Table 11.

Quality-of-life scales, definitions, and strengths

Scale	Definition/Details	Strengths/Weaknesses
Short Form (36) Health Survey (SF36)38 (General)	Consists of 8 equally weighted, scaled scores in the following sections: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, mental health. Each section receives a scale score from 0 to 100. Physical component summary (PCS) and mental component summary (MCS) is an average of all the physically and mentally relevant questions, respectively. The Short Form (12) Health Survey (SF12) is a shorter version of the SF-36, which uses just 12 questions and still provides scores that can be compared with SF-36 norms, especially for summary physical and mental functioning. Gives more precision in measuring QOL than EQ-5D but can be harder to transform into cost utility analysis.	Advantages: extensively validated in a number of disease and health states. Might have more resolution than EQ-50 for AF QOL. Disadvantages: not specific for AF, so might not have resolution to detect AF-specific changes in QOL.
EuroQol Five Dimensions Questionnaire (EQ-5D)39 (General)	Two components: Health state description is measured in five dimensions: mobility, self-care, usual activities, pain/discomfort, anxiety/depression. Answers may be provided on a three-level (3L) or five-level (5L) scale. In the Evaluation section, respondents evaluate their overall health status using a visual analogue scale (EQ-VAS). Results can easily be converted to quality-adjusted life years for cost utility analysis.	Advantages: extensively validated in a number of disease and health states. Can easily be converted into quality-adjusted life years for cost-effectiveness analysis. Disadvantages: might not be specific enough to detect AF-specific changes in QOL. Might be less specific than SF-36.
AF effect on Quality of Life Survey (AFEQT)40 (AF specific)	20 questions: 4 targeting AF-related symptoms, 8 evaluating daily function, and 6 assessing AF treatment concerns. Each item scored on a 7-point Likert scale.	Advantages: brief, simple, very responsive to AF interventions. Good internal validity and well validated against a number of other global and AF-specific QOL scales. Used in CABANA. Disadvantages: validation in only two published studies (approximately 219 patients).
Quality of Life Questionnaire for Patients with AF (AF-QoL)41 (AF specific)	18-item self-administered questionnaire with three domains: psychological, physical, and sexual activity. Each item scores on a 5-point Likert scale.	Advantages: brief, simple, responsive to AF interventions; good internal validity; used in SARA trial. Disadvantages: external validity compared only to SF-36; formal validation in 1 study (approximately 400 patients).
Arrhythmia-Related Symptom Checklist (SCL)42 (AF specific)	16 items covering AF symptom frequency and symptom severity.	Advantages: most extensively validated in a number of arrhythmia cohorts and clinical trials. Disadvantages: time-consuming and uncertain generalizability.
Mayo AF Specific Symptom Inventory (MAFSI)43 (AF specific)	10 items covering AF symptom frequency and severity. Combination of 5- point and 3-point Likert scale responses. Used in CABANA trial.	Advantages: validated in an AF ablation population and responsive to ablation outcome; used in CABANA trial. Disadvantages: external validity compared only to SF-36; 1 validation study (approximately 300 patients).
University of Toronto Atrial Fibrillation Severity Scale (AFSS) (AF specific)44	10 items covering frequency, duration, and severity. 7-point Likert scale responses.	Advantages: validated and reproducible; used in CTAF trial. Disadvantages: time-consuming and uncertain generalizability.
Arrhythmia Specific Questionnaire in Tachycardia and Arrhythmia (ASTA)45 (AF specific)	Records number of AF episodes and average episode duration during last 3 months. 8 symptoms and 2 disabling symptoms are recorded with scores from 1–4 for each.	Advantages: validated in various arrhythmia groups; external validity compared with SCL, EQ5D, and SF-36; used in MANTRA-PAF; brief; simple. Disadvantages: one validation study (approximately 300 patients).
European Heart Rhythm Association (EHRA)46 (AF specific)	Like NYHA scale. I = no symptoms, II = mild symptoms not affecting daily activity, III = severe symptoms affecting daily activity, and IV = disabling symptoms terminating daily activities.	Advantage: very simple, like NYHA. Disadvantages: not used in studies and not well validated; not very specific; unknown generalizability.
Canadian Cardiovascular Society Severity of Atrial Fibrillation Scale (CCS-SAF)47 (AF specific)	Like NYHA scale. O = asymptomatic, I = AF symptoms have minimal effect on patient's QOL, II = AF symptoms have minor effect on patient QOL, III = symptoms have moderate effect on patient QOL, IV= AF symptoms have severe effect on patient QOL.	Advantages: very simple, like NYHA; validated against SF-36 and University of Toronto AFSS. Disadvantages: poor correlation with subjective AF burden; not very specific.

AF, atrial fibrillation; QOL, quality of life; CABANA, Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation; SARA, Study of Ablation Versus antiaRrhythmic Drugs in Persistent Atrial Fibrillation; CTAF, Canadian Trial of Atrial Fibrillation; MANTRA-PAF, Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation; NYHA, New York Heart Association; AFSS, atrial fibrillation severity scale.