171(86.9%)
Yes 37(13.1%)
Age (years) 62.48±13.60
Weight (Kg) 63.25±13.65
AF disease duration (months) 62.0±69.3
Ejection fraction (EF) 41.47±11.38

Data collection. The instrument used for the study was the atrial fibrillation quality-of-life (AF-QOL) questionnaire. The questionnaire consists of 18 items in three dimensions of psychology (7 items), and physical (8 items), and sexual activity (3 items). Questions were related to the past month, and responses were adapted from the five-choice Likert scale (totally agree, relatively agree, agree, no idea, and disagree). For better understanding and interpretation, all dimensions of the questionnaire were scored between zero (the worst quality of life) and 100 (the best quality of life). Research nurses were responsible for distributing the AF-QOL questionnaire to study patients. The questionnaire score means were categorized into poor quality of life (less than 40), moderate quality of life (41 to 70), and good quality of life (71 to 100).

A prospective observational study conducted by Arribas and colleagues in 2010 in Spain aimed to determine the validity and reliability of the AF-QOL questionnaire at 29 centers in Spain.19 To determine the validity and reliability of the AF-QOL questionnaire in Iran, the authors developed a pilot study. The AF-QOL questionnaire had a good internal consistency. Cronbach's alpha was 0.91 in all scales and above 0.80 in all dimensions.

Data collection process. At the first visit, the demographic information of the study subjects (for example, age, gender, level of education) as well as the history of AF diagnosis and heart disease and concomitant illnesses was collected. After listening to an explanation by the researcher regarding the aim of the study, 210 participants with all required criteria were selected as the study sample for the intervention. Participants completed the questionnaire. Oral and written informed consent was obtained from the participants before the intervention.

Data analysis

Considering the descriptive nature of the study, qualitative variables were analyzed using the frequency distribution table (frequency and percentage). Additionally, quantitative variables were analyzed by mean and standard deviation. All analyses were carried out using the SPSS statistical software, version 16.


A total of 208 patients participated in the study. Females made up 72.6% of study participants, and the rest were male. Of the participating patients, 78.2% were self-employed and 82.7% had a high school diploma. Married patients made up 64.3% of participants. Heart valve disease was diagnosed in 42.4%, and 13.1% had thyroid disease. The mean age of the patients was 62.48 ± 13.60 years and the mean duration of illness was 62.0 ± 69.3 months. Their mean ejection fraction (EF) was 41.47% ± 12.38%. (See Demographics and underlying variables in patients with AF.)

QOL component Mean Standard deviation
Psychological 41.0 9.08
Physical 48.4 11.04
Sexual 31.20 9.12

The mean score for components of the AF-QOL questionnaire was reported in the physical (48.4 ± 11.04), psychological (41 ± 9.08), and sexual (31.20 ± 9.12) dimensions. (See Results: Mean patient score for components of the AF-QOL questionnaire.)


The aim of this study was to evaluate the quality of life of patients with AF with a specific questionnaire. The results of this study showed that the patients had poor quality of life in sexual and psychological dimensions. It should be noted that this was the first study on quality of life assessment in patients with AF in Iran.

According to epidemiologic studies, patients with AF experience some psychological disorders. For example, stress and anxiety have been identified as common psychological factors in these patients.15 Patients are often embarrassed to discuss sexual issues. Because of their AF, they may be afraid of engaging in sexual activity. Patients revealed to the authors that they fear that sexual activity will aggravate their AF.

In a study by Najafi and colleagues that examined the effect of telenursing on quality of life in patients with AF referred to Qazvin University of Medical Sciences, the mean score of patients before the study was low to moderate in the physical and psychological dimensions. The study used the SF-36 quality-of-life questionnaire.21 In order to explain their results, the researchers stated that the psychological dimension of quality of life can change under various conditions, including chronic illnesses, feelings of weakness and disability, fear of death, loss of function, and many other conditions. The results of this study supported the results of the authors' current study.

According to the results of the study by Rahimian and colleagues, after cardiac surgery, patients with AF were more likely to have depression, anxiety, and stress.22 Mattioli and colleagues also concluded that psychosocial stressors and life-related stresses play an important role in the incidence and persistence of AF.23 The results of the current study provide more insight into the negative impact of AF in patients' quality of life, as has been observed in various studies.

According to Dabrowski and colleagues, the presence of psychological factors independently or in association with other demographic factors increases the likelihood of AF. Therefore, the association between AF and psychological disturbances needs further attention. In fact, identifying the underlying psychological factors involved in the incidence and continuation of AF is one of the first steps in the rehabilitation and improvement of quality of life.24

Although prevention of stroke and control of heart rate and rhythm in patients with AF are important therapeutic goals, symptom reduction, physical limitation, and quality of life associated with AF are equally important.25 The results of this study indicate the importance of attention to the quality of life of patients with AF by assigning a disease-specific quality-of-life questionnaire as opposed to other general questionnaires that have been used by other researchers so far. Due to the importance of quality of life as an outcome, assessment of quality of life using properly validated tools is an important component of caring, research, and daily clinical practice related to patients with AF.


AF is a chronic disorder that is not generally life-threatening but is likely to affect the patient's quality of life. Assessment of QOL has not only been used to screen for psychologic morbidity, but also to monitor patient progress and prioritize patients for different treatments. This assessment is the foundation for a clearer insight into the most effective way to enhance treatment efficiency and quality of nursing care for these patients.


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AF-QOL questionnaire; anxiety; atrial fibrillation (AF); ejection fraction (EF); quality of life

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